Case 70: Case of Recurrent URTI
Dr BHAVINI MEHTA

Baby SS, 2 and ½ yrs old, Residing at Ahmedabad came to me on 18/3/08

CHIEF COMPLAINT
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
APPETITE: Normal. 
THIRST: ++
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
G1P1A0L1: FTND
Threatened abortion at 1st month. So was advised rest for that month.

DEVELOPMENT: Delayed Speech. Rest all normal
VACCINATION: All given till date
DAILY ROUTINE
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.

LIFE SITUATION
Stays with PGrFa, PGrMo, Mo, Fa, Uncle, Aunt and their kids.
Patient close to mother.

EMOTIONAL STATE

·         Irritable. Anger < contradiction.

·         Calms down only when mother shouts and then she sulks.

·         Hurt easily by anybody

·         Affectionate but strangers and opposite sex aggravates.

·         Restlessness3

·         Fear alone

·         Obstinate3

·         Perfectionist3: Must clean

·         Company3

·         Weeping3 not > consolation

·         Talks ++.

·         Likes going out

TREATMENT