Advantage of Homeopathic IPD
NATIONAL JOURNAL OF HOMOEOPATHY 2004 Sep / Oct VOL VI NO 5.
Dr Dinesh Rao
'Calc-c / Phos / Kali-c

Case 1
Smt TR, 48 yrs Housewife Married since 32 yrs, Illiterate, Bengali, H: 50 yrs, working in Pvt Co. .Mo: Expired 10 yrs back, Br 5. Sis 1 (all younger to patient), Sons: 2, Daughter: 1

Patient was seen in the Diabetic OPD on 16th July 04 with UTI. H/o DM since 4 yrs . She has gradual weight loss since 4 yrs and complained of burning soles since 4 yr. This indicates peripheral neuritis. On 10/7/04 FBS: 225, PPBS 362.8mg/dl

She was irregular in treatment. She was given Puls 30 on 2/4/04 and Merc-cor on 9/9. Apart form this; patient was taking oral hypoglycemic agents for 2 yrs., which she had discontinued on her own since 2 months.

Patient had consulted MD physician who is attached to our hospital, for fever, off and on since one month. On evaluation she had:
FBS: 307.5 with urine sugar ++++
PPBS: 371.8 with urine sugar ++++ & traces of acetone
Looking at the high blood sugar levels and presence of acetone in urine, which indicates patient's compromised metabolism and that she can go into Ketoacidosis the physician advised hospitalization.

Patients Status on Admission 21/9/04

1. Patient has fever on and off since 3 months. Chills +. Fever 5 am and 5-6 pm. Accompanied by headaches.
2. Month back had fever with chilliness without rigors. Subsided by itself.
3. Since 3 days fever with chills and rigors once a day.
4. Rigors start at 10-11 am and continues for 30 min.
5. Rigor is followed by chill, which starts from the back and then spreads to the abdomen and chest. Patient feels sleepy with chills. Dryness of mouth and thirst increases, large quantity 2-3 glasses at frequently intervals.
6. Chill is followed by heat sensation all over the body; lasting for 30 min. Thirst is normal and patient experiences mild headaches.
7. This is followed by profuse perspiration, drenching her. She experiences intense weakness during and after perspiration. In apyrexia, patient has reduced appetite and a bitter taste in mouth.
8. Patient also complained of burning soles.
   O/E: Looks Weak#. GC: fair. Temp: 99.2 F. Pulse: 80/min regular, good volume, BP: 130/70, R: 20/min, Bowel Sounds: Sluggish. Per A:bdomen: Liver 0, Spleen 1, Kidney 0. Tenderness over abdomen.

Investigations
CBC: Hb: 14.2, TC: 6,800, N: 58, L: 35, E: 4, M: 3.
Urine: Alb: ++, Sugar +++, Acetone: ab, RBC: Occ, Pus cell: 4-5, Ep cell: Occ Bacteria: +
Lipid Profile: S Chol: 160, , STrig: 114.7, HDL Chol: 42.4, LDL Chol: 95, VLDL: 23, Chol/HDL ratio - 3.8. Sr Creat: 0.6, BUN: 7.9

Treatment 21-9-04.

Summary of Treatment And Patient from 21-9-04 to 24-9-04
Blood sugar on 22/9/04 showed FBS: 367.8 US: +++, PPBS: 388. Acetone: Ab. RBS on 23/9 was 387
Inj Insulin Human Actrapid SC 16-20-20
Inj Monocef 1 gm IV 12 hrly.

Patient had almost continuous fever for 5 days: ranging fron 99.4 to 104. Spikes of 103 -104 were recorded at 10-11 pm (more pronounced) and at 10-11 am. Till 24th patient had fever with rigors.

The generals and particulars of the patient used to fluctuate: App, weakness, fever with rigors, burning soles, pain abdomen. Patient looked very weak and depressed.

BP had gone up to 180-160 mm of Hg (systolic) and 110-120 mm of Hg (Diastolic) on 2 occasions and then settled down.

24-9-04: Inj Insulin 20-24-24. Tb Zifi 200 1-0-1 x 5 days
Looking at this state, we thought of starting homoeopathic medicines after the consultation of physician and orienting the patient. He had suggested Lariago Inj 5CC IM 6 hrly 6 doses to be added to the treatment. But agreed to wait.

On 24-9-04 the case was redefined.

Understanding Of The Case
Patient was born in a middle class agricultural family in West Bengal. They had agriculture as the source of income. Patient was eldest and was pampered by all. They had a big joint family and patient was not allowed to work. Patient did not go to the school as it was far and there were incidences of 2-3 dog bites Patient had tremendous fear of dark in childhood and still has it.

Patient got married at a young age. FIL had expired early and MIL was a very irritable lady who used to taunt and even beat her, as she did not know anything about household, kitchen work. But this did not affect her. Patient from beginning was jovial used to make everyone laugh. The only feeling was that her mother did not teach her anything. Patient looked after her MIL in her last days when she was bed-ridden. Her death affected her. Pt said that she was like my mother and every mother has the right to scold her children.

Patient lost her mother 15 yrs back and could not be with her during her last moments. She grieves about it and weeps occasionally. She often sees mother in her dreams. Patient gets along well with her only DIL. Sometimes DIL scolds her, saying that she is very childish. This has no effect on the patient. Patient has financial anxiety. Patient was child-like during interview, laughing most of the time, although she was very weak and in distress.

Physical Generals:
Perspiration: Profuse, Scalp³.
Craving: Sweets³, Spicy³, Fasting <2.
Menses: Menopause since 5-6 yr
O/H: G3P3L3, Morning sickness: 3-4 month in all pregnancies.
Stool: Hard, has to use laxative occasionally. Patient had < Before Menses
Thermal: Chilly³ < Sun (General uneasiness).
Sleep: Disturbed due to thoughts.
Dreams; Mother. MIL
P/H: Mo: HT, IHD. Father: CVA

Diagnosis: UTI and Malaria / ?mixed infection with. DM (not insuline dependent. Wrong as Insulin started in hospital; earlier she was being given oral drugs and had stopped them. Insulin dependent means - Insulin for survival not for control)

Investigations: X-ray Chest: N, Widal: Not positive, Urine R: N
The case after studying in depth reveals following
H/O: Essential HT in parents followed by CVA - IHD in parents revealing a strong tubercular base. (Fundamental Miasm)
Fever Totality

1. Fever aggravated 10-11 am
2. Chills beginning in the back
3. Thirst increased during chill.
4. Heat - Headaches with
5. Perspiration profuse - weakness with.

Remedies: Tub, Sep, Calc, Nat-m, Nux-v, Verat, Rhus-t
Looking at the case we find a very strong tubercular activity in terms of a fundamental as well as dominant load.

Long standing infection with high swinging fevers.
Intense weakness
Underlying diabetic state with its affect on general metabolism  Tendency of the system to go into Diabetic Ketoacidosis

Tub-bov also covers the fever totality, except the time. The other remedies like Sep, Calc, Nat were kept in mind, but with the above mentioned understanding and past experiences Tub-bov 1M, was given on 25/9 at 1 am and temp came down to 98.8 F.

Synopsis of Follow-Up From 25/9/04 TO 26/9/04.
Patient on her own said that she felt much better and all symptoms appetite, weakness, sleep, generals and burning soles, abdominal pains were better. Resident physicians and consultants who were following up with the patient could see a definite change on the patient’s face and said that she looked much better in terms of weakness and general well - being. Restlessness/Depressed look also had gone away.

There were no chills or rigors and the maximum fever spike was 100.6 F. This was expected of Tub-b but the improvement did not progress. Tub dealt with the miasmatic load in this case. We had to find out another force which would carry on the good work initiated by Tub. The current state of susceptibility did not throw any form suggesting an acute remedy and so this indicated that the susceptibility needed a deep acting force ie constitutional remedy.

Totality of the Constitutional Remedy

1. Grief
2. Fearful
3. Timid
4. Mirth
5. Sentimental
6. Dreams: dead relatives
7. Anxiety: financial future.
8. < Before menses
9. Fasting <
10. Morning Sickness (< Pregnancy)
11. Perspiration profuse - scalp
12. Cr Sweets
13. Hard Stools

This totality points towards Calc-carb as the constitutional remedy.
Action: Calc-carb 200 1P given on 26-9-04 at 10.30 am temp was 99.2 F. The plan was to give a single dose and assess response after 12 hrs and then plan the repetition schedule. This is one of the advantages that we have in a IPD set up The FU after 12 hrs showed no significant improvement- Fever range remained 99 F and so it was made TDS.

FU on 27 evening: Generals much better . Fever touched Normal 2 times in 24 hrs FBS: 210.7 US: + PPBS: 254.8 UR: N due to insulin doses and antibiotics.

After this there was a gradual improvement in general + specific symptoms in patient. Fever range was between 99-100 but more on 99. On 29th it remained normal for more than 6-8 hrs, for the 1st time in 8 days!!

Patient was discharged on 30th. She followed up after 4 days. She had only one spike of 99 at home, that too she did not feel it. Patient has been reporting regularly and is much better. Her diabetes is being taken care of by insulin injection, diet and exercises.

Learning

1. Scope of homoeopathy in fever case where diagnosis is not very clear.
2. Advice of treating complex fever cases in a homoeopathic IPD set up
3. Role of homoeopathic management in co ordination with allopathic consultants in fevers

Case 2
Mr NP, 30 years, Occupation: Service MIDC Contract, Married since 7 yrs, Br: 2 younger, No sister, Children: (3): 6 yrs, 4yrs, 6mo.

Date of screening 6/10/04 at 10 am with C/O.

1. Fever high grade since 21 days. Usually associated with chilliness and 3-4 episodes of rigors. Fever < 4-6 pm²
2. Vomiting since 21 days F: 2-3 times / day. Vomiting <2 immediately after eating and drinking warm water, can retain cold water for sometime.
3. Pain + in Right Iliac Fossa, continuous mild pain
4. Along with fever: App , Thirst  large quantity frequently 1 glass ½ hrly Cr. For cold water², (His last symptom but  during acute), Weakness³
5. Stool N. Urine N.

Patient has pain in RIF since 1 yr. This pain is always associated with vomiting and fever. F: Once / Month, D: 3 days & >3 allopathic treatment

O/E: GC OK, T: 104 P 116/min, Wt: 46 kg, BP 112/60, RS: Clear, CVS: S1S2-N, P/A: Liver 1 FP non tender Spleen0, Tongue. Thick coated white²

Previous Investigation
21/2/04: Hb: 16.6, PCV: 47.4, RBC: 5.84, WBC: 6,800, N58, L31 E4, M7
S. Creat: 0.7 U. R: E/C 5-6 P/C: 2-3
3/4/04: Barium Meal follow through: Appendix not filled.  liver echopattern

Recent Investigation:
6-10-04: USG Abd: Parenchymal inflammation of liver with subacute on chronic appendicular mass. ? Inflammatory iliocecal mass with minimal fluid collection.
X-ray Chest: prominent Bronchovascular markings.
Widal: Typhi 0  1:120
Paratyphi A:  1:120

Thus we see in this case, the patient has contracted an acute infection (typhoid) & at the same time has a sub-acute on chronic infection. Initially this presentation possesses a problem of clinical diagnosis. But careful history taking along with investigations makes our task easier.

Totality
Acute: Fever < 2 4-6 pm
Desire Cold drink² with fever
Thirst large qty. and frequent with fever.
Vomiting < 2 immediately after eating and drinking
Can retain cold water for some time
Susceptibility/ Sensitivity- Moderate - 200

Case was defined in detail on 6-10-04 evening
Totality after going through lifespace.

Chronic Totality

1. Fear of dark+
2. Atatchment² with parents
3. Anxiety² anticipatory about daughter
4. Sleeplessness anxiety from
5. Dreams of dead bodies
6. Dreams of snakes
7. Dreams of water
8. <+ Riding - Vomiting
9. <2 Fasting - Weakness, Backache
10. <+ Sun - weakness, occ headaches
11. Cr. Spicy³
12. Perspiration profuse³
13. Chilly

Correspondence- Kali-carb
Susceptibility / Sensitivity - Moderate

Treatment / Follow Up Summary

1. Patient admitted on 6-10-04
2. All investigations were done & in spite of totality available we waited for investigation reports and to study the temperature range. It is always better to wait for 12-24 hrs to observe the temperature charts and confirm what patient says. It is also important to observe pt and ask them about their subjective symptoms. Eg. one patient with rigors in a malarial fever (P. vivax) assumed a knee chest position during chill and rigors and on being asked said she always does it and feels better (she never gave this history)
3. Temperature range around to 100 to 102.4 F Phos 200 QDS was started on 27-9 at 11 am. Patient gradually improved in all his symptoms. 1st there was no subjective feeling of fever/Chills. His appetite, nausea, weakness gradually improved. Patient had dry cough which was better within 2 days.
4. By day two his concomitants of increased thirst was better. His temperature range (Highest fever) fell by 1 F every day & on day 2, i.e 9-10-04 it was 100 F. Phos was continued as it was giving relief to the patient. Patient also reported that the pain in rt iliac fossa was much better.
5. Then on 9/10 there was one spike of 101 and the general distress again increased. This indicated that the Phos 200 QDS was not holding. At this point of time there were 2 options. To go to phos 1M or go to the constitutional. As the form of Phos had disappeared Kali-carb 200 1P was given on 9/10 at 10 pm. After introduction of the constitutional, patient made a very rapid progress and temperature touched normal with in 24 hrs and remained so for the next 24 hrs. On 11am there was one spike of 100 after which Kali-c 200 3 powders was given. Patient was kept under observation for 24 hrs after the fever touched normal. Patient was discharge on 12 & all his reports came normal.

Learning

1. Phos 200 QDS was fairly slow in its action. Probably going to 1M on day 2 or day 3would have cut short the duration of acute disease.
2. Phos 200 was continued even after the susceptibility stopped throwing indications for Phos - (Totality of signs & symptoms). The demand of the susceptibility was fulfilled by Kali-carb. If this force would have been given on 7th or 8th, it would have sped up the recovery process.