Kelly DID finally surface–briefly; said something about soccer and then vanished into thin air….Luckily, Inez got sick again! (Way to go Inez!)
So, now, I give you the second episode in our exciting dramatization of, “I Can’t Believe It’s Not Butter!”
On Sun, 7 Jan 2007 19:01:21 EST [email protected] writes:
Acute Case Questionnaire
1. Describe the complaint in your own words–and tell when it started and whether it came on suddenly or gradually.
Inez has swollen tonsils and a fever of 100.6. She said at school yesterday that she was not feeling well then slept (uncharacteristically) at nap time for over an hour. She woke with the tonsils and developed a fever by the time we got home (15 minutes). She has slowly been losing the stuffy nose and cough that were left after her last bout of tonsillitis(?) about 3 weeks ago.
2. Etiology–meaning, what caused it, if you know. What was going on at, or around, the time of the occurrence?
Much illness at school. Assorted colds, fevers, sore throats, etc. It has become quite cold for our temperate climate, so we are inside more than usual. I think her tonsils are Inez’s weak spot, her line of defense against illness. If she gets sick, they will be the spot where the illness shows most.
3. Sensation–describe the pain or other feeling. Does it extend anywhere, does it shoot anywhere? For instance, “It feels like there’s a crumb in my throat, I’m constantly trying to swallow. The pain shoots to my left ear.”
It feels like knives in her throat. While eating, drinking and while just sitting.
4. Appearance–what does the person, or the part that’s bothering the person, look like; anything remarkable? Red skin, droopy eyes, etc.?
She is pale-ish. Her throat looks exactly like last time: tonsils touching, slightly red with a dark red streak running through the right side. No white spots.
5. Location–where on the body is the complaint located?
Throat, tonsils. She says her whole neck hurts.
6. Modalities–what makes the complaint better or worse? Consider: heat or cold, bathing, warm rooms, fresh air, drafts, motion, time of day when person gets worse, what position is best/worse; stimuli: conversation, noise, light, touch, pressure, massage, music, company, consolation, etc.
She says she can’t lie down, her neck hurts if she does. She must sit up. I think her tonsils are so swollen that she feels anxious about lying back, her breathing may be impaired some. Her voice is certainly thick sounding.
7. Concomitants (additional symptoms that came with the main complaint)–for instance, pain with crying; pain with excessive salivation; pain with nausea–the things that have come along for the ride, fellow-travelers, in other words.
She has a few itchy spots on her legs and one on her arm. They look like bug bites that she has scratched open. They are slightly red and bumpy around them. Not spreading to any other parts so far. She was itching in the night 2 nights ago, the night before she got sick.
8. Discharges–color, odor, consistency. (A discharge is anything liquid that’s coming out. So, for instance, runny nose, diarrhea, lacrymation and so on.)
No runny nose, no sweating, very light colored and small amount of urine when she woke this morning.
9. Generals–these are all the “I” symptoms: I’m hot, I’m cold, I’m thirsty, I’m tired, I’m sad, I’m irritable, I’m hungry, I want pickles, etc.
Not much here, just I don’t feel good. I don’t want to go to school. She did say that she should stay home so that she didn’t get her friends sick.
10. The mentals: Have the mentals changed from normal, in what way? What’s different mentally and emotionally?
Droopier than usual. Knitted brow, a little anxious. Wants company
11. What does the person say? For instance: “I’m fine, leave me alone.” “Don’t leave!” “I wanna go home!” “I want ice”, etc.
‘No, I’m ok.” When I offered her anything to eat or drink last night she just kept saying that. She did eat of all things at the meal, roast beef, a typical favorite of hers. Today she has had only a scrambled egg and a small glass of limeade.
12. What is the person doing? For example, tossing and turning, pacing, fidgeting, moaning and groaning, etc.
Sitting up still in bed. Quietly watching Sesame Street, she now wants company. “I want some company” are her exact words.
14. Sweating? When does the sweating occur? Where on the body? What’s it like?
15. Odors? Are odors an issue, such as bad breath, foul odors of any sort?
Thick stale breath. She hasn’t brushed her teeths ince yesterday morning.
16. What is most striking about the condition or most peculiar–for instance, person is cold but heat and covers aggravate; person has burning pains but is better for hot drinks like tea.
Like I said, this seems very like her bout with sore throat 3 weeks ago but I have twice given her pulsatilla 200c since last night to no real effect. Last time her tonsils immediately shrunk and the fever subsided. she did have a lingering cough and stuffiness though.
She is not interested in any food, not even butter, which I jokingly offered her last night to which she answered in all seriousness: “no, I’m ok.”
17. Is there a diagnosis? For instance, flu, teething, etc.
Probably strep throat again.
18. Describe the patient’s energy–is he quiet, restless, agitated, sleepy, prostrated, collapsed, stuporous, anguished, desperate, etc.
Quiet. Wants company but is sitting still in bed. She is a bit anxious, her brow knits and she looks at me plaintitively when I cuddle her.
19. Thirst–is the person thirsty, not thirsty, what temperature drinks, what kind of drinks, does he only want sips, or gulps, does he drink a little bit frequently or a lot infrequently, and so on.
Not thirsty. Won’t drink unless I offer the water.
Elaine Lewis, DHom, CHom takes online cases. Visit her website at: elainelewis.hpathy.com