Gujarat Ayurved University - Jamnagar

Shri O.H. Nazar Ayurved College, Surat.

Streeroga(Gynaecology) Examination Form
PARTICULARS OF THE PATIENT:

Name: Ki'jal Hitestbhai shah Sr. No.

Age: 3S e a Date: 22/1/2022
Caste: OPD No. 22126
Religion: i'ndu IPD No. tI o S
Address: Ad hau,Swat Bed No.

D.O.A.: 22/ 11/20222

D.O.D.: 29/t/2o22
Occupation: HCuseuwife Diagnosis:3 R
Education: IcT pcAS Result: Tmprom e t
Socio-economie Status:
meelt um
Marital Status: wsAI eel
PRASHNA PARIKSHANA (HISTORY):

Chief Complaint (with Duration):

Heavy bleedrig duirg meuses iute Cyele
6mcu tti
abclominal pain cdlusig m e s e s since
.

History of Present illness (Origin, duration and progress):

Patrieut haui t/e heoy meuses aleu oit ablcuuiul
peuin Siute 6 meutt
mcolicune but she diclut get
atieut took allepcettuy veelit h e a e u t
Aliivek 60 pt. Cene fer Cyut
Past History

Medical History: Alopeutly neoltcie fakeu fe

ACLLtl
Surgical History
ramily History (If any specific related illness):
Menstrual History: Age of menarche(FMP): 4 yean

Present Menstrual Cycle: Regular / Iregular

Duration Interval S
20-30
day
Quantity Py|day
Colour Odour ( Painful/Painless
Character of flow: watery/clots//other

L.M.P.1s/u/a02
Marriage Life: 1S yeos
Obstetric History:
G (Gravida) - 2 P(Parity)- 2A(Abortion)- L(Live)- 2 D (Death)- o

Male Female

Total Delivery
Nature of Delivery: Fullterm Preterm Post term

Normal Instrumental Surgical (LSCS)

Last Abortion:

Last Delivery: yes ao

Coital History: Frequency of intercourse Dyspareunia: Present/ absent
Contraceptive History:
Personal history:

1) Diet (Type and Quantity)

Mixed/Veg-
Details of dietary articles Rot, Satyi, Dal, Fuce, buttetulk
-

2) Addiction- Tea/ coffieel tobacco chewing/ smoking/ alcohol/ other

Quantity _ / day Duration 2 o Yrs.
3) Appetite (
4) Sleep N
5) Urine

6) Stool (M)
 GENERAL EXAMINATION:
Built: Obese/ Avruge/ Thin
Face: (N Tongue: (M) iye: (N) (
Neck: Extremitie: ( Specific:N
Weight:2 kg Height: /5em
Vital Data:

Pulse: 72 /min. RR: 18 /min. BP:20 mm Hg. Temp.: 2 / p HR: 76 /min.

Prakriti Sareerika I tUd Manasika -21&7t14

PER ABDOMINAL EXAMINATION:

YONI PARIKSHANA (PER VAGINAL EXAMINATION):

(P/S) examination:

Aavarta
Appcarance Discharge Specific
I"Aavarta: External genitalia Notmak
Vagina
2" Aavarta (Cervix): Shape Cyulindaical
Size Notmal
PVexamination):
1 Aavarta: Vagina NoEmCe

2 Aavarta (Cervix):
Consistency: m
Mobility: trueely movable

3 Aavarta (Uterus): Shape (

Size
Position utivers10u

Consistency: ()
Mobility MOVable

Fornix Right ( Left

No tencdernes
 Parikshana (Breast Examination):
Stanyavaha Strotas

Left
Breast: Right
Noemma NOewal
Size
Shape: Crtla Cintul
Consistency: Sott
Discharge: -t
Nipple
Lymph Node Examination:

General Investigation:

Urine other
Blood

Hb mldR N
wine )
Bloeg%0as r8+ve

Specific Investigations:

1. Garbha Vinishchaya (UPT)

2. Ovulation Study-
3. H.S.G./S.S.G.

4. E.B. (Endometrial Biopsy).

5. FNAC
6. Vaginal Smear / Culture -

7. Pap test
3. U.S.G. Bulky uterus witt sub mutous tibreId
9 Blood Examination Hormonal (Specific)_
12M xly i
10. Laparoscopic/Hysteroscopy examinationn- 10/9/22)
Semen analysis: Total Count: .

Actvely motile: Sluggish motile: Non motile:

Abnormality: Head Body Tail
Pus cell:
 Samprapti Vivechana (Etiopathogenesis)
(Symptoms present in patient during clinical examination or investigation)

Dosha Lakshana -
Vata-B Ck batrn, (o4t þoun, abdOutnal
Pitta -
heon vy meusey, blwt ning chesf
Kapha-
Dushya Lakshana Rasa-
Rakta- 37fa H l
Mansa
Meda -
Asthi
Majja-
Shukra

Upadhatu Stanya-
Aartava Exte1 v thlgulah uesey
-

Mala lakshana Mala-

Mutra -

Sweda

Strotas-

Stroto Vaigunya -

Atipraymtti/ Sanga/ Vimargagamana / Shirajagranthi

Nidana Panchaka:
Nidana (Etiological factors)

Purvaroopa (Premonitory sign and symptoms):- Back þeum abdomi nol ms

Roopa (Cardinal sign andsymptoms) 31Tdq 3TtAJgT

UpashayalAnupshaya (Aggravating and relieving factors):-

Samprapti(Pathogenesis):-AGI4`Ia4
aTT
Upadrava (Complications):

Sadhyaasadhyatva (Prognosis)- +Fqau-y

Sapeksha Nidana (Differential Diagnosis):

371
Chikitsa Sutra (Line of Treatment)

Bahya (External)-

Abhyantara (internal)
ge2uT-3g
Shodhana: (Biopurification)

TDA
Shamana: Pacification

Treatment given:

Date Symptoms Treatment

Aabhyantara (Internal) Sthanika (Local)
with Anupana, Kala and
Matra
Heauy memesOTauorde (2-0
P2//to99 t+) Nau
abolouiual padegeg)-s9m Vaus qswahaia
44)
fo 8 days
ADR
wte

| {12|2 022 Hea ey meuses

t) as Ccebove as chove
aloel oua bau
+)
 Pathya-apathya (Do's and Dont's)

Pathya- Ahara(diet)-
377E K

Vihara (activities)-
Meolicatt @u
Poober pest
Apathya-Ahara (diet)
31 , HTO, 5 , tGTET , J 3/T6

Vihara (activities)-

31c211

Signature of Student Signature of Teacher