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    Ayurveda Case Sheet Sample

    Uploaded by

    DrMohamed Rifas
    This medical record is for a 62-year-old retired male presenting with obesity, depressive psychosis, knee and back pain, cervical spondylitis, BPH, fungal infection, tiredness, increased craving for sweets, allergies, abdominal bloating, and hypertension. His past history includes a TIA in 2008. Current medications include Urimax D, Telma, Ceruvin, Ecosprin, Librium, Serlift, and Atorva. Physical examination revealed tenderness in the left knee and crepitations in both knees. The patient was admitted and underwent Virechana treatment with improvement in symptoms over subsequent days.

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    Ayurveda Case Sheet Sample

    Uploaded by

    DrMohamed Rifas
    1K views14 pages
    This medical record is for a 62-year-old retired male presenting with obesity, depressive psychosis, knee and back pain, cervical spondylitis, BPH, fungal infection, tiredness, increased craving for sweets, allergies, abdominal bloating, and hypertension. His past history includes a TIA in 2008. Current medications include Urimax D, Telma, Ceruvin, Ecosprin, Librium, Serlift, and Atorva. Physical examination revealed tenderness in the left knee and crepitations in both knees. The patient was admitted and underwent Virechana treatment with improvement in symptoms over subsequent days.

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    Ayurveda Case Sheet Sample

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    This medical record is for a 62-year-old retired male presenting with obesity, depressive psychosis, knee and back pain, cervical spondylitis, BPH, fungal infection, tiredness, increased craving for sweets, allergies, abdominal bloating, and hypertension. His past history includes a TIA in 2008. Current medications include Urimax D, Telma, Ceruvin, Ecosprin, Librium, Serlift, and Atorva. Physical examination revealed tenderness in the left knee and crepitations in both knees. The patient was admitted and underwent Virechana treatment with improvement in symptoms over subsequent days.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    1K views14 pages

    Ayurveda Case Sheet Sample

    Uploaded by

    DrMohamed Rifas
    This medical record is for a 62-year-old retired male presenting with obesity, depressive psychosis, knee and back pain, cervical spondylitis, BPH, fungal infection, tiredness, increased craving for sweets, allergies, abdominal bloating, and hypertension. His past history includes a TIA in 2008. Current medications include Urimax D, Telma, Ceruvin, Ecosprin, Librium, Serlift, and Atorva. Physical examination revealed tenderness in the left knee and crepitations in both knees. The patient was admitted and underwent Virechana treatment with improvement in symptoms over subsequent days.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 14
    At a glance
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    The patient has multiple medical issues including obesity, depression, knee and back pain, urinary problems and hypertension. He is 62 years old.

    The patient's main complaints are obesity, depressive psychosis, pain in both knees and low back, urinary problems including increased frequency and poor stream, and hypertension.

    Examinations of various body systems like ENT, gastrointestinal, respiratory, circulatory, urogenital, nervous and locomotor were performed. Vitals like pulse, blood pressure, respiration rate were also recorded.

    MEDICAL RECORD

    DEPARTMENT
    IN - GUEST
    I.P. NO.
    Name :

    Age: 62 years

    Sex: Male

    Occupation: Retired

    Phone :

    Number to Contact in emergency:

    Person to Contact in emergency :

    1 Page

    Medical Record Department

    Case Record
    Complaints/Present history:
    1. Obesity
    2. Depressive Psychosis since the age of 20, had flared up 1-1/2 months back with panic attacks.
    3.Pain in both the knees and low back since 2 years. Low back pain increases on exertion and long sitting, buckling of left k
    4. History of Cervical Spondylitis
    5.BPH, increased frequency, very poor stream, sleep gets disturbed.
    6.Fungal infection in groin region.
    7.Generalised tiredness on exertion
    8.Increased craving for sweets at night.
    9.Allergic to dust, has congestion during winter
    10.Abdominal bloating and history of haemorrhoids.
    11.Hypertension, postural hypotension (black-out)

    2 Page
    Past history: TIA in 2008

    Treatment history:
    Current medication
    Urimax D 1-0-0
    Telma 20 mg 1-0-0
    Ceruvin 75mg 0-1-0
    Ecosprin 75 mg 0-1-0
    Librium 10 mg 0-1-0
    Serlift 100 mg 0-0-1
    Atorva 20 mg 0-0-1
    Treatment history:
    Current medication
    Urimax D 1-0-0
    Telma 20 mg 1-0-0
    Ceruvin 75mg 0-1-0
    Ecosprin 75 mg 0-1-0
    Librium 10 mg 0-1-0
    Serlift 100 mg 0-0-1
    Atorva 20 mg 0-0-1

    Family history:
    Nothing specific

    Personal history:
    Appetite - Good
    Bowel - Normal
    Bladder - Increased frequency, weak stream
    Sleep - 10 1/2 hrs, but disturbed

    4 Page
    Gynaecology history:
    NA

    Socio-Economic history:
    NAD
    Socio-Economic history:
    NAD

    History of Allergies:
    Allergic to dust, comgestion during winter

    5 Page

    Diet:

    Are you a vegetarian Non-vegetarian Mixed yes

    Food Allergies:

    Describe Your Food Pattern: Time of the Day Food Generally eaten

    Breakfast/Morning meal: 9.00 AM Any South Indian item

    Lunch/Afternoon meal: 1:30 PM Phulka, Rice, Dal, Curds, Sambar

    Dinner/Evening meal: 9.45 PM Phulka, Rice, Dal, Curds, Sambar

    Beverages: Cofffee 2 cup, tea 2 cup

    Daily Routine & Habits:


    * Sleep: at what time do you go to sleep daily? Varies
    * At what time do you wake up in the morning? Varies__________Sleeps for 10 1/2 Disturbed, due to urination
    * Are you initially refreshed on awakening? Yes
    * Exercise: Do you excercise? if so what time? __Morning___________________________________________
    * How many days in a week do you excercise? __7___________________________________________
    *How long do you excercise daily _____45 minutes____________________________
    *Habits: How much alcohol do you consume in a week? __2
    * Do you smoke? __No_______________________
    * Sleep: at what time do you go to sleep daily? Varies
    * At what time do you wake up in the morning? Varies__________Sleeps for 10 1/2 Disturbed, due to urination
    * Are you initially refreshed on awakening? Yes
    * Exercise: Do you excercise? if so what time? __Morning___________________________________________
    * How many days in a week do you excercise? __7___________________________________________
    *How long do you excercise daily _____45 minutes____________________________
    *Habits: How much alcohol do you consume in a week? __2
    * Do you smoke? __No_______________________
    * Have you ever tried any stimulant drug? Is so give details __No___________________________________

    6 Page
    General Physical Examination:

    Pulse: 68/min
    B.P: 140/90 Right Arm: Left Arm:

    Orthostatic Blood Pressure:


    R.R: 16/min
    Ht:
    Wt.: 105.4 kg
    BMI:
    Temperature:
    EENT Examination:

    NAD

    Other Examinations:

    Tongue - Coated

    G.I. System:

    NAD

    Respiratory System:

    NAD

    Circulatory System:

    NAD
    Circulatory System:

    NAD

    Urogenital system:
    NAD

    Nervous System:
    NAD

    Locomotor System:

    Tendrness in left knee, Crepitations in both the knees

    7 Page

    A. Prakruthi : Pitta - Kapha


    (Physical constitution)

    B. Vikruthi : Kapha Vata


    (Morbidity)

    C. Saara: Madhyama
    (Excellence of Dhatu or Tissue element)

    D. Samhanana : Madhyama
    (Compactness of Organs)

    E. Pramaana: Madhyama
    (Measure of the Body organs)

    F. Sathva : Avara
    (Mental Condition)

    G. Saathmya : Madhyama
    (Homologation)

    H. Aahaara Shark
    (Power of intake and digestion of food)
    I. Vyayama Shakti : Madhyama
    (Power of performing exercises)

    J. Vayaha : 62 years
    (Age)

    8 Page
    Investigation:

    9 Page
    Consultaion Notes :
    Date BP Weight Bowel Sleep Appetite Notes
    3.4.2012 140/90 105.6 Semi solid Satisfactory was feeling giddiness in the morning, which
    4/4/2012 110/70 105.2 twice, watery Satisfactory Urine stream has improved, feels light in th
    4/5/2012 130/80 104.4 once, watery Satisfactory Nothing specific
    4/6/2012 130/90 103.9 twice, semi soGood Burning sensation in the anal region, Advis
    4/7/2012 140/90 103.1 once Good No anal burning, stiffness in the knees redu
    4/8/2012 140/80 103.5 twice, watery Good Nothing specific
    4/9/2012 140/90 102 Virechana - 5 vegas, headache and weakne
    4/10/2012 130/90 100.9 twice, normalGood No bloating, feels light in the body, mild tire
    4/11/2012 Check out

    Medication Advise during the stay


    Hingwashtaka Choorna - 2 teaspoon mixed in warm water, before breakfsat and dinner
    Tablet Anuloma DS - 1, at bedtime.
    Tablet Punarnava Hills - 2, after breakfast and lunch
    Amrutha guggulu - 2, after breakfast, lunch and dinner
    D

    Date of Admission:

    Date of Discharge:

    I.P. No:

    Room No:

    Fax No:

    E-Mail ID/Website

    Mobile:

    epartment

    ord

    h panic attacks.
    xertion and long sitting, buckling of left knee
    yes

    al, Curds, Sambar

    al, Curds, Sambar

    /2 Disturbed, due to urination

    ________________________
    __________________
    ____
    Notes
    as feeling giddiness in the morning, which gradually subsided.
    rine stream has improved, feels light in the body
    othing specific
    urning sensation in the anal region, Advised Maha thikthaka G
    o anal burning, stiffness in the knees reduced
    othing specific
    irechana - 5 vegas, headache and weakness
    o bloating, feels light in the body, mild tiredness persisits
    out

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