Registration no.-147/2022

Date of examination-18/01/22

Name-Angelyne kharwansah

Age-06 years

Address-Umpling

Informant-Mother

Reliability-Reliable

Chief complaint-Location-Dryness over upper eyelids(both side)since 6 months.

                             Sensation-Itching

                            Modalities-agg-night,winter.

                             Onset-gradual

-h/o of chest pain on and off.

Past history- h/o Pneumonia at 2 years of age.

Birth history-Weight of baby-2kg 800gm.

                      Baby cried after delivery.

                       Meconium passed after birth.

Antenatal-Check up was done on time.

                 -vaccination taken on time.

Post natal-Vaccination taken on time.

Medication history-Nothing particular.

Developmental history-On time

Family history

Maternal side-grand mother is having gastric cancer,

                          grand father-died of cancer

Paternal side-1st aunt-T.B

                         2nd aunt- T.B

Personal history-

Appetite-Good

Aversion-Nothing particular

Bowel-regular,passes everyday,no difficulty in passing.

Diet-Non vegetarian

Dream-Nothing particular

Perspiration-Increased,more on occiput and nape of neck.

Sleep-Sound sleep

Thirst-Not much

Thermal-chilly

General examination

Pulse-120beats/min

Respiratory rate-22/min

Temperature-98degree F

Anthropometry

Weight-19kg

Height-115cm

BMI-14.4

Pallor-Absent

Icterus-Absent

Ear-no abnormality detected

Eyes-no abnormality detected

Head-no abnormality detected

Hair-no abnormality detected

Face-no abnormality detected

Nose-no abnormality detected

Mouth-no abnormality detected

Throat-no abnormality detected

Tongue-no abnormality detected

Teeth-no abnormality detected

Local Examination

Upper eyelid-Dry,white scaly.

Diagnosis-Atopic Eczema on upper eyelids (both side)

Investigation-not done

Differenrial remedies-Sulphur,

                                      Arsenic album

Final remedy-Calcarea carbonicum200

 

18/2/2022 -1st visit-  Calcarea carbonicum 200 is given.

                     2nd visit-     SL

                                       5pills /BD

               

12/3/2022-3rd visit- patient improved

     

Conclusion

Miss Angelyne kharwansah 6 years old residing in Umpling Camp with the chief complaint of dryness of upper eyelid(both side) since 6months was diagnosed with Atopic eczema and was given calcarea carbonicum 200 as her final remedy on her 1st visit and on her second visit no new symptoms were present SL was given and on third Visit she was cured.

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