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 1½ 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, can’t 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 Fa’s 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
