Name : MR J E Date: 12/09/2017
Age/ Sex : Male,38 DOB: 1978 Marital Status: Married Occupation: Sales Job
C/o-
1. Asthma since 8 years of age, severe episodes every 2-3 months > lying on side < night > sunlight/ sun, sometimes fever during episodes, starts always with runny nose
2. Eruptions on scalp, ace & neck, flaking + since about 4 years < sun, > exercise & sweating
3. Stool- 3 times in morning, sometimes in evening also, flatulence++ > stools after, Flatulence < skipping meals > exercise
K/C/O-
Medication: Allopathic ( inhalers), Homeopathic for 2 yrs with temporary relief
| Appetite & Diet: Regular, once a week, non veg Thirst: less Desire: NS Aversion: NS Bowels: Burning in anus < spicy food Urine: N Sleep: regular, catnap Dreams: not remembered Thermal Rxn: chilly? Ambi? Sensitive to cold Perspiration: N Seasonal Modalities: dec/ winter/rainy Tongue: posteriorly white coated Sexual Functions: Normal O/E: hand, noise & warm to touch Constitution: avg build Height & Weight:70 kg, 5 feet 7 Habits: occ intake of alcohol |
| P/H: Anal fissure 2 year back Chicken pox at 13 y of age F/H: F- RA, CAD M- DM Investigations: NIL Mental Symptoms: Socialable & expressive Impatient+ Anger ++ now reduced with age Childhood- had reserved nature, was good in study Hobbies- sports, art, music, dance, adventure Observation- Sceptical , doubts about homeopathy wants to try again , critical ? , impatient |
| DATE | C/o | Notes | Prescriptions |
| 12/09/17 | 1st RX | DD arsenic | Sulphur 01 1 pill per day Sac lac 30 BD 2 weeks Blatta q SOS Nat phos 6x SOS |
| 18/09/2017 | Uncomfortable at night sometimes Sneezing in morning Stools better, yet 2 times a day Taking inhalers, once in 3 days now Scaling + | Sulphur 01 1 p per day Sac lac 30 BD Blatta q BD 10 drops for 3 days + SOS 2 weeks | |
| 5/10/2017 | Difficulty in breathing < dust > fresh air Sneezing in morning + Stools 3-4 times, after the dose of medicines mostly Sleep- sq Took Blatta q several times Scaling + | Sulphur 01 Sac lac 30 BD Blatta q HS daily 3 weeks | |
| 01/11/2017 | Throat infection since 2 days Fever with body ache Cough with yellow green expectoration,< talking Low grade fever Acidity , at times, takes Nat phos with relief Nose block + Sleep good Stool 3 times a day | Use of inhaler very rare | Hepar sul 200 QID 2 days Followed by Sulphur 01 1 p per day Sac lac 30 BD Blatta q SOS |
| 19/12/2017 | Inhalers stopped since some time Better overall Not required Blatta Skin dry+ Perspiration / exercise GIT- mild acidity , gases, stool 3-4 times | Sulphur 01 1 pill per days Sac lac 30 BD Rest meds SOS | |
| 5/03/2018 | Itching in throat sometimes Acidity, sometimes Stools- 2-3 times a day Avoids spicy food Sometimes pain in rt abdomen due to gases Skin- itching on face , increased | Visits are infrequent , pt better without meds, yet some complaints occur | Sulphur 02 once a week 1 pill Sac lac 200 BD Mag phos 6x for bloating ( SOS ) |
| 31/08/2018 | Itching in ENT passage since 1 week Stool- occ undigested particles Bloating & acidity < change in diet | Sulphur 02 OD for 7 days Sac lac 30 BD MP 6x- SOS | |
| 20/9/2018 | Wheezing since 10 days? < 3 days Pain in throat Mild phlegm , white in color Dullness No fever, but feeling feverish Acidity < outside food Pune < travelling< oily food | Hepar 200 Bio no 6 Blatta q QID 5 days f/b Sulphur 02 OD Sac lac 30 BD | |
| 1/07/2019 | Throat infection, off & on With pain, feels feverish, pain < night Phlegm- yellow n thick Dryness felt in throat Honey & lemonChilly+ Acidity, Rare Gases, mild Stool- 2-3 times in morn Vomiting < over eating once Scaling on eyebrows & scalp, at times | Winter & previous monsoon went well & asthma is almost NIL, yet allergic sore throat , at times | Hepar 200 QID Sac lac 30 QID 5 day |
| 22/ 10/2019 | Overall better Requires refill of meds GIT- better, depends on diet Dry skin, on neck & jaw, no scales Scales on eye brows mild | Skin complaints are always last to go, hence same rx | Sulphur 02 1 p , per days For 1 month |
| 21/11/2019 | Sneezing at times Throat irritation at times < dust < cow | Blatta 200 was given instead of q, as patient requested not to give liquid, he travels a lot | ADVICED TO USE MEDS SOS on change of weather Sulphur 02 , Blatta 200 |
| 18/07/2020 | Patients is well, Uses meds rarely |
DISCUSSION & CONCLUSION-
Treating a sceptical & impatient patients is always a challenge & the results are most rewarding.
This patient was extremely sceptical since beginning, yet he had some faith in natural remedies & was willing to stop conventional meds , which was in much favour of case.
Patient counselling is very relevant in such cases, the doctor has to have answers to all queries & doubts, at the same time should be confident to instil the same in the patient.
Such patients are usually ( esp SULPHUR ) intelligent , they may question many things , they may be very curious , the doctor must be prepared for intelligent answers.
Remedy selection in this case, was purely based on Materia medica knowledge, repertory was not used.
Skin complaints are always last to go, yet some relief in seen during the course of treatment, so best to talk to patient about it .
Use of complementary & follow-well remedies, always yields good results ,without disturbing original rx. Here it was HEPAR SULPH, one of the best antipsorics that helped in acute states.
Use of tincture & biochemics may be frowned upon by some, but its my view that, in a chronic case, with a life style which is not very ideal, use of the above is much safer then use of inhaler & antacids for long term.
Lastly , no matter how chronic the case may be, there is always hope, do not hesitate in trying.
Thanks !
Dr.Anshita Singh Rathore
BHMS, MD, PUNE