Patient Information:

  • Name: Mr. ABC
  • Age: 42 years
  • Sex: Male
  • Occupation: Lab Assistant
  • Address: Nehru Nagar, Bhopal
  • Religion: Hindu

Chief Complaints:

  • Cough with expectoration since 2 months
  • Cough aggravates in the morning after waking
  • Chronic cough with white-greenish expectoration in the morning
  • Constipation with hard, difficult, and ineffectual stool
  • Pain in chest better on lying down

History of Present Illness:

  • Mode of onset: Gradual
  • Progress: Slow

Past History:

  • Patient has a history of cough after taking cold every year.

Family History:

  • Mother: Hypertensive
  • Father: Asthmatic

Personal History:

  • Mind and Disposition: Despair about recovery, hopeless, melancholy
  • Physical General:
    • Thermal: Chilly
    • Stool: Constipated
    • Urine: Normal
    • Disagrees: Cold things
    • Bathing: Warm water
    • Perspiration: Offensive
    • Salivation: Normal
    • Sleep: Normal
  • Built/Nutrition: Average, tall slender

Systemic Examination:

  • General Examination:
    • Pulse rate: 78/min
    • Blood pressure: 120/80 mm of Hg
    • Temperature: 98.6°F
    • Respiratory rate: 14/min
  • Respiratory System:
    • Inspection: Normal shape of chest
    • Palpation: No abnormal bulging
    • Percussion: Normal note
    • Auscultation: Crepitation in middle lobe of left lung

Provisional Diagnosis: Viral Bronchitis

Lab Investigations Advised:

  • X-ray chest PA View
  • CBC ESR
  • Sputum culture

Analysis of Symptoms:

  • Mentals: Melancholy, hopeless, despair about recovery
  • Physical General:
    • Thermal: Chilly
    • Stool: Constipation ineffectual
    • Bathing: Warm water
    • Perspiration: Offensive
    • Thirst: Decreased
    • Urine: Normal
  • Particular Symptoms:
    • Cough: Chronic, with expectoration
    • Chest pain: Better lying down

Selection of Remedy Based on:

  • Mind: Melancholy, despair recovery
  • Cough: Cold after, morning waking on
  • Chest pain: Better lying down
  • Expectoration: Mucous green
  • Rectum: Constipation ineffectual urging and straining
  • Generalities: Cold aggravation

Prescription (Date: 29/12/22):

  • Psorinum 200, 4 pills one dose in the morning
  • Placebo 30, 4 pills three times a day for 7 days

Follow-up 1 (Date: 06/01/23):

  • Complaints:
    • Cough decreased
    • Color of expectoration turned white
    • Constipation better
    • Cheerful
  • Prescription:
    • Placebo 200, 4 pills three times a day for 7 days

Follow-up 2 (Date: 15/01/23):

  • Complaints:
    • Cough better
    • Constipation better
    • Cheerful
    • Slight crepitation in left lung
  • Prescription:
    • Psorinum 1M, 4 pills one dose in the morning
    • Placebo 200, 4 pills twice a day for 15 days

Follow-up 3 (Date: 30/01/23):

  • Complaints:
    • Cough completely relieved, constipation better, hopeful, crepitations disappear
  • Prescription:
    • Placebo 200, 4 pills BD for 15 days

The patient’s condition improved significantly with the prescribed medication. The cough, expectoration, and chest pain decreased, while the constipation and mood improved. Psorinum 200 and 1M were effective in treating the patient’s symptoms, which indicated a deeper underlying problem. The patient was advised to continue with the prescribed medication and follow a healthy lifestyle. A follow-up appointment was scheduled to monitor the patient’s progress.

ABOUT THE AUTHOR

DR. UPENDRA KUMAR TIWARI

MD (HOM.) SCHOLAR (Batch 2020-21)

Department of pediatrics

GOVT. HOMOEOPATHIC MEDICAL COLLEGE, BHOPAL