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CASES MATERIA MEDICA GENERAL ARTICLES ABSTRACT MISCELLANEOUS Q & A

Case 84: A Case of Allergic Rhinitis

Mast TS 15 months old came to me on 31/7/08

Dr Bhavini Shah

CHIEF COMPLAINT
RS once in 3 weeks: Throat redness → nose block → White discharge from the nose → turns yellow → fever 100. A/F change of weather. Difficult to sleep. Restlessness. Thirst increases with the C/C.

DIAGNOSIS: Allergic Rhinitis

PATIENT AS A PERSON
WT: Not gaining enough
SKIN: Fair
PERSPIRATION: Excessive3.
APPETITE: Normal.
THIRST: 5-6 glasses/day
FLATULENCE: Occasional+
CRAVING: Sweets3, Spicy
STOOLS: 1-2/day
URINE: Bedwetting +
SLEEP: 10 pm to 7 am. 12.30 - 3.30 pm. Restless in sleep.
THERMAL: Hot pt
MOTHERíS O/H: G1P1A0L1. FTND.
DEVELOPMENT: 1st 9 months = stools 8-9/day
Breast feeding for 1 year
Speech: Babbles.

DIET
07.30 am: Milk
11.30 am: Dal rice
01.30 pm: Roti
04.00 pm: Milk
07.30 pm: Khichdi/thuli/Idli
10 pm: Milk

LIFE SITUATION
05/05/05: Mother and Father, arranged marriage.
08/03/07: Pt planned baby. 1st child. Father very calm. Mother very tensed by nature.
Mother and GrMother does not get along well.

EMOTIONAL STATE
Irritable3.
Sulks in anger.
Contradiction <3.
Brooding3
Affectionate3 more with mo
No fears
Obstinate
Perfectionate3
> Company

REPORTORIAL TOTALITY
1. Irritable
2. Contradiction agg
3. Sulks
4. Restless
5. Affectionate
6. Obstinate
7. Fastidious
8. Company amel
9. Perspiration Profuse
10. Cr sweets
11. Cr Spicy
12. Allergic rhinitis

PLAN
ACUTE: Ars-alb
CONSTITUTIONAL: Calc-iod
INTERCURRENT: Tub-b

TREATMENT

Date Symptoms Treatment
31/07/08 Wt 10 kgs O/E: Fauces red. Tg clean. Thirst ++. Chest clear. Restless. Ars-alb 200 TDS X 3d
Tub-b 1M 1 dose
05/08/08 >3. No cough since 2/8.Took Tub-b on 3/8/08 SL
28/08/08 Didnít came for 3 weeks after which they went out of town. Called up for Cough and cold ++ with fever. Couriered RX Ars-alb 200 QDS X 3d
Followed by
Tub-b 1M 1 dose
Calc-iod 200 1 dose
04/09/08 Cold cough was not better. Took antibiotics. I could not follow up since pt was out of town. No well was taken Now no C/o. Tub-b 1M 1 dose
Calc-iod 200 1 dose
23/09/08 Mo said perspiration is much reduced.New C/o. The legs are slightly bent outwards. Falls often while walking. Pediatrician asked to start Calcium. Calc-fl 6x 2-2/day
25/09/08 Since 25/9 10.30 am became restless. Didnít have his Breakfast. Ars-alb 200 TDS X 3d Followed by
5 pm: Vomited after Khichdi.O/E Throat red. Chest clear. Fever 99. No cough or discharge from nose. Tongue wet.Thirst++. Clinging and irritable Tub-b 1M 1 dose
Calc-iod 200 1 dose
Calcium continues
22/11/08 Came with mo and fa. Fa asked why the cold and cough is recurring so often. BM: The last episode was in Sept. Was > in Oct. Now cold since 7/11. So symptomless for 5 weeks which was once in 3 weeks when you came for the 1st time. Also the last treatment taken was before 2 months which was also very irregular. They took Allopathy for the current episode. Now pt is on 2 cough syrups.Dry cough + restless. Thirst ++. Tg wet.O/E: Throat Slightly red. Chest clear Ars-alb 200 TDS X 3d
Followed by
Tub-b 1M 1 dose
Calc-iod 200 1 dose
02/12/08 No c/o. Wt 11 kgs. Throat Normal. Calc-iod 200 1 dose
11/12/08 No C/o. Teething + SL
18/12/08 Since 16/12, cold, fever 99-100°F. Mouth ulcer Rt cheek. Tg wet, Saliva ++. Thirst ++. 17/12/08 Macular eruptions. O/E 3 macular eruptions on legs. ?Measles.To report next day if not better or go to pediatrician Merc-i-f 200 Tds X 3 d
23/12/08 No eruptions since 19/12/08. Wt 12 kgs.Mo happy since gain in weight. Tub-b 1M 1 dose
Calc-iod 200 1 dose
06/01/09 >3. No cold cough. C/o itching around anal area. ?Worms.Speech: Repeats what mo says. Cina 200 X 3 HS
13/01/09 No complaints SL
29/01/09 Discomfort in abdomen. Stools 2-3/day. Loose and offensive. Ars-alb 200 BD X 2d
Followed by
Tub-b 1M 1 dose
Calc-iod 200 1 dose
07/02/09 Stools 1-2/d. Went to Hyderabad but no c/o. No URTI since 7 weeks. Wt 12.2 kgs SL
19/02/09 Since 13/2 cough and cold +. Cough → vomiting. Thirst +. Nose - white discharge. App reduced Cocc-cacti 200 BD X 2D (Ars-alb 200 BD X 2d was given as regular acute if Cocc-cacti didnít work) Tub-b 1M 1 dose Calc-iod 200 1 dose
21/02/09 Called to say >. To start well
24/03/09 No C/o since 5 weeks. Talks full sentence. Walks well. No bed wetting. No anal itching.Wt 12.5. To stop treatment and report SOS
19/04/09 Mother called for herself and said pt has no c/o.

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