Name: Miss. SSK
Age: 9 years Sex: Female
Since age 4 she has been suffering from recurrent tonsillitis. Change of weather and slightest exposure to cold causes inflammation of tonsils B/L with pain. Usually begins with morning cough and coryza later pain and swelling of tonsils. Advised tonsillectomy.
Present c/o cough since 2 days. Cough < morning on waking and continues in bouts throughout day. Cough with white thick expectoration. Daily morning coryza with thick white discharge from nose.
H/o similar recurrent c/o in past- taken allopathic and ayurvedic Rx
h/o severe gastrointestinal infections in infancy.
h/o endocrinological consultation? Early pubertal development – on Ayurvedic Rx
Maternal grandmother k/c/o hypothyroid, DM
Maternal aunt K/c/o Hypothyroid
HISTORY OF MOTHER DURING PREGNANCY :
Mother had to go through lot of family issues right from preconception time. Financial tensions and emotional stress+: FTLSCS- non progress of labour and fetal distress at birth- baby 3.2 kgs – uneventful neonatal period.
Diet: veg+egg. Appetite: has been advised strict restrictions by endocrinologist to control obesity. Thirst: moderate
Likes: fried foods, sour foods – but lead to throat c/o.
Perspiration: only on exertion- in axillae+, around hairline, neck
Bowel: satisfactory mostly, occasional flatulence
Sleep: very sound. Dreams: daily activities – sometimes talking in sleep
MENTALS: vivacious child- likes making and telling stories, talkative ++, very obstinate, tantrums only when asked to study
- Build: obese for age weight- 39kgs
- Pulse: 78/min
- Pallor, Oedema, Icterus, Cyanosis, Eruptions: absent
- S. – nose- congested- mucus secretions+
Throat- Both tonsils enlarged, no redness, <rt side. AEBE, no abnormal breathing sounds
DIAGNOSIS: Recurrent tonsilitis
- First Prescription: 14/8/16:
Silicea 30 * 2OD, Ferr. Phos 6X * 2bd* 8days
- Follow up 1: 23/8/16: Child better: All c/o < > mild morning coryza on cold exposure o/e: tonsils enlarged but non inflamed:
Ferr. Phos 6x 2bd*15days
- Follow up 2: 2/11/16: f/u after 2months. c/o throat pain, cough, coryza, fever.o/e: Tonsils b/l inflamed. Fauces red. Afebrile
Phosphorus 30 *2 OD* 8days , Ferr. Phos 6X 2bd*15days
(The Phosphorus was chosen as it specifically covers the a/f, the character of expectoration and the clinical diagnosis. Also, it is complementary to the first prescription as a remedy that follows well)
- Follow up 3: 9/12/16: f/u after 1 month. Child better. No major c/o. occasional coryza now and o/e: tonsils enlarged but non- inflamed.
Tuberculinum 200 STAT , Ferr. Phos 6x* 2bd* 15 days
(The child predominantly presents with tubercular miasmatic trait, and hence in the presenting symptom free period, Tuberculinum as the antimiasmatic intercurrent was introduced with the aim of providing an impetus to the case.)
- Follow up 4: 30/1/17: f/u after 1.5 month. c/o cough, coryza, swelling tonsils: Silicea 30 *2 OD , Phos 6X 2bd*8days
(here the totality presentation being similar to that at time of first prescription -though of lesser intensity – prescription of Silicea was repeated. Also, Silicea and Phosphorus being remedies that follow each other well, the prescription was justified here)
- Follow up 5: 5/3/17: f/u after 2 months. Recurrence of cough and coryza has reduced. Child tolerates cold better. Child generally better. o/e: tonsils large but size –regressed: Phos 6x 2bd* 15 days
Scores for Health Related Quality of life :
Pre- treatment: 350/450
Post treatment = 250/450
Scores for Symptom Severity Guide:
Pre treatment = 280/450
Post treatment = 120/450
RESPONSE TO TREATMENT – GOOD
- In the following case, a prescription was made considering the child’s presenting totality at each episode of illness.
- The prescription of the anti- miasmatic intercurrent (chosen on basis of repertorisation of constitutional characteristics) has been catalytic in achieving the much needed impetus in this case.
- The use of Biochemic remedy, in this case has been seen to be aiding the homoeopathic simillimum in maintaining the child’s health.
- The aggregate effect of the Anti- miasmatic, the indicated Biochemic remedy and simillimum were selected using Robin Murphy’s Clinical Repertory. The repertorization was successful in achieving improved health.