You are on page 1of 45
jeg al . | COCbbE | No__01__—— Sumig.eriy dept ed No. = Date of Case Taking COPD /IPD NO. ___—_—__________ ee Age: a1 yecnia Sex Male —__ Education: Bom = Occupation:_Jofp Religion: Hind Veg. / Non-Veg. / Eggitarian : Jeg National Status Peli Issues - Socio-economics status : Gino ch Real 1 Roa. Bayles) Chief Complaints : with ODP asymptomatic beborie 2 years Address. fatien! cvas Then he developed the complaint of imimedsed Fatequency ‘of Stoo! Since 1 yeorr, he developed complaint of blood in stool with cating pain in left hypochondstiue aegion CONCOMITANTS Ww (MODALITY) L Ss (LOCATION) (SENSATION) Ce cutting pain <2 hours hee in Abdomen after eating | Lying down Hypochonddiiac xegion > motion S00! - yy = ay, SIN I yea, Blood in ‘Stool. PASTHISTORY : pio} speihic FAMILY HISTORY ; (in table form by own) No} specibic PERSONAL HISTORY : Habits / Addiction: — Not Paiésent Appetite 2-4 chuppati | meal Dosire Sweet Aversion Nol speci bic Agg/Amel- Nlol Specibic This: 10-12 Glasses! day Urine: Diy °9%o Stool: Ny. - 4-5 /o po Sloop Refsjeshing Dreams : Thermal State: Hol Patient Life Situations : . Oracle a i il a el ita al al 8 al al al al al a eS al ach 2S. 4) Bloatiog Presenie of blood a SYSTEMIC EXAMINATION : cvs : RS: CNS or LAB, INVESTIGATIONS : AdviceFor; 7 cac 1. Radiology 2. ECG. ETc Urine Report : ANALYSIS OF SYMPTOMS Mental Gienestal : ©) Restlessness Physiol Gienesral ~ ci) Desiove boot sweets Si = (2) Blood in stool G) Tnoreaseel Frequency of stool 4) Hol patient ulust : (2) Cutting Pain in abdomen in teFy Physical ot L hypochonasiiac se9/on {2 has afier eating, Lying down y ~ motion @) Bloating of abdomen EVALUATION OF SYMPTOMS : a Cutting Pain in abdomen left Hypochonaniuc »tgion 4 ahs afler eating, Lying down + motion (2) Bloating 6f abdamen (3) Tnoreased Prieqwency of stool (uy Pnesenre of blood tn stool (5) Desine Fox Sweets (6) Resiless- Oaytime. E'S 792s PRANARAAAAAR ADA s Me -ymyaing Shy. rok smu coy Mra, > StUtufro9) (x) ‘onda BvTINIS 40 dnowo. bis GY Burfi Gureym * ruiya ~ NIWOOBY (oD ‘bts Bg Fatyo Guna Buyin“ NIVd - NILIOURY (e) Burky “prepuowodty ‘Nig - NIWOGBY (3) °£95 & 1a}y0 Buywa - oupuopodhy wiv ~ NaWOGRY (by th 64 -2WHRIG “ssasay - ANIA (2 in By “SP2es -Sayisza ~ HVLAOLS (52 sro - GJ. hogs -TooLs 085- Gd = 12 YOHOU’ Gum? iy -NIWOGSY (© 505-83 - 1477 PiRPUSwOdY Nuys -NaWODRY bhE pss NOLNALsiG - NILOGBY () ON 39Vd HLM NOLLWOIZINENS 12222229222292222222222227 > Dysenteric soo! renewed each Hime by the leasi food: om tints Telly. Vike Stool. Canine hunger with desisie Fox sweels < afer eating anger > doubling up, haid prtssute, lying on back Mental Symptoms Exisemely ismituble ~ Becomes angziy cohen quesHoned. - Restlessness during day- me | a ih a Follow up Frequency steduied and no blood in Stool PL is impsiove Precription Ry Sac LAC? 44347 days “SAC LAC. U9379 clays RESULT : pt ig, im proved Po RNR ee a ee ee ee ee ee ee ee Oe ee Oe ee hl " Chief Complaints = wir OOP She develoes the Aiffioly im Seeing image, LeHer om cing - bined espediotty in Kei ext - she cas see Meneild - fain & medness in [eA ext ; at medial fanih oasing aratering of ye 4 copesene while Seeing tor side - Shades KE AN tmouble < by SMOkC. dust. SOUP, Puatide PY SHIA gid at} > EON cain : ; MUU tected PAST HISTORY : History of Maluntic bebome 4 Yor cuned by alloeatnic Treatment FAMILY HISTORY : (In table form by own) Relation AINE! Sut Poxing fiom | Probate couse of Drath Father x Niatunal Mone ve Na\uxed Boromner “ Diaheles methitus _Sisior 3 Divbeles mellitus PERSONAL HISTORY : * Habits / Addiction : Jeu. “a Appetite 2-3 chappalis! Meal Deoieaed during conyzra » Desire Nol Specibic Aversion Nol Specibs© Agg/Amel ¢ (old ait 1 UAT alot Thirst: g- 10 glasses! “ay Urine: Oyny > HS a Stool: O/ny 1p (eonslipated sine S yrs). Sleep: Sound . Deer z Dreams: Nilo any . ‘Thermal State : Chilly CAN complaints we genoratty 4 by cold ind ) Life Situations ; Forin) cannot atte to do her day 40 day activity due bo difFiaty in Steing UW mone Sinaining (ouse Painful condition. diss — ins iJ MENTAL SYMPTOMS : Mind » basily gets emo ional Gets very mud anxious member ave suffering Pe nommal shings bebore epilepsy - when her child O21 © om any {nouble- Forgets easily Not likes 40 being alone dof hex Purtents are not ative Coie yhai makes hee ery offenty CHILD HISTORY : Bit: 4 child C1 gint) Mother State during Pregnancy: p\os\mncal Mile Stone development ; G\oou Wiovaccinaion Compleré FEMALE HISTORY : Menstrual History: No ony Menarche: 1G Years. LMP : | Duration: 3-44 clays tooma TTT Menopause : G14 Pa Ao Nowmal delivery Obstratic History. GENERAL EXAMINATION : Giood Wiheatis Built ‘Complexion lust, hair Head! Scalp: . Noma! Conjuctiva ; Pale Tongue: Pint Teeth &Gum: Pink Swelling /odema: Not Present Skin / Nails : Pa € Heignt: 5'u1" Weight: 5@ \KqS- Rotlexes: Niosimal VITAL DATA: . Puce: sel min. Temp.: As F OTHER OBSERVATION : Sligh 84 Jook Palo, anxious look clout her complaints BP; IROlko mmHg Rate: imino ' =>. Cicenieiens ‘SYMPTOMS : qeek eye can't See object Properly PAIN U siedness pohich is < by Aust, Seeing down smoke @) Gels very much anxious g cortied cohen any Farily member iy in trouble G) Long - Lasting guief about theist ponents are No} alive wnic makes her oftenty cry. (4) Vleakness of memory easily forgets normal things. (s) & -by cold ai blind. — > = Weim cid Open Airy Differential Diagnosis: Glutomu , ReFoiucive Ov10%1, Catanuct Provisional Diagnosis: Couaucl, Giluioma, Hy poime}sopid Final Diagnosis: (ajoniact | Family | Histomy ‘SYSTEMIC EXAMINATION : CVS : Nod reauirted RS: Nome Negus . eNS: Not ~eduined GIT; Not r*eauired LAB. INVESTIGATIONS ; a ‘Advice For cac. 1. Radiology Nol weauibted 2. EC. Urine Kot a\eauinr edd SRETS. Report: . norimad ANALYSIS OF SYMPTOMS : Menial General - Gels very much amxious t @osmied when any ly membor ere In frtouble cebout that her parte See menikes her ony aflenty Mosumect hings, Feaamil = Long Lasving grit Not ative eohidy _Wleakness of memory . castly Forget Physical Groner - 4 by cole wind y by wus ads Physical parriweot In let Cae cand see Only objech, PooPery, with paint neamess» ehich is < by dusy by sting down, Smoke EVALUATION OF SYMPTOMS : 1) Tw tefl eye. Can't see any object Propeny with Pain & stedness wich is *« by Aust by Seeing clown, Smoke, (2) Gets very much emxlous Y worried cohen any fam ute in double. 3 “y femvee (3) Long. Lasting garief about that her paients are nod cls makes het Ory ofienly. (4) Weakness of Memory, easily, Forgets “ionnanid gg al ts) AN, dhe @mplinis sel. stele : ag rb al (©) (NS# Pation. 1 ae meerveornroccenretcerceeroneeses PRESCRIPTION : Rx, CAUSTICUM - 200. © dose SAC LAC - Ux347 days: AXILLARY MEASURE : ) Avoid bending over to parevent Pulling exista -Paiesswrt on eye. (2) To seduce xisk of infection, avoid sola on using 0 hot tub . G) Dont expose youre eyes to inmitunts. (aw) Dont sub eyes. FOLLOW UP: Sight imesiovemen) Ry : SAC LAC in vision. Fain Decreased. Por Ralient Lal RESULT: Pyhjend 15 imPrtov clowsterier L eoneuses Ry, SAC TAC GAN hogy 0 * onc LAC: Upant elegy OEE UU UU EOE EEELEE ESE % Sung ety Dept Date of Case Taking 30. OPD/1PO NO. Mame! x7 Age: 40 yeuris. Sex: _Femey\e Education: _*1'N_Slendastel_ Occupation | __Aetich 5. 1G Religion: _ Winey Veg. / Non-Veg. / Eagitarian | V6 Ge National Status : naian. Je - Socio-economics status : Chief Complaints : win ove Folin} cous asymptomatic bebore 3 yeares Then after developed Lhe tomplain of Pain over lave badksjon and Right eq Cespecially knee Joint), segion Teuning ype of pain Right beg especially Knee Joint PAST HISTORY ; Disease Age Yeux in cohich i+ Teatment | guy ] Z MASI! CSO Calunac Bebo 3, yeasts in Allopathic Carer RA eye Taken | Huseclomy, | Bebore - 35-35 yeany Altopetie | cated! e rm Taken [Ts FAMILY HISTORY : (in tabie form by own) § tr Baother- Disbeles Mellitus SG fy Stool: Drny - Ty Sleep: Sound Dreams: Nod remember ‘Thermal State: chilly Life Situations : 1 MENTAL SYMPTOMS : Mind + Fea of being alone _____ Avtssion 40 _Lompany No inisiest im any evortke — Wleale - memosty — (onfused. thoughts 7 CHILD HISTORY : Birth: Rlonmal Mother State during Pregnancy: Healthy Mile Stone development : Normal H/o Vaccination Done as Per schedule. Ubecidicccccced FEMALE HISTORY : Menstrual History : Menarche ; \3 Years ump: 21.11 [1s Duration: 4 days Quantity: Sm. pUbdidi Morons: - 52 Yeo batts: 612 Ps Ae GENERAL EXAMINATION : Built: - Well built Complexion: - W\hile complexion Head / Scalp Conjuctiva: Pinkish Tongue: Pinkish Tooth & Gum: Hygieni& Swelling /odema : = skin / Nails: Pinkis Height: 5!" Jim Weight: 5° kgs Reflexes: Krome 1S. S.fi veddideeed Ci a a 2 a VW 4 fi anal Beene ae ‘TOTALITY OF SYMPTOMS : : t4) Severe Pain in lower Parr of bade 4 Aewting in navare and also in > (ay Heaning \mpalaed in wighi eer. (3) Acuity CQ) & - Standing, walking, hot ais, fight ys by comm food t% artinks. (S$) Avorsion to Company. Fean of baing alone (Weal memory i DIAGNOSIS : * Ditferential Diagnosis: Sciatica, Spondylitis . Rheurnatisra — Provisional Diagnosis: Sciatica. Sponayli}is. ‘ Final Diagnosis : Sei. ic, MIASMATIC EVALUATION : SYSTEMIC EXAMINATION: nlo} sPecibtc. cvs : RS: cNs can LAB. INVESTIGATION: CBC. Wh: 12-5 gmy Uine TE "4200 Cells /mm3. 2 ECE. ETC, Report ANALYSIS OF SYMPTOMS : Mental symptoms + 02) Fen of being alone aversion fo tomPany (2) Not intorested in any work G3) Weak memory. Physical Grenerats © 1) Desire for Sweets Physical Panticalus: 2)Sevore Pain in Lower Pant of back cohich is ——— fearing type of Pain @) Hearing impat ment ) Right Leg pain especially knee Joins (a) Acidity EVALUATION OF SYMPTOMS : (2) Severe Pain in Lower part of burke which is Stabbing & dearing in nalure 2) Heong Impatined in Right evr. (3) Aversion 4o Company Few of being alone ca Right Leq pain especially lance Joint 5) Adidlity cc) (+ by Standing , walling hol aist ‘ y > by coum food Y ddtinis. = aa ahaa tie af oi DDD LO. DDD) Ube ccd codied a eee —— ©) HEARINor- IPYPAIRED. svignt - Pq -322. RUBRIFICATION WITH PAGE NO. : () BACK. PAIN: Lumb, pulsating- fy, (2) EXTREMITIES - PAIN- Lower: back. (4) STOMACH. HEART@DRN fy - 499. CS) EXTREMITIES PAIN . Lower Limb, Sciatitu. ¢ (6) EXTREMIMES .- PAIN Lowes Limb, Seiatita, Ilalking (1) EXTREMITIES - PAIN- Lower Limb, Sciatica. silting amet () MIND = COMPANY: aversion fo Pq -I2 (MN NIND = FEAR s alone of being Pg - 43. GROUP OF SIMILAR DRUG : Q) Lytopedium - loys (2) Nux Vomica - ay, (3) Sulphust- ®/q, (5) Caleaea ceore - Tvy Loe mac 43, ) Palsatitta- 473. PRESCRIBING INDICATION O1 Ly cop ociarn B2APAAAPARAARAANRE FE RRR AMO H HOO ED vudd? ee ee a ee ee a Ry AXILLARY MEASURE : Take Physiotherapy UO exeteise Pass urine on uigt, do nol Guoid Stay adive dori} x14 bor fo long” ‘Ampsiovement in th fomplain of Pain All complaints Re ane arelived “SAC UAL Hxaed days Putient dmproved SAC LAC- WAS MS Improved Ri ope ac. uranadauas resuit: Polient is imPxoved. 2 yay te vintenl, , ete etait ate. ae Ge. sa) ] ~ dé oedddd —Sunigerty Dept : No___ 04 Date of Case Taking Bed No. OPD/ IPD NO. s Name: x2. Age: GS yeans Sex: _ Male Education: i'M sic Occupation: _Parintin 4 Poses s_——§£@ Religion: lined Veg. 1 Non-Veg. /Eggitarian: Neg. _— National Status :__ “Indian Issues: Socio-economics status Se Address: News plillkanth Cinema. Rajkot Chief Complaints : With ODP Sof Vision in Right eye sine 3-4 months - Pogsiessive 1055 and bludk spol on both eyes : Pattee beborie 5S yeans, then develops comelai of Atabeles and Hypeiiension 7c PAST HISTORY : TPschemic hawt). Disease bebore 5 yeurs FAMILY HISTORY : (In table form by own) Not Spedbic + Decreased Sugar (444). 4 {aj night ) sitting glasses day WS 40 MENTAL SYMPTOMS : Mind ie sie Th. rm S ~: (1) Impulsive. ants fo do things in husisty, . 2) Gea apprenension 7 (3) loss of Memory rs? CFarequent Fouls in Speech, he can’ Find night @ 7 . PD — > ~~ > ~~ a) ~ re ~ (a) Melencholic CHILD HISTORY : Birth: Noximal Mother State during Pregnancy: \\p»\meal. oe 7 ion No» Done FEMALE HISTORY : 14 agpliub\e. Menstrual History : , GENERAL EXAMINATION : Built: Fay . Flubby Complexion: Cachecli c Head /Scalp: Secnetony ta Pale Conjuctiva: Pale, proaue: Blau dots on it ToTA Q) ay Past Histor fori His tor Mine TOTALITY OF SYMPTOMS : i (1) Loss of memory ¢ frequen) Faults in speech he cand fi avigh 1 coosicls) Ga) ‘Tmpalsive wants to do Wings tn hwoy & wants to j fron hight (4) Blulsh spot beborre eyes, bluvied Vision, aching Ui tdved Feeling in eyes (4d Booming dy Slomach (3) Vomiting ob bile & Sout erudation with headache. Ge) Desisye bor Sugar > ‘CNS ; GIT: “| ~ “| x LAB, INVESTIGATIONS : hes | x TO Retvice Fors SIRT OTB Sn ae Fee re. Chowne Caner IMfivrey ANALYSIS OF SYMPTOMS : enorel » 0) Melancholic a » (2) boreal apprehension a © (3) Tmputsive .wants fe do In hunry & Hants’ fojum pe Forom hight (4) Lass of memory Chrequent, Faas W Speech. can t Find xtight words. AV Grneriats. 7 Desire port Sager (2) sensarion of Seriigo CC stoning , > sitting ) 3) Dirowed SEP sleeplessness, . 1511) Bluish spol bebwre tyes bluMned vision, etching Hined Feding In eyes (2) Bunning sensa\ion in stomach, £3) Vomiting of bile ti Sow) enuclation, wlth heaekeech ¢ on oF sympronig |) Fook —y Jalking tole Memony CFarequend fawit In Speedy, cannot Fine Night ttt) ala al al al af el eussee nn ae en SIUUHOHVHHHUKEH wants Yo do ANINGS in heoiy Wa) a@arnty to Jump high} RAS RUBRIFICATION WITH PAGE NO. : “— ae G1) MIND MEMORY Kleakness of words fos: Pg < < ~~ () MINO - IMPULSIVE - Csuieiclal disposion) 4 howing ae, Gote55 swutric- Fatom hight - 9 “5. —» 3) EVE - SPOT. specks, bluish- Pq - 265. o- MU) NUSION- BLURRED. Woiiting, while Pq > 41. > (5) VERTIONO. STANDING. Wlallting, aFler Pg -204 a (2) STOMALH- DESIRE - Sugunt - Pg - BG > 1) STOMACH VoraiTinion- Bile Headache itn Py 535- GROUP OF SIMILAR DRUG : ©) Angentam nitniam- Xy (2) Cealewea fextbonicum Ve. => > —» —> > ‘>> = (3) Aunatiiium - 42 vs ae PRESCRIBING INDICATION OF REMEDIES ; Calcunea Ceri. SPots & Ulwers on Cornea asenaing o> chile Standing & afer adi a « eee PRESCRIPTION : RX, Calustea “feribonieu- 200 - © Dose STAT. ORALLY SAC LAC: 453%9 days, AXILLARY MEASURE : + Fad well nutstitive lied ~ Inlert Sunglasses during coom\s of Porinting - Avoid iimilunts fiom eyes. Avoid eye sinuin 0% Over- eotHon. a a a Bunning sensation & | S01 erudation 1s | Cleeied. Feeling good. Follow up. Patient is AmPove dd, Rete 10 tomPlain Precription Ry, No Medicines Nequi seat SAC UN ut A dagr Re SNe LAG: U4 34 Feluy, CRAIG PAST HISTORY : Diubeles mellitus at the age ob 2s yeers- Allopathic “Tseadment taken & Wis in conimol FAMILY HISTORY : (In table form by own) ~ Not Specibic gg 090 DTTP MENTAL SYMPTOMS : Mind > Toinituble & Mentally stesiless > Anxious CHILD HISTORY : n\o Gbrormatity. ‘Birth: Mother State during Pregnancy : FEMALE HISTORY = Kot applicable 7 Menopause : Obstratic History.: tt of o) )! dat <| ww) » 3) = () Sp piact GENERAL EXAMINATION : => “ Buit: Avorage ep F Complexion: {hea lish pa F ~» . 7 : MAS a2 Sp he > Hiskom id Family ope fe 3 ina Bay, BP: TElko mm Hg Rates Lumin su “Te « « ‘bog TOTALITY OF SYMPTOMS : we 4) Busining Pain IN anal steqion. hile pass « © (2) a1Blody t offensive: stool. & re (3) Stitching & cutting type ob Pain. © r tu) Lampy Sensation ¢ in anal siegion. I (3) 4. aHoy midnight op? GY y> Head, swum application, ts S DIAGNOSIS : => Ditferential Diagnosis: FBleeding Piles . Fissunes. ‘ Provisional Diagnosis: Bleeding Piles Final Diagnosis: Bleeding Piles MIASMATIC EVALUATION : | _£ — SYl0515. | Past History Family SYSTEMIC EXAMINATION : cvs ral CNS are LAB. INVESTIGATIONS : - ‘Advice For CBC. Who. 14.5 gmy 1. Radiology 2. ECG. ETC Urine Roport: No abnormatity ANALYSIS OF SYMPTOMS : Jal Generals: 1) Taoritoble % mentally. estes (2) Anxious A) Devieasea appetite (2) noreased Vhitst (3) Distwibed Skep Ave fo Pain. In-anal negion WHINE ysi iadanrs 0) Bustning Pain " > @) ae taiting type of Ee 3) lumpy Sensation in anal gio (uy (+ aXe midnight ts) y- eek. wry application Physical Gynerals Passing Seo! EVALUATION OF SYMPTOMS = (2) Burning Pain in anal xegion while Passing stool. (2) Stitching ty Grecting Palo 4 Lumpy sensation 19 anal ¢ gio £3) Bloody & offensive Stool. ta) < alos midnight 4s.) P= head Joonro application, ® | itd (it —~ atetLd 7 CCL LE Rhee RUBRIFICATION WITH PAGE NO. : ta) RECTOM » PAIN » buowning, 1 Stool, during - Py. Gag RECOM - PAIN Shitching , Stool auxing Pq- Gls CS) RECTUM PAIN - culing stool duwing Pq -62G tay RECTOM PAInt- LUMP. Sensation ob - Pg -623- CS) RECTUM HAEMORRAAGE - Stool, duming- Pg -GI4 GROUP OF SIMILAR DRUG : GY Naisam mw ye (2) Alumina: 673 3) Amon coh - Cry &4)-Saliphu 5 —— tS) Phesphosius - 6) J > Pudsatitlu C5 Re, PRESCRIPTION ; © YP NATROM MORIATIOM 200 @ Hose. SAL LAC 118K 1 aays. AXILLARY MEASURE : H 2) Tnorease the caily pibye intake to + 25 glday Via dlfel eoith om withour Fibre Supplement @) Bathing In wim @ador has a Soothing ebbeck ON anal aisiombost) Date Follow up Precription Relic in FAC AC Ley 34 UU complain | CTC a} i eee eeeenne %! Lan nnn awn

You might also like