Patient's Clinical Case history

oG
Sr.No.:
Name: D~lo\r{;u D e..v )LQ,j'\J
Age: (, '2-- Sex: ~ -
Caste: {)~ -'lau-1_\' Religion: K..i~
O.P.D. No.: 2.0 \y;t : J :
I.P.D. No.: {09 6
Ward Dctdhi u/4 u?OA!
, Bed No.:
Address: t,0..-1'4lliif' ,
Name and address of Relatives/Attendant:

Occupation: lcuool..l)i
Financial Status:l.cu.X>z e~
Marital Status: Mcu.,J e.&,
D.O.A.: D-(orc[ i-2>
D.O.D. i-/ o~ / 12..3
Result: Cured/MarkedlV'11proved/ Moderately improved/ Mild improved/
LAMA/Referred

Chief Complaints (with duration):

(D (,<o-U-ti5\I~
© ~lt,16'1i\Z '3~~1Wli\
@ 61~ - ...i~ c\1tte1 r _ S~flce a 'd~ -
6) Jfct1f~n - .S('(')ce 6 'YYl~s.
History of Present illness (Origin, duration and progress):
A~-, to pl'.\.tle.tlt kt- e,p~e.t'lti"1 0a.tl.Ll 6 ~ i-t1 fd)tk
b ~ Lt-s- iCU:t>i ayt, kl- g , ~ clibt,kuli:iv.. ·,v1., lH±i 1
J fb
So UXM a.ll0pcu1Nj t ~ fe-ut &id.ri't iillf.j
~ . 9 d - {..u_ C.o.m.Q, to h . ~ ~ed.ic lr\O~pitQL faJi..,,
~mettt.
Past History:

l) History of past illness - \ pVt,te.N)j on ~i-nc.e, 4 'mM~ , ~vi cl -\ +ve. ·1-n 2-0 2-t
2
) Previous health status - J

Page 1 of 15
3) Treatment/Surgical history - -

Family History (If any specific related illness):

NO tcm'ti~ 1,,-v__bto~ .

Personal history:

1) Diet (Type and Quantity) ~at.~t- : 1U-lf tea( "" Re-ti

MixedN.,- lu.ilc.k : s P-oti -t- i howl~ i
Oi"/'Lf\Vi.,: 2. Rctl-t -:Lbot.cl ~i-t :L (so~ R.w..
Details of dietary articles - 1.1 OQi .

Details of quantity of dietary articles -

2) Addiction- Tea / coffee/ tobacco chewing/ smoking/ alcohoV other

v . .
Quantity ~ / day Duration :LC) Yrs.

3) Sleep 6-=F- h.ou.9t! / n.i~

4) Dreams

5) Rest -

6) Urination : Frequency-, -per .day, ---per

..,. ,l,
night with associate complaints (if aby)
3--Lt ti~ !--2 B!W.-\ ..

7) Defecation: Frequency --- duration --- with associate complaints (if any)
tt'1"l'l.Q. / (N'.:lt 60-W ~>J.J 1

8) Flatus -
. 1
9) Menstrual History ·
I ,\
10) Obstetric History: ·1 '

Delivery-

Abortion-

Miscarriage-

General Examination:

page zofl
p

l) General Constitution: a) Constitution type (Built/Stature) . No.9u'Y\.o£.~ c_

b] Facial appearance N0.9uYla.l

2) Vital Data

Pulse: a] Rate/Min- io IWLtn

b] Rhythm-

c) Tension- N o.J-t.rn.ct..l
d] Volume- f ' - l o ~

e] Arteria~ wall fo_el- Pcupct.b~

f] Doshika assessment- c\ I o l F~ cf> cn"Cf)

Respiration: a) Respiratory rate/Min j_=f. / -rYU-n

b] Type of Respiration f\lodo'il'\.t'Y'\O ~ c . ,

Temperature: 9 ~, E, °F.
Blood pressure: j_4 °/ 110 mrl\ tt1 ,:.
Body weight: b =f-

3) Skin: w-91'.i'ill<\ed 'bl

4) ~ral cavity examination: -

S) Lips: Pi'f\ Kl61tv b.9u,,u:,n.,

6) Tongue: PrYl Kuk

7) Teeth and Gums: NO~
8) Hair- &t.9<.UJ i ~IA., wW tL
9) Scalp- ·

lO)Body hairs- ] N 0~ 11
ll)Nails-
, '

12)Agni:

Page 3 of 15
13) Koshtha: kos.n.t:wt

Atura Bala Pariksha (Assessment of Patient strength)

1. Prakriti: Sharirika- O. l ci I\~ <\,J c:flq-i

Manasika- RaJcu.i Kot, j • '

I•·
2. Sara (Excellence O/tissues)-Pravara/ Madhyama/ Avara
v • , , I ',,
3. Samhanana (Physique)-Pravara I Madhyama I Avara
V
4. Pramana (Anthropological assessment) - Pravara I Ma~ama I Avara
~- <. ..-·-,--r··r'r~ ·.
5. Satmya - Pravara I Madhyama I Avara
v
6. Satva (Mental status) : Pravara I Madhyama I Avara
v
7. Aahara Shakti (State of digestion):

• Abhyavaharana Shakti (Capacity for food Intake)-

• Jarana Shakti (Digestive capacity)- ft-i~ · '

8. Vyayama Shakti (Capacity to exercise)- Pravara I Madhyama I A~ara

' 'y. , \ ;·
9. Vaya (Age)-Pravara/Madhyama/ Avara
v
Indriya Parikshana
' l
Examination of Sensory organs:

1. Ears (Vestibulocochlear Nerve examination)-

I 1,, ,·· I

2. Skin (Superficial/Deep sensations) - Touch -

l
rJ~4~ciol
-Pain- .. ,
!:.eN\a.tiO~
- Temperature -
,,.'I I , . ' I I
3. Eyes (Ophthalmic Nerve examination) - Visual acquity
--= ;
- Visual field

- Color Vision

Page 4 of 15
p

4. Nose (Olfactory Nerve examination)- • ) .

,-J AD
s. Tongue (Glossopharyngeal Nerve examination) -

Srotasa Examination:
1) Pranavaha Srotasa (Root - Hridaya and Mahasrotasa)

Presenting symptoms and involvement of dosha-dushya - }

tvftD
Examination of Respiratory system

• Upper Respiratory tract-

1. Nasal examination
. .
' l NAD
2. Throat examination (Tonsils, Pharynx, Larynx, etc.)

• Examination of Lungs

1. Inspection: Shape of the chest-

1•

Equality of movement- ~IL. fev-laJ-

Rate of Respiration- j_-={- f 'n'\.\--ri

Type of Breathing- .f\\od..o-rr(iYl..QJ ,~ c . . , '

·I

Any other evident findings- Not

2. Palpation: Equality of movement- ,.J Ao

Palpation of trachea- pb.c...a...&..

Tactile vocal fremitus (TVF)- 01"\ kxYtk {.j~
3. Percussion: Resonant/Tympanic/Hyper resonant/Dull
v
4. Auscultation:
N o ~ ~11(.W) va,c.J.L.lcJJt. ~u-nc:L -

2) Udakvaha Srotasa (Root-Talu and Kloma)

Presenting symptoms and involvement of dosha-dushya - NA;;; ,

Palate examination- j

Page 5 of 15
 Tracheopharyngeal examination- N A-{)

State of Hydration (Dehydration, Edema, etc.) N ~ ½~

3) Annavaha Srotasa (G.I.T.) (Root-Aamashaya and Vamaparshwa) .:l_
~ 11:1{ -c:trc\
Presenting symptoms and involvement of dosha-dushya - -

G.I.T Examination -

1. Inspection-Shape and contour of abdomen: Nl\cl c:ltbte.MiCIYl p;lll~

Umbilicus : ToveMed.
Movement of abdominal wall : f'-lo~ t.0t& ~pi -'utl:i()¥'J
Any visible peristalsis · 1'lot P9-Uetlt ,
SkinNisible veins on abdomen : Not pJ..%~
Hernial sites Not

2. Palpation-
p,A- sout , No o~CLn~ ra.lf~

3. Percussion- f'Ulcl ~onCUlf::;

4. Auscultation- f\Jo pai.sto..itil'..- 6ouncl.

,_ ,- ,, i

4) Purishvaha Srotasa (Excretory system) (Root~f qkvashaya and Guda)

~ - ql(\ ~tel'Yl
Presenting symptoms and involvement of dosha-dushya -
<a,.tEf-~ .Jf'~
Large intestine / Sigmoid Colon- Any visible peristalsis-j ~"1~[\ri
- Peristaltic sounds- NDt f7U<.el\L

- Herniation-
Rectum (P/R Examination)

Stool examination-

5) Mutravaha Srotasa (Urinary system) (Root-Basti and Vankshana)

Presenting symptoms and involvement of dosha-dushya - NI\ D

Page 6 of 15
>
J(idney- Palpation (Bimanual)- Not Patpa..b\e,
Bladder- }
Urethra- NA D
Urine examination-

6) Rasavaha Srotasa (Lymphatic system) (Root-Hridaya and Dasha dhamam)

Presenting symptoms and involvement of dosha-dushya - ; NA-n

Circulatory system (Heart) J 1

• Inspection- 1. Shape of precordium - Nor-'31/Bulging/Retraction

2. Apex beat- P£llro..:cecl
• Palpation -1. Palpation of apex beat- To stt't rrt.K\.~ta.e Spo-L-Q-, -f..9t.OYY\ Mt. L
2. Palpation of Car~tid artery- N O ~ 1
• Auscultation - Heart sounds- N ~ S 1 S2,.
- Murmurs- N c YY\..l..l.'i,n'Ll.lJu. f.Jt.oJ.eil:t
Lymph nodes (If enlarged) ..'.. ('Jot fb.l{lctloiQ.,

1 Stanya-

. Aartava -

7) Raktavaha Srotasa (Hemopoetic system) (Root-Yakrit and Pleeha)

Presenting symptoms and involvement of ilosha-dushya -

. f\f'AD
Liver-

J
• IJ ' I

Spleen- NO\: f~o.Jol.L

Gall bladder-

Veins (Deep Vein thrombosis,Varicosity,Thrombophlebitis, etc.) N tr()

Skin pigm t .
en atton / discoloration:

I ,

8) Ma111savah S . ,
a rotasa (Examination of Motor system of CNS) (Root-Snayu and Twak)

L Page 7 of 15
 ~-cmr
Presenting symptoms and involvement of dosha-dushya - <'Ri - -TiiJ
o-:-'1 vi 1, I

Powerofmuscles- ~tm-vl..o: ~ _
Tone of Muscles- Hypertonia (Spasticity, Rigidity, etc.)
½N ~ t:DY1£
- Hypotonia j
Coordination- Finger Nose finger test- j 1
ct..LL

NO~
- Heel Knee test-

-Romberg's sign- f\{)S,W

Involuntary movements - Convulsions/Tremors/Chorea/Fasciculationffics

NotP~
Nutrition of muscles - Wasting/Pseudo hypertrophy/Hypertrophy/Atrophy
NO~ ·
Deep tendon reflexes - Biceps

- Triceps

- Brachioradialis N~
~e,&
- KneeJerk

- Ankle Jerk/Clonus

- Planter reflex

9) Medavaha Srotasa (Root-Vrikka and Vapavahana)

Presenting symptoms and involvement of dosha-dushya I Symptoms of Atisthaulya

NAf)

State of Adiposity (Obesity/Emaciation) /Distribution of fat deposition

10) Swedavaha Srotasa (Epocrine/Sweat glands) (Root-Meda and Lomakupa)

Presenting symptoms and involvement of dosha-dushya -

Skin (3~ g.,, D.Juj

Skin pores ope.tlQ.cl

Sweating p.AQ.l.el\.t .
11) Asthivaha Srotasa (Skeletal system) (Root- Meda and Jaghana)

page sofl'.
 . g symptoms and involvement of dosha-dushya -·
presentin
;,
Gait- ..:::
t)Jctc!cUJ'(1Q q ctl!-
V
o sw,!f\f\'7] 0 be.At .
posture- 110 ""'-""""' -- J

)\1obility- ('-10~

Deformity- rJo-l ruVJ ·

t Porosis/Osteopenia/Osteomalacia
•
Fractures- Not
,1 ..
12)mOJJO
vaha Srotasa (Bone marrow) (Root-Asthi and Sandhi)

Presenting symptoms and involvement of dosha-dushya - I\J M

Joint tenderness J . ·'··

Swelling P.Jt.tSe/\.t in bot¼ ·
Joint Crepitus '· · •

Range of movement Wt~.k.te..&,

13) Shukra-Artavavaha Srotasa (Reproductory system) (Root-Shukra,Artava,Stanya)

Presenting symptoms and involvement of dosha-dushya - }

Examination of male genitalia (Penis,Scrotum,Testes,etc) .- , N f\D

Semen analysis - 1

Examination of female genitalia (Perineum, Vulva, Labia majora, etc.) - ..-

PN examination - ..-

PIS examination - 1

Breast examination - -
l4) Manov h s · ·
a a rotasa (Psychiatric assessment)

Mana (Examination of Manasika bhavas like Thinking, knowledge, etc.) -

.

Page 9 of 15
 Buddhi (Examination of intellectual faculties of mind like intelligence, lllellJo
patience, etc.) - } ty,
No-'t.ma.1 ' .' i j
Appearance and Behavior-

Speech - Mute/Flight of ideasillysphasiaillysarthria J

t-J(TD
Mood- Euthymicillepressed/Anxious/lrritable

Thought content - rJo3t.n'\OJ.

Abnormal beliefs (Delusions, Hallucinations, etc.)- Not p.tue.vtt-
Assessment of Cognitive state -

• Level of Consciousness - funbC.to Ub

• Orientation- tJJe1\ oJc..iuu:e.d to time 1 plo.u.., &; peJt.i~Y)

• Attention and Concentration - l\loJLma...l

I I
• Memory- If\:ton:

• Intelligence - No~.
Laboratory investigations: Not deY\..Q....

_Quantlli'_ Consisteng_ Odour

Stool Colour Sama/Niram,
Urine
Sputum
Vomitus
Sweat
Menstrual
blood
Others
-
Other Laboratory findings and relevant investigations like X-ray, USG, etc.:
:t I ~/1i3 : y..-
JtrJ.W,.
0
•
5/o- ~et'Wtlilirt c ~
Sufficient Extra space needed here

Page 10 of 15 :

J
>

LakshanaSamuchchaya Dosha ' Gu11a Dushya · Srotasa Sama/

Sr, ·
involved/
(Sign and Symptoms) Nirama
Ams/tans
ha I

.
Kalpana
·•
-1. \5~2-totl~ __,
I Sf~ r~ '

2. -~ cfi~ctl
- &trJ<:4ctt
3. s{[~1a qm -
4. <fiF~ JTf7I crrn - i;-\'~?5'Ht WP[
5.
6.

Differential Diagnosis:
Concerned/Related Diseases- ?snW\\<1 , .1'.ff~JI <i QI('\
Provisional diagnosis- C\ \ (I ' '

Final diagnosis- ..2-i M.:1 I" a:Gi

- l,r ;

a1<1idtsh1-<-qit: .,2~ .2-\faff.:llctS~a1"/

Nomeeelature of Disease Criteria for final diagnosis:~i-?.ul\~?:!IS"I-Jl: II ,
Type/Subtype C.-q. ftj' · ?..¥J3-+J

Stage of disease (Saama./2Viraama/Acute/Chronic/Episodic)

Nature of disease (Mild/Severe)

Nidana Panchak :".' _

1. Nidana (Etiological factors):- ~ ) ~T\ci I 3fcYQ') d'lut J ftim I an ~o1

2. Samprapti (Pathogenesis):• a? fa<¾"l Ir.\ cp:ru~ f .<; fodlT -~.: I
• General:- (c\('qt.ifr\ oUl~\'6i ~ ~16fl 1if{ .2-t~~~\'-c.r.Zk;)

• Specific :- .. ,-.=a, . - TI T
I ~ -i'1<->1-. 4' Qlo ~"',,'1 -9 ){1qW1-rl q CYJZjfO i(lri'
Samprapti Ghatak (Constitution of Samprapti):- J-tr:Jm crn-f

• Dosha- <fief
Origin- t\cfo.l~I 'Z.w~
Page 11 of 15

L I ~-
 • Dushya- 1 &t l-'Af Rogamarga-
• Srotasa- ..z.i-iqt, 1 Place of manifestation of disease-
• Srotodushti Prakara- Stage of disease- ~c -
• Agnimandya- ~miii il( Doshika nature of the disease-
qjfrj--~
• Aama- Aggravating period of disease-

Remission period of disease-

3. Purvaroopa (Premonitory sign and symptoms):- -

4. Roopa (Cardinal sign and symptoms):- \3§1<-t c5-I I'3 di

..2~

6'-\'!m - I

5. Upashaya/Anupshaya (Aggravating and relieving factors) :-

-:.~ ,,,
<S1~-.Y1~1~
6. Upadrava (Complications):- _

7. Arishta:-

8. Sadhyaasadhyatva (Prognosis):- ~-c:..e_Q

Treatment Protocol: ~---,--'-+---,---,- .,--9-: i?-:. ,,

©~\<1:+--zi1L1.c;fuj : ~'c, """9~ .-!ci""<ll~O'\ t
Principle line of treatment o¼l~Sd)q ut\ fuu(i\ ~16'L\lo'i.NL\~·1~cl~ \/
(A.rf. t.?. / 1)
Drug of choice ·

Shadvidha Upakrama (Six modes of treatment)

1. Langhana {Therapeutic fasting) [ insert check box in front of each Karma as

shown below]

A] Shodhana (Biopurification) B] Shamana (Pacification)

i) Vamana i)Deepana

Page 12 of 15
 I~
ii) Virechan~ , ii) Pachana I
iii) .Basti , (~ 11.1 ~f) iii) Upawasa [Fasting)
r
iv)Nasya iv) Pipasa Nigraha [Restriction of fluids/
v) Raktamokshana
v) Vyayama /Exercise/

vi) Aatapa Sevana /Exposure to sunlight/

vii) Maruta Sevana [Exposure to fresh airl

2. Brimhana (Nourishing)

3. Rukshana (Drying)

4. Snehana (Oleation) v
5. Swedana

6. Stambhana(Styptic)

Treatment given:
I • • r I 1

Medicines Dosage Time of administration Anupana (Vehicle)

2.-'2..- '2-

2.o'r'\1\1.
+
:i.otY\.l

2...-z. - 2..

®I ~ Lll-uii

0 ~™ (J'.)it{A. o-tf,l6li-'-1'l.\01
@lm)t, ~11<1 't tu- fi:£1 }l._air
U)
Add sufficient space here'-' 1

@) Uil~ ~r)ef1 t.Ditl,,.., ~Bfe:l~..t191' I~

PathYa-Apathya (Do's and Don'ts)

Pathya-Ahara(diet)- - -

Vihara (activities)-
1

Page 13 of 15
 "ii

Apathya-Ahara(diet) J ~ J Q\<1~ ~lBZ,. ~ft,t(i ~----lltR

Vihara(activities)- ~bl¼~ 1 ?l(h-tj15iifD1
1

Follow up record:
Date Symptoms Treatment Percentage improvement

1
12.10<..-J 2-3;, ©\ J ~ !IJif I -f _
•I tt+ 'l. 1 ').. J 3 J Lf I S.; b J ,
® J~ Cfl~(1f
tt+

let !o~/j.3 (!) J9l2loll'1

@ J~
~r ~- 1 2-
1 1
~
1
l-1 S, 61:f-
1

t-+

Page 14 of 15