Case 70: Case of Recurrent URTI
Dr BHAVINI MEHTA
Baby SS, 2 and Ĺ yrs old, Residing at Ahmedabad came to me on 18/3/08
Since birth recurrent cold, occurring 1/wk.
Sneezing3 → Watery discharge → Lachrymation. No cough or fever.
Mother did not know of any aggravating factors except aggravation in winter season. Baby salivates and snores in sleep. Nasal twang in Speech.
Feels hot. Tongue wet clean
Patient as a Person
HT: 33". WT 10kgs. No considerable wt gain.
SKIN: Dry. APPEARANCE: Fair. HANDS: Dry
PERSPIRATION: Excessive all over the body
CRAVING: Spicy3, Sweets, Chocolate, Salt eats just like that.
STOOLS: Hard. Small quantity, frequently, 3/D
URINE: No Complaints
SLEEP: Deep, Snoring+, Salivation+.
THERMAL: Bath: S=Cold water. W=Warm water. Fan++. Covering: S=0. W=Thin
Ambithermal towards hot. (Considering extreme climate in Ahmedabad)
OBSTETRIC HISTORY OF MOTHER
Threatened abortion at 1st month. So was advised rest for that month.
DEVELOPMENT: Delayed Speech. Rest all normal
VACCINATION: All given till date
8 am: Milk. Has to have.
10 am: Roti, Chana
12.30 pm: Lunch
1.30 pm: Sleep
4 pm: Milk. Plays
7 pm: Dinner
10.30 pm: Milk. Then sleeps.
PAST HISTORY: An episode of diarrhea and vomiting. Had to be given top feeds since mother had reduced lactation.
Stays with PGrFa, PGrMo, Mo, Fa, Uncle, Aunt and their kids.
Patient close to mother.
- Irritable. Anger < contradiction.
- Calms down only when mother shouts and then she sulks.
- Hurt easily by anybody
- Affectionate but strangers and opposite sex aggravates.
- Fear alone
- Perfectionist3: Must clean
- Weeping3 not > consolation
- Talks ++.
- Likes going out
|18.3.08||No cold today.Fastidious, hurt easily, restless. Crying not > by consolation. Didnít talk to me when I was taking the history. So Nat-m.She was leaving tonight so given a months medicine. Advised to call if any queries if not better in 24 hours with SOS.||Nat-m 200 1 dose Tub-b 1M next wk SL X 2 weeks Merc-sol 200 as SOS|
|26.3.08||Cold> but cough + started as dry then croupy since 26/3. Medicine was couriered urgently.||Ant-t 200 QDS Kali-s 6x 2-2|
|9.4.08||Called to say she was better in 3 days. No complaints after that. 1 month Rx was couriered.||Nat-m 200 1 dose SL X 3 weeks Ant-t 200 SOS|
|3.5.08||ARx over. No C/o for 5 weeks.
Wt gain +
|Nat-m 200 1 dose SL X 3 weeks|
|1.6.08||No complaints since 9 weeks.||To stop Rx|