Patines Clinteal Cage hivtary SHNos ty Names oy Ra thed Ager S® v Serve pel Caster Wotialons (LY OWRD NO hy LAD. Now 908 Ward Ks ¢ Med Not 0 aAddvesss ep Name and address of Relatives, Mtendant: Occupations Finaneial Sts: yi le ob 5 Marita Stats meryaiect G/9/ 2008 DOD. Fe/ 1/0 vwred/Markedly improy LAMA/Referred D.O.A. Result «l/ Moderately Improved! Mild nproved/ Chief Complaints (with duration): k/e7o6 br = Assocla Heel Symptoms of DI ~ Beth sole of ley tinglinrg Serna alyory fe Burning since Sy ccey = Fregetently vyivrt tion. History of Present illness (Origin, duration and progress): 2, , - according fo pattern f he weds hedit y before Tyeers then in 4 random Aiage osis He was ditgnosed with bri-rype-2 . 50 He took allopathic management For the disease bering that He was SubFering vith Frequently arvina Hor since cast Kye, He develops Hogling senseition & Burning im sole of hoth Legs pve 10 these complaints & for bettey tredtoment He tel vk omurlidhay aywrred Hospibatl , fF past iness = Mo past Lilness 2) Previous health } pask Fines is Pa 1) Histon Scanned with CamScanner3) Tr tment/Surgical history - — Family History (If any specific related illness): — Personal history: , 1) Diet (Type and Quantity) Bhakhav! Ct), Nedmkeen. areatk Fast! tretcewp), Bhd : ; Mixed/Veg - veg “Lumeh = poticn), SUbFI, RICE T eee ; pivmeY :-khichaeli cLboco! ) chhas (aglaSS) Details of dietary articles - ‘ Details of quantity of dietary articles - ; 2) Addiction- Tea / coffee! tobacco chewing/ smoking/ aleohol/ other “e Quantity 2°? j day Dura 40 Yrs. 3) Sleep — a /sturbed 4) Dreams - vo dee gm S S)Rest - wight- shes Pay-2hrs 6) Urination : Frequency —per day, — Maher tO er night with associate complaints (if any) 7) Defecation: Frequency duration -—- with associate complaints (if any) atime /dety 8) Flatus - vo flaty s 9) Menstrual History ~ 10) Obstetric History: Delivery. - Abortion. — : Miscarriage. ~ General Examination: Scanned with CamScanner‘al Constitutions a] Constitution type (Built/Stature) Joven os then Ie | Facial appearance - nlevrn | 2) Vital Data Pulse: al RateMin- 24 / pain | Rhythm prow | | Tenston- prerrnal J Volumes pyowrna | ¢] Arterial wall feel- owrna | f] Doshika assessment- poor a | Respiration: a] Respiratory rate/Min 2.6 /mm 77 b) Type of Respiration - vorm 4 | Cabdomine Therasic ) Temperature: 97.6 Blood pressure: L20/ 70 emmy Body weight: Fo Kz 3) Skin: Dry 4) Oral cavity examination: norma | s) hips: oerod | 6) Tongue: Coated spore | 8) Haire se ethabh krisho? 9) Scalp: Verma | J0)Body hairs 077 OF f LI)Nailse ewe thdbh paket 12) Agni: - (ib Ti7e oF Scanned with CamScanner13) Koshtha: ma chhyp7r7 Atura Bala Pariksha (Assessment of Patient strength) 1. Prakriti: Sharirika. | Manasiker 3-2 sie Vv 2 Vierutl 3. Sara (Excellence Of tissues) — Pravara /Madhyama /Avara snysique)-Pravara /Madhyama / Avara Le 4. Samhanana (PI 5 Pramana (Anthropological assessment) - Pravara/Madhyama /Avara 6 Saimya = Pravara/Madhyama/Avara ~ mercthryrcy rh kbey 4. Sarva (Mental status) : Pravara / Madisyama / Avara & Aahara Shakti State of digestion): 1 Abhyavaharana Shakti (Capacity for food Intake) Para vet eet fi Jarana Shakti (Digestive capacity) Poet verre} 9. Vyayama Shakti (Capacity to exercise) ~ Pravara /Madhyama/ vara 10. Vaya (Age) ~ Pravara/Madhyaima / Avara Indriva Parikshana Examination of Sensory organs: 1. Ears (Vestibulocochlear Nerve examination) - 40 2. Skin (Superficial/Deep sensations) — Touch oo-y7er | =Pain= vo per Ie.6 6/6 ial field Worm ef | = Temperature -yes (Ophthalmic Nerve examination) ~ Visual = Color Vision ovr al Scanned with CamScanner PPP PR wReeeraonnr _. ROPaH e eC E . oe VuevVuUeUGUHKd ye \ S ewvve Vue vw mination) ~ VAD 4. Nose (Olfa y Nerve ex coated 1¢ (Glossopharyngeal Nerve examination) ~ Srotasa Examination: 1) Pranavaha Srotasa (Root - Hridaya and Mahasrotasa) Presenting symptoms and Involvement of dosha-dushya = pore Fe vctart Syn p torn 5 Examination of Respiratory system Upper Respiratory tract 1, Nasal examination wa 0 2. Throat examination (Tonsils, Pharynx, Larynx, ete,) 40 fi Examination of Lungs atewet] Spmrmetricetl] f efehest wall on both stele 1. Inspection: Shape of the chest- Nomme | (B¢ ofmovement- Unifevrn mever7er Equality Rate of Respiration» 16/77 ‘Type of Breathing- Abiornind Hovrasic ‘Any other evident findings- 0 2. Palpation: Equality of movement- £4244 | 071 both side Palpation of trachea- comtreilly placed Tactile vocal fremitus (TVF)- VA 0 3. Percussion: Rest 1ani/Tympanie/Hyper resonant/Dull ra 4. Auscullation: woxmnd] Alrientry im both emys Normal] Breath Soune heave! wo added saune 2) Udakvaha Srotasa (Root-Talu and Kloma) Presenting symptoms and involvement of dosha-dushya = Vo rele vamt Symptom § Palate examination- VAD Scanned with CamScanneration- VD, Yracheopharyngeal exam on (Dehydration, Edema, ete.) Hye! ted 3) Annavaha Srotasa (GALT.) (Root-Aamashaya and Vamaparsiwva) senting symptoms and involvement of dosha-dushya= vo weladvel™? t symptoms 1 Examination - ‘on-Shape and contour of abdomen - pen [ou S Umbilicus - cemtoally placed Moyement of abdominal wall AD Any visible peristalsis AD Skin/Visible veins on abdomen) AAD Hernial sites WA D 2:Palpation- Soft | -~No tenderness - NO oxgernomegzaly 3. Percussion= tympanic sound heare 4, Auseultatio nermal peristalsis heard 4) Purishvaha Srotasa (Exeretory system) (Root-Pakvashaya and Guda) Presenting symptoms and involvement of dosha-dushya - No vel vax t symptom 5 Large intestine / Sigmoid Colon- Any vi Je peristalsis- VAD = Peristaltic sounds- prov | \\ +Herniation: AD, Reetum (P/R Examination) - VAD Stool examination- AD 5) Mutravaha Srotasa (Urinary system) (Ruot-Basti and Vankshana) Presenting symptoms and involvement of dosha-dushya ~ freqaently Usina Hon pesha~ kapha Dushyq - mitra, Rass Page 8of 17 Scanned with CamScannere e we CCHS VDevovdvuvuvvuvovuse . ewe vevvwwwe Stanya- Wao 8) Mamsavaha Srotasa (Examin: Palpation (Bimanual)- 1/49 Bladder- 700 Urethra VAD Urine examination- 74 0 6) Rasavaha Srotasa (Lymphatic system) (Root-Hridaya and Dasha dhhamani) . Presenting symptoms and involvement of dosha-dushya- Joe lavant symptoms Circulatory system (Heart) Inspection- 1. Shape of precordium ~ Normal/Bulging/Retraction 2. Apex beat- $,- 52 sound hecrvel - Palpa apex beat- J AD 2. Palpation of Carotid artery- NAD Auscultation - Heart sounds 5-52 soul herrea] = Murmurs- ,bsent Lymph nodes (If enlarged) — po enieagement of cervical, AxtihIry or inguinal lym phnecles Aartaya - AD 7) Raktavaha Srotasa (Hemopoetic system) (Root-Yakrit and Pleeha) Presenting symptoms and involvement of dosha-dushya- wo relavan t Symptom x Liver- NAD Spleen- NAD Gall bladder yA Veins (Deep Vein thrombosis,Varicosity,Thrombophlebitis, etc.) Skin pigmentation / discoloration: No pipmenta Hon Joiscoloration of Motor system of CNS) (Row snayu and Twak) Scanned with CamScanner> relavant Symptoms Presenting symptoms and involvement of dosha-dushya - WO Welaver 777 27 77F Power of muscles: Grade 5 Tone of Muscles- Hypertonia (Spasticity, Rigidity, ete.) -Hypotonia a , Coordination- Finger Nose Singer test- ¢- VE) - Heel Knee test-- ¢-v¢ ) -Romberg’s sign- (-v¢) Involuntary movements ~ Convulsions/Tremors/Chorea/Fasciculation/Tics Nutri 1 of muscles ~ Wasting/Pseudo hypertrophy/Hypertrophy/A trophy Deep tendon reflexes — Biceps - ew. | - Triceps -Norrna | - Brachioradialis ~ Jeera | - Kneederk - worrng | Ankle Jerk/Clonus - 20%r74 | - Planter reflex . ovr a] 9) Medavaha Srotasa (Root-Vrikka and Vapavahana) Presenting symptoms and involvement of dosha-dushya / Symptoms of Atisthaulya - No velavant Symptoms State of Adiposity (Obesity/Emaciation) Mistribution of fat deposition yore | 10) Swedavaha Srotasa (Epocrine/Sweat glands) (Root-Meda and Lomakupay Presenting symptoms and involvement of dosha-dushya ~ 17 -linn psensation Skin = ringling. sensaHen berrninng fn both ley Skin pores - Newrme / dosha ~ pitta. kapha pushyg = Swe: ¢- excessive sweating Ress, medey 11) Asthivaha Srotasa (Skeletal system) (Root- Meda and Jaghana) Scanned with CamScannerPresenting symptoms and involvement of doshacdushya= 12 <1 y =< Gate nereeng |} Posturee wero | Mobility. pore | Deformity. pio defer TY WAD Osteoporosis/Osteopenia/Osteomalacia Fractures: VA1) 12) Majjavaha Srotasa (Bone marrow) (Root-Asthi and Sandhiy wolvement of dosha-dushya - Presenting symptoms and in Joint tenderness - 42227 r Swelling - Absent Joint Crepitus A b520 F Range of movement —¢4errnd f 13) Shukra-Artavavaha Srotasa (Reproductory system) (Root-Shukra,Artava,Stanya) symptoms Presenting symptoms and involvement of dosha-dushya - 7 welavant Examination of male genitalia (Penis.Scrotum.Testes,ete) - “#0 Semen analysis - 14D Examination of female genitalia (Perineum, Vulva, Labia majora, etc.) - PIV examination ~ P/S examination =~ Breast examination ~~ 14) Manovaha Srotasa (Psychiatric assessment) Mana (examinetion of Manasika bhavas Vike Thinking, knowledge, ete.) _ Scanned with CamScannerBuddhi (Exam patience, ete.) ~ ion of intellectual faculties Appearance and Behavior- Now 7] & worried Speech ~ Mute/Flight of ideas/Dysphasia/Dysarthri Mood — Euthymie/Depressed/Anxious/Irritable Thought content= ovesth Ar ix1g. eo norma | Abnormal beliefs (Delusions, Hallucinations, ete.) — No Assessment of Cognitive state — Level of Consciousness — 2017 Sc102/ § Orientation = wel] oriented Attention and Concentration ~ Grooe/ Memory - ooo Intelligence - Groce] Laboratory investigations: s of mind like intelligence, memory, | Stool Quantity Consistency Odour, Colour Sama/Nirama Urine Sputum 45m eledy e185. Vomitus Sweat ‘Menstrual blood [Others Other Laboratory findings and releyan RBS = I¥o-mg far FBS = 150 mny Jb PPBS = 185g Jab. investigations like X-ray, USG, ete,: Scanned with CamScanner° PRD 37 ¥ ‘Srotasa Sama/ Samuchchaya Guna SrNo. | TakshanaSamuchchay involved / ic | | (Sign and Sy mptoms) Amshans | | ha | | Kalpana | __| -———-} jp tosaere PP Pa 3° oY anger 4! pitta laze! iTeteor pf et sat 4 | wefet agrict! gapha | q71 aprte i a aTret 3g? TFT. Lo | ai 16. 1 Differential Diagnosis: Concerned/Related Diseases- H1G21E , wae Provisional diagnosis #2272 Final diagnosis-#% 2+ Nomenclature of Disease-Criteria for final diag Type/Subtype Stage of disease (Saama/NiraamalAcutelC} gancredSE APPE erte Nature of disease (Mild/Seyere) s2ve7 \Nidana Panchak :- 1. Nidana (Etiological factors): 2. Samprapti (Pathogenesis): (24371 er General = Specific Samprapti Ghatak (Constitution of S Dosha- keaaph asia 3 EPPS 2H fade teiat , sti mnic/Episodie) ? ic ahd —. bea YMA A SITALT es ¥ Hd 2 cifetofeagrad onan. < ci het fet g ra Origine 9179718 TEL Scanned with CamScanner iss frequently uxrrd Hon AF > TIT ATIF PELE GBT > 219 aT petDushyae 531, 841, ABT 37, 4074 —Rogamangae 3118 12e7e Place of manifestation of disease- 7/27 Srotasae YAS, PFGE, PEASE, 378, ed Fete ; ‘Srotodushti Prakarw 0? Stage of di seg (A Agnimandya: (24%77 657 e- CHOW C Doshika nature of the disease- Ket ph q pitt —— amas Aggravating period of di Remission period of disease-_ ry sign and symptoms): ~ 3. Purvaroopa (Premonit urgeteig le HoeT Pic) 4. Roopa (Cardinal sign and symptoms): 5. Upashaya/Anupshaya (Aggravating and relieving factors) BURY 1 RAGA, ROTA , HOAGOMTA 1 ByaRTa :- Bull, BERT, alaati ee ere 6. Upadrava (Complications):- — Arishta:- — 8. Sadhyaasadhyatva (Prognosis) ‘Treatment Protocol: Principle line of treatment GBANAD, MA; GIGhAaT] Fela Drug of choice Shadvidha Upakrama (Six modes of treatment) 1, Langhana (Therapeutic fasting) | insert check box in front of each Kari shown below] A] Shodhana (Biopurification) Bl Shamana (Paci i) Vamana | i) Deepana Scanned with CamScanner 2 © Ge @ a ow om 22 PfASA PSPsfi) Virechana | il Based ivy Nasr ¥) Raktamokshana 2. Brimhana (Nourishing) | — 3. Rukshana (Drying) — 4. Snehana (Oleation) ~ abhy IF 7. 5. Swedana (Fomentation) ~ wacli'swe dd 6. Stambhana(Styptic) — Treatment given: cihanaratt Add sufficient space here Pathya-Apathya (Do’s and Don'ts) Pathya- Ahara(diet)- Vihara (activities)- c%4Ty oF | ciga>107 Apathya- Ahura(diet) - RUKSHG , Sheets , maseore Viharutaetivities Dieoaso4P™ 4, Yea dhawrend ii) Pachana Uparvasa [Fast riled, Yusha, Boilecl veg Gqtictnye iv) Pipasa Nigraha [Restriction of Nuidsy v) Vyayama [Exercise] Vi) Aatapa Sevana [Exposure to sunlight vil) Maruta Sevana [Exposure to fresh air] Medicines Dosage Time of administration Anupana (Vehicle) Ovigayseradi oval alt warm water fee ax2 ne mamegak + @mernegan ga we acircta & rm bu Biza -2- 1 Owe Fa 2-2-2 aAlF warmudtes , shal; Scanned with CamScannerFollow up record: Percentage impro Date Symptoms eae ae 6/4/22] Both ieg - Ovigay saves tingling sensrHon oe & Buoning emi eit Sensatron ty a Hone . Frequently — |@)memegak ghar vrimagHen 2-2-2 alt (Dzer7b4 BiZ4 ghanard 2-2-2 AIF Quiruhg saste 450m | e pathy qed) Koadth #19122] goth leg Hngling. com... +0 SeNSa4tion lap ere Seach 1H 10/24 Buaning sensation co Preguentl areteetion| 25/9/22 ~Goth leg Hrogling cont... . o +o Sensdfion 3 mild 'y 20/9 / i: im ateea! a 22 | Buen ingsemsa Hen Tenpreved Foede ent! hind Hon 21/3 [2 aoth leg Hrgling) cor ty i sensation Sf onaee qu ialy bviegs, 227.2 4 T- Peto M74. sense tibn fi \ Em proved Frequently , : apindhon Gea eo Scanned with CamScannerFollow up record: rT 71 Dae | Symptoms Treatment Percentage improvement $ corinne mil elliL-mn proved F ensHion 1,2, 314 Lauren ing sensation CL) Vreguen tly - aning tency J 25/9/22 gethieg Hagin, CoMHNYE mildiy to |sensrtenl CL) Z,2,3;4 Im proved Br/s/22 summing sensattn ov) Frequently ari nq Hen Cy weit eothleg ting lip come modevately sensation) 1£,2,3,4 Zoenprove |3e/9 /22| eyeing sense on ch) ent aringtion ty) C4 -5 tme/day Signature of student fe Signature of teacher Scanned with CamScanner