Dear friends, in cooperation with Hpathy.com I am preparing a series of quizzes to develop your prescribing skills. There are different type of quizzes that I will share with you. Some of them are focused on finding the similimum, others on developing your ability to ask the patient the right questions, differential diagnosis and also skills of observation. My goal is much more than finding the correct remedy. We know from practice that the strategy for finding the simillimum is highly dependent on the type of case and the information given by the patient. Therefore, my main goal with these quizzes is to explore the correct way of thinking through the process of case taking. In next month‘s journal we will reveal the approach taken to case analysis and evaluation of symptoms that led to the simillimum. This part will also include differential diagnosis.
CASE QUIZ #1: In this case you have the advantage of seeing the questions I have put to the patient and her responses. Your goal is to find the remedy.
C.C. Baby girl 10 months old, suffers from chronic cough last 5 months. The cough is caused by accumulation of mucus in trachea. Four months ago she had the first pneumonia (left sided) treated with antibiotics and soon after she developed her second pneumonia that was right sided and which also was treated with antibiotics. She was waking frequently from her sleep due to the cough and the cough was accompanied by vomiting. She vomited 5-6 times every night. Her sleep was restless and she rolled her head from side to side.
Question: What was the beginning of the cough? Was there vomiting from the very beginning?
Mother: Yes, from the very beginning. It started as an influenza or something similar with fever 39,5°C. Fever diminished but cough remains until today. When the cough developed, the vomiting was there from the first night.
Question: Was this vomiting violent?
Mother: Very violent. She also vomits mother´s milk ever since she was breastfed, but now it is more intense than ever before.
Follow up after 2 months after the remedy:
Immediately after the remedy there was an aggravation of vomiting for a few hours and then the cough was getting better gradually. One week after the remedy her cough had reduced to only 3 times a week. The following week was without vomiting at all but the next week the cough was a little bit worse. Then it started gradually subsiding and now the child has gone one and half month without vomiting, and the cough is less and it does not disturb her sleep at all. Her sleep is calm without roling of the head. She does not vomit mother´s milk any longer.
Take some time to ponder what remedy you would choose, THEN POST YOUR ANSWER AS A COMMENT. …and then see the answer below…..
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Analysis of the case and the remedy selected:
When the mother said that the child had cough caused by accumulation of mucus in the trachea, I had two remedies in mind, namely Antimonium tartaricum and Ipecac. Why? Because although many remedies have this symptom, these are the only two remedies having this symptom as a keynote.
Both of them have cough from accumulation of mucus but the question is how to differentiate one from the other, especially in the baby who cannot be asked anything and all the information we have at our disposal comes from the mother and from our observation.
I did not cling to these two remedies but was just trying to find out if the child had other keynotes of either Antimonium tartaricum or Ipecac. If not, it’s not a problem and I will keep observing.
Antimonium tartaricum vs Ipecac
Basically there are quite clear differences especially when we face a patient who we can question. Both remedies have nausea but nausea in Antimonium tartaricum comes in waves (it is intermittent nausea) but nausea in Ipeca is felt constantly. What does that mean?
When we trace how the pathology develops within the Antimonium tartaricum picture, we can see the progressing weakness of the lungs that are losing the ability to expel the mucus. For this reason the mucus cannot be expelled and accumulates there. This proccess is not quick and does not appear suddenly but only after several days. When the amount of mucus reaches its critical point, the organism will try to get rid of it by vomiting which develops together with nausea after the period without nausea.
When the vomiting accomplishes its mission and clears up the lungs, the nausea disappears as well as the vomiting, until the time when the volume of mucus in the air passages reaches the critical point again. During the nausea the patient feels anxiety and the more nausea he feels, the more anxious he is. It is obvious here that after the vomiting (which helps to expel the mucus from the air passages) there is an amelioration and the patient feels better.
Now, the Ipecac is a totally different story. There is a very strong expulsive power of the lungs,while in Antimonium tartaricum it is the exact opposite. On the other hand the nausea and vomiting in Ipecac simply accompany every problem, whether it is cough, bleeding, itching, headache, stomachache, whatever. The organism is excited with a very strong tendency to vomit for whatever reason. That is why in Ipecac we can see the vomiting during the cough from the very beginning (which is why I asked the mother that question.), while in Antimonium tartaricum we see the vomiting during cough after several days when the cough reaches an advanced stage. In this stage the organism loses the oxygen in the blood stream, the brain is not supplied with oxygen and the fever with sleepiness sets in.
What is obvious in Ipecac is that the nausea and vomiting do not come from the stomach and that is why it does not ameliorate anything. The patient vomits with great force, vomits from cough, from bleeding, from weakness, from itching, from anything, and this nausea is still there and it is not influenced by vomiting at all. The next symptom showing us that the nausea does not have its roots in the stomach (in Ipecac) is that the tongue is clean. So this is the main difference between these two remedies.
Hope you enjoyed it!
Toss up for me between Ant-t and Nux-v.
Based on the strong history of vomiting mother’s milk I will go with the Ant-t.
My choice is Arsenicum alb as it covers aetiology which I feel is Influenza fever, Rolling of head, Vomiting coughing on, Wakens from sleep due to cough.
brayonia, antimtard an balladona,
brayonia and antim tart for pnemonic and ommiting milk, belladona for pain and cough
Ipeca, because the vomiting is present from the begining
I think the remedy is Lachesis, as it started with Left side, trouble (vomit) after sleep only.
Nice quiz anyway, will wait for the answer!!
Well….a straight repertorization leads to Phosphorus with Silica in second place:
1. coughing from mucus in trachea
2. coughing after pneumonia
3. sleep, cough during, wakes from
4. stomach, vomiting, coughing on
5. sleep, restless
6. head, motions of head, rolling head
7. Children, breast-feeding, vomits milk after nursing
8. stomach, vomiting, violent
9. Clinical, pneumonia, infants
10. Pneumonia, chronic
First four remedies: phos, silica, kali carb, ars. However, the main remedy for vomiting mother’s milk is Aethusa. Because the prescription cured this aspect of the case, I have to wonder if you didn’t prescribe Aethusa.
Dear Friends, thank you for your comments. You made a great job!