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Case 89: Doc! I am Allergic to Milk

Reg No S/43/04
Mast JPM, 6 yrs Hindu egg eating vegetarian, came on 29/4/04 with the following complaints:

CHIEF COMPLAINT

Location

Sensation

Modality

Concomitant

RESPIRATORY TRACT
Since Oct’98

D1 Sneezing, running nose, occ. Fever
D2 Cough with yellow expectoration
D3 Wheezing
Dry cough

A/F Cold climate
< After bath
< Stress, Fear
< Monsoon
< Night3+
< Gets up 9am 
> As day advances
> Antibiotics

Earlier Nebuliser
Now Seroflow inhaler OD since 3 month
Allergic to milk and milk products

EXTREMITIES, Legs 1/2 - 3 days

Pain3+

 

 

PATIENT AS A PERSON
HEIGHT: 3'8"
WEIGHT: 21.5 kg
BUILT: Lean
APPETITE: N but takes 1 hour to eat
DESIRES: Salty3+, Fried3+, Idlis,
Noodles, Parathas
AVERSIONS: Sweets
THIRST: 1 ½ Liters per day
STOOL: 1-2/day

TONGUE: Wet, saliva drooling
URINE: Normal
SKIN: Allergic to milk
and milk products
SWEAT: Only when playing
WARMTH/HEAT: Palms and Soles
BATH: Lukewarm water
THERMALS: Hot. Summer <,
Fan likes. Winter likes
SLEEP: 10-12 hrs. 
Lazy in the morning

MIND: Anger when scolded, > Consolation. Fears dark, alone, sudden noise. Company likes. Contradiction aggravates

MOTHER’S OBSTETRICS HISTORY: OEDEMA: Feet last month. BP:  Last month of pregnancy MIND: Loneliness and Boredom. LABOUR: Forceps Delivery. LACTATION: 4 months

DEVELOPMENTAL LANDMARKS: BIRTH WEIGHT: 3.55 kg. DENTITION: 15 months. WALKING: 15 months. TOILET HABITS: Well developed.

LIFE SPACE AND INVESTIGATION He is the only child of his parents. He was born I 1998 in Mumbai. His mother is South Indian while the father is from MP. Father is an actor, lyricist and creative artist. He has busy schedule and has no fixed working hours. Father dots on his son and never raises his hands on him while the mother who is a housewife is a strict disciplinarian. He has been studying in pre-school and picks up things very fast. He learns music also. Wants to do everything on his own. He is friendly in nature and mixes with everyone. Angry when scolded. Cries occ hits mother or sulks > consolation. He follows a group and becomes popular very easily.

REPERTORIAL TOTALITY

·         Affectionate

·         Extrovert

·         Intelligent

·         Restless

·         Hurried, movement in

·         Laziness, children in

·         Fear dark

·         Fear alone

·         Obstinate

·         Company ameliorates

·         Food, milk aggravates

·         Allergic bronchitis

TREATMENT: Nat-s 30 1st dose. NIH pills 3-3/7days

FOLLOW-UP

DATE

SYMPTOM

REMEDY

06/05/04

Cough 50% >. Now only < in morning. Evening and night. Cold0, Expectoration0. Inhaler OD

1st week Nat-s 30 3P
2nd week Bacil 200 3rd dilution
3rd week NIH 200 3P
SOS Nat-s 30 3P

03/06/04

Pt went to Chennai >3. Sneezing L0. Cold L5. Cough < monsoon and night ++. Allergic to milk L5/month. Fear dark and alone +. No inhaler since 1month.

1st week Nat-s 200
2nd week NIH 200 3P

17/06/04

Cough dry < morning, Expectoration 0, Colds L0/month, Itching back and boils L0. Appetite disturbed

1st week Bacil 200
2nd week Nat-s 200

05/07/04

Cough L3, Cold0, Slow eating , Fear alone, dark L0. Cough, wheezing and use of inhaler 0/2weeks

1st week Nat-s 200
2nd week Pla 200 3P

26/07/04

Cough < laughing, talking, morning, playing Sneezing A/F Change of weather, thirst, Wt, 22.6kg, Ht 126cm. Uvula elongated. Bites pencil. Embarrassed when mother complements

1st week Bacil 200
2nd week Nat-s 200
3rd week
Calc-p 6X 2-2-2/7days

30/08/04

>3+. Cold L0, Bites pencil, Craves Pica, sand.

1st week Tub-b1M
Nit-ac 200 1st dose
2nd week Pla 200 3P

07/10/04

Cold 0. Sneezing occ. Back itching > 60%. Had Rash 1-2 days after eating Curd. Use of inhaler 0.

1st week Tub-b1M
2nd week Nit-ac 200
3rd week Pla 200 3P
4th week Puls 30 3P; 1P=2
Kali-s 6X 1-1-1/7days

18/11/04

Sneezing, cold, cough, wheezing L0 since 1month. Had eaten curd which had delayed reaction.

1st week
Tub-b1M 3rd dose
Nat-s 200 4th dose
2nd week Nat-s 200

3rd week Nat-s 200
4th week Nat-s 200

   

06/01/05

>. All the complaints are at Level 0. Pt had Gulab jamun 3 days back but no allergy. Wt 24.9 kg

1st week Tub-b1M
2nd week Nat-s 200
3rd week Pla 200 3P
4th week Nat-s 200

27/01/05

>3+.

On NIH