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
MOTHER’S 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 | Didn’t 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. Didn’t 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 didn’t 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. |
