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
