Personal Data

Name - MR ABC

Age- 14 YR

Gender- MALE

Religion- HINDU

Nationality- INDIAN

Occupation- STUDENT

Married/Unmarried/Divorced- UNMARRIED

Contact details-

Address- VADODARA GUJARAT

 

Chief/Presenting Complaints

Location: EAR

Sensation: Pt came with complain of tearing and throbbing type of pain in ear after exposure to draught of air with sensation of humming noise in ear

Modalities: <noise, <sleep

Concomitant: noting specific

 

History of Chief/Present Complaints:  ODP since 3-4 days

Family History: noting specific

Gynaecology/Obst History: NA

 

Physical General

·       Appetite: good

·       Thirst: 1lit/day

·       Craving: not specific

·       Aversion: not specific

·       Addiction: NA

·       Perspiration: moderate

·       Bowel: regular

·       Urine: no c/o

·       Sleep: disturbed due to pain in ear

·       Taste: NS

·       Tongue: NS

·       Thermal: chilly

Mental General: irritable due to pain

Physical Examination

·       General Appearance: lean and thin

·       Vital Signs (Pulse/B.P./Temp/RR): 78/Min, 110/70mmhg, 96’f, 16/Min

·       Weight and Height: 50kg, 149cm

Systemic Examination: NAD

Differential Diagnosis:

 ? Acute otitis media

 

Laboratory Investigations (If any)

Final Diagnosis: Acute otitis media

Totality of Symptoms

·       Throbbing pain in ear

·       A/f draught of air

·       <loud noise

·       <sleep   

 

Repertorial /Non-Repertorial method: non repertorial

 

 

N

 

Preion (Rx), Dose, Repetition: BELLADONNA  200 1 DOSE

FOLLOW BY SL 30 BD FOR 3 DAYS

Management (If any): 

Follow up:

1)    1/4/22 – BETTER IN PAIN / RX SL 30 BD FOR 3 DAYS

 

2)    5/4/22- NO NEW C/O AND OLD C/O ARE BETTER / RX SL 30 BD FOR 3 DAYS

 

 

3)    9/4/22 – ALL C/O ARE BETTER NO NEW C/O / RX SL 30 BD FOR 1 WEEK

 

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