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CASES MATERIA MEDICA GENERAL ARTICLES ABSTRACT MISCELLANEOUS Q & A

Case 94: When Reflux Oesophagitis Mimics Cough

Mr DM, 63yrs, Non-veg, CA came on 20/03/2007 with the following complaints

CHIEF COMPLAINT

LOCATION SENSATION MODALITIES CONCOMITANTS
RESPIRATORY TRACT
Since 2004
2/yr X 3 months
Throat
Cough 3+
Expectoration white, sticky, lump
Heaviness
Hoarseness
< Jan-March3+
< Night 10pm-2am
< Talking
< Draft? Uneasiness
> Plain water
> Tea
18/3/07 →
Tab Azithrocin
Diagnosis: Reflux Oesophagitis
Body ache + Lethargic
Sips water
GIT
Since 25 yrs
Flatulence 3+
Belching
Tab. Pan 40 OD
Since 3 days
RECTUM
Since 10 yrs
1/day
Hard stool, occ. ball like
Strain
Water intake 1Ĺ lit
Suppository 2/wk
F/H Mo
HEART
Since 2000
LBBB
Palpitation
< Exertion ECG→N
Thallium→N
Canterfol, Colstar,
1tab/day
&uarr Pulse rate
GENERAL
Since 1972
Fingers→ Soles→ Since 1997 20/03/07?→
Diabetes Mellitus
@28yrs age.
Tingling, nephropathy
Sensation ↓
Fasting 220
75kg&rarr 56kg
Insulin Mixtard BD
Lantase HS
Glymer 1tab
Pyopar 0-1-1
Glycomet 250, 1-1-0
Losar 25

PATIENT AS A PERSON
WEIGHT: 62-65 kg constant
BUILT: Lean
APPETITE: Nv
DESIRES: Cold drinks 3+, Sweets, Tea 15-16 cups/day, Ice-cream
TONGUE: Posterior1/3rd white and moist
URINE: 3-4 hrly
SKIN: Haematoma due to injection, Warts3+
HAIR: Male pattern baldness
PERSPIRATION: Armpits
THERMAL: CH4. Winter >3+, Likes fan, canít tolerate direct breeze, Likes open air.
BATH: Cold or lukewarm
SLEEP: Refreshing. Cramps at night > Walking
DREAMS: Funny, Abstract
MIND: Obstinate3, Perfectionist as to punctuality, Company >3, Excessive speech, Affectionate3, Sympathetic to others suffering. Weepy when watching movies and when Da going to her in-laws house.

LIFE SPACE INVESTIGATION: The pt was born on 27th Feb 1944 in Mumbai. His basic education has been in Mumbai and he has been good in academics though not a topper. He completed his CA in 1966. He joined his Faís firm in 1967 and achieved 80% of his goals. He had an arranged marriage in 1970. He was diagnosed DM in 1972. He had a wonderful and supportive wife. He is just like his Fa who expired in 1998 at the peak age of 95yrs. Mo expired in 1997. She was a lecturer in Ruia College and was very short tempered.

REPERTORIAL TOTALITY

  • Sympathetic
  • Joking
  • Company, desires
  • Crying, easily
  • Warts
  • Oesophagitis
  • Diabetes mellitus
  • Cramps < night
  • Cough < talking
  • Cough < draft of air

TREATMENT & FOLLOW-UP

DATE SYMPTOM REMEDY
20/03/07 BP 120/80 mmHg, P=80/min, Wt. 66kg Caust 30 stat HS 3P
Pla pills 1-1/7days
23/03/07 >3. Cough L0 in one day. Constipation +, Breathlessness and palpitation L0,
Nightly urine passing 2/HS, Night cramps 1/wk. < Reflux L0, Body ache 2/HS, Tingling 1/wk, Sugar→ F190, BD 125
Thuj 200 1st dose
Caust 200 1st dose
Pla pills 1-1/7days
03/04/07 >3. Passed clear bowels. No cough. Mild hoarseness +. Cough, Reflux L0/2weeks, Hoarseness L2, Body ache +, Tingling +. NIH 200 3P
Pla pills 1-1/7days

Dr Vishpala Parthasarathy

Case 93: I had a Child Marriage

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