CASE TAKING PROFORMA CHRONIC CASE

DEPARTMENT OF :- HOM. Metria Medica

Physician In-charge :- DR.Sindhu Suryawanshi

(A) Interrogation :

OPD no. 4666/476571 Date of Examination :11/12/20

Name of Patient : Laxmi Singh

Guardian’s Name :

Age : 58 Sex : female Religion & Caste : Hindu

Occupation : housewife Address : Barkhedi kala, bhopal

(B) Chief Complaints which is purpose of consultation :- Distension of abdomen &

flatulence since 1 month

(C) Present Complaints (symptoms recorded with regards with regard to : Location,
sensation, modalities, concomitants, causation and duration) : -
Duration:- 1month , causation – N.S , Modality- L- 4pm, after meal
Pain in abdomen- stools – infection, unsatisfactory , Cruetation – no relief
Likes HOT food & drink other cfo – sweeling of RT. Leg – pitting oedems

(D) History of Present Illness :

Onset : Gradual

Progress :

Treatment adopted : Allopathic

Result : NO RELIEF

(E) Past History :

Childhood to adulthood : CA Cervix – 2013 get hystretomy done in 2013 H/O swelling of
gland side of neck in 2017

(F) Family History :

Father : H- of cancer

Mother : H- OF cancer

Other members :

(G) Personal History :

- Mind & disposition : fear of alone, dreams of husband married to other women ,of
running her children
- Married or single : married
- No. Of children : 2
- Health of children : healthy
- Marital relations : death of husband in 2012
- Diet : veg
- Desire : sweet, heri
- Disagrees : oily causes indigestion
- Thirst : thirsty during meal
- Tongue : clean
- Taste :N.S
- Salivation : Normal
- Perspiration :on face & lower extremities
- Stool : D2-3 , ineffestnal, unsaticfaction
- Urine :D5-6 NO, NAC
- Bathing : daily
- Covering : likes covering
- Sexual relations : ----
- Dwelling place : pakka makan
- Appetite :3 meals/day
- Aversion : N.S
- Habits / Addictions : N.S
 Tabacco :
 Alcohol :
 Coffee / Tea :
 Drugs etc :
- Thermal reaction : CHILLY
- Skin : healthy
- Sleep : sleeplessness
- Dream : sneeets, puri
- Tendency to any Pathological conditions :
(Haemorrhages, Tumours, Warts, Cysts, Polyps, Moles, Susceptible to etc.) –
swelling-on RT.leg RT side of neck

- Restlessness, Prostration, Weakness, Sensation, Trembling etc. – n.S

Others discharges : N.S

(H) Gynecological History :

- Menarche : AT 14 yrs of age
- Menstrual Cycle : regular, profuse
- Leucorrhoea : N.S
- Menopause : attained at 28 yr (hystractomy done in 2013)
(I) Obstetrical History :
- Pregnancy : G2P2A0L2
- Labour : FNTVD
- Delivery : N-9
- Abortion :N.S
(J) Observations :
- Behavior :mild
- Mode of talking : confident
- Complexion : fair
- Built / Nutrition : obese
- Colour of face, eyes & skin : face wheatish, skin- wheitish coulour
- Decubitus : sitting
- Expression / Fancies : smiling
- Anything special related to Mind & Disposition : dictatorial

(K) Examination :
1- General Examination

Anaemia A/N Cyanosis A/N

Jaundice A/N Oedema A/N

Nails – Clubbing A/N Koilonychia A/N

Hair : BROWNISH Neck glands Not enlarged

Neck veins not enlarged Teeth clean white

Gum healthy Tongue 4cm

Smell from mouth N.S Hearing proper

Pupils proper reflex to li Pulse 76/min

Temperature afebrill Blood Pressure 140/80 mmh

espiration 16/min Skin in general

2- Systemic Examination
A thorough examination of the affected system done under the following heads :-
(a) Inspection : distension of abdomen
 (b) Palpation : non-tender , no added sound
(c) Percussion : tympanic sound on percution
(d) Auscultation : N/A

Brief examination of other systems

(L) Laboratory Investigations Previously done : NAD

(M) Laboratory Investigations advised : 16/11/20 – FATTY liver, thick- nealled

urinary bladder PVR urine – 60cc, gaseous distended abdomen

(N) Provisional diagnosis : DYSPEPSIA

(O) Differential Diagnosis : -PEPTIC ULCER

-GASTRITIS

(P) Miasmatic Diagnosis : SYEO – SYPHILLITIC ( PRE-DOMINANT)

(Q) Prescribing Totality : -INTROLERANCE OF CONTRADICTION

-ANGER.VOILENT
-DELUSION- BETRAYED SHE IS
-DELUSION- PERSECUTED HE IS
-DICTATORIAL
-PERSPIRATION ON FACE
- RT-SIDE
DESIRE-SWEET, CHILLY PT

(R) Analysis & Evaluation as per Dr. : M/G – DICTORIAL

- Introlerance of contradiction
- persecuted, he is

P/G – perspiration – on face

RT.side
Desire – sweet
Chilly pr
Particular distension of abdomen

(S) Reportorial totality : 1) MIND – ANDER - VOILENT

2) MIND – CONTRADICTION- INTPLERANT OF CONTRADICTION
3) MIND- DELUSIONS- BETRAYED THAT SHE IS
 4) MIND- DELUSIONS-PERSECUTED –RE IS PERSECUTED
5)MIND-DICTATORIAL
6)FACE – PERSPIRATION (7) GENERAL – SIDE – RIGHT
8) GENERALS - FOOD & DRINK – DESIRE (9)GERNAL-HEAT-LACK VIRAL
HEAT

(T) Reportorial result : LYC – 9/23

NUP-V – 9/22
AUR – 9/17
CHIN – 9/17
SIL – 9/17
ARS-9/14

(U) Final Selection of Medicine with comments regarding selection of remedy :

- LYCOPODIUM
On the bais of totality of symptoms & repertorization

(V) Prescription :
RX
1) Lyco 1M / OD/ 2DAYS
2) SAC LAC 30 / BD/ 15 DAYS

(W) Follow up :
AFTER 15 DAYS