Case Sheet in Ayurveda

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History,examination......ashtastana,srotas,nidana panchaka,samprapthighataka.......

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Case Sheet in Ayurveda

  1. 1. Scheme of case taking Particulars (Bio data) Of Patient Name : Age : Sex : OPD/IPD No: Religion : Bed No Education : P/M/HS/GR/PG DOA/DOD : : Marital Status: UM/M/D/W Occupation : ML/HW/ST/SO/A Social Status : BPL/APL/LMC/MC/UMC/R Postal Address: The History or History Proper 1. CHIEF COMPLAINTS/CC/ PRESENTING COMPLAINTS/PC/ Pradhana vedana: A subjective statement made by a patient describing the most significant or serious symptoms or signs of illness or dysfunction that caused him or her to seek health care. Record the chief complaint using the patient's words along with time period and avoid replacing the patient’s words with their diagnostic interpretation. It is considered bad form to proffer a diagnostic impression in a chief complaint. As a result, the chief complaint usually states the key symptoms that a patient is experiencing. 2. ASSOCIATED COMPLAINTS/ Anubandi vedana: Make a list of all the associated symptoms you would ask for certain chief complaints. For example: For headache as the cc, you would ask: Nausea/vomiting? Jaw claudication? trauma? dental surgery? Sinusitis? Also: exercise? stress? fatigue? menses? meds? Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 1
  2. 2. Scheme of case taking 3. HISTORY OF (H/O) PRESENT ILLNESS/Vedana vrattanta/Adyathana Vyadhi vrattanta: In chronologic order, starting with the current episode and then filling in the relevant background information. For example, if a patient with long-standing diabetes is hospitalized in a coma, begin with the events leading up to the coma and then summarize the past history of the patient’s diabetes. Add an asterisk or underline important points. 4. HISTORY OF PAST ILLNESS/PAST HISTORY /Poorva vyadhi vrattanta: Childhood Illnesses : Measles/chickenpox/scarlet fever /rheumatic fever/etc. Adult Illnesses : Medical/Surgical/Ob-gyn/Psychiatric/etc. Health Maintenance : Immunizations, Screening tests, etc. 5. FAMILY HISTORY /Kula/ Koutumbika vrattanta: Obtain the family history by asking open-ended questions. e.g. 'Are there any illnesses that run in your family? Like asthma, allergic disorder, malignancy, TB, etc. 6. PERSONAL /Atura charya /Vayakthika vrattanta: Ahara/Diet : Veg/Nonveg/Mixed!? Agni/ Appetite : Manda/Vishama/Teekshana/Sama Koshta : Mrudu/Madhyama/Kroora Nidra : Alpa/Ati/Sama/Diwaswapna/Ratrijagarana/None Vyasana/Habits/ Addictions : Tea/Coffee/Alcohol/Tobacco/None/Others High risk behavior : IV drug abuse / Multiple sexual partner /Homosexuality Mala pravrutti / Bowel : Regular/constipated. Mutra pravrutti / Micturition : Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 2
  3. 3. Scheme of case taking Position during work : Standing /Sitting/Walking/Stooping Nature of work : Hard manual/Moderate manual/Table work /Household/Sedentary/Others 7. SOCIAL AND OCCUPATIONAL HISTORY/ Udyoga Parisara vrattanta: Upbringing, Home life, Occupation, Finance, Relationships and domestic circumstances, House, Community support, Sexual history, Leisure activities. 8. TREATMENT HISTORY /Poorva chikitsa vrattanta/ Chikitsa vrattanta: Allopathic medicine - Medical Surgical Ayurveda - Medical Surgical Others - 9. PSYCOLOGICAL HISTORY/Manasika vrattanta: Mood of patient /Anxiety /Depression /Irritability /Euphoria /obsession /Neurosis / Depersonalization are present or not. 10. GYNAECOLOGICAL HISTORY: a) Menarche / Aarthava pravurthi /Rutumathi : b) Menopause/ Rajonirvrutti : c) Menstrual Cycle/Aarthava pravurthi/Arthava chakra: Regular /Irregular Scanty/normal/excess Amount of bleeding Number of days Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 3
  4. 4. Scheme of case taking Inter Menstrual period Any associated complaints d) Menorrhagia e) Metrorrhagia f) Leucorrhoca g) Dysmenorrhoea h) Ammenorrhea 11 .OBSTRETICAL HISTORY: a) Gravida : b) Para : c) Abortion : d) Miscarriage : e) Still birth : f) Number of deliveries : g) Nature of delivery : Normal /Forceps /Surgical h) Last delivery/Last child birth : Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 4
  5. 5. Scheme of case taking PHYSICAL EXAMINATION (Includes -- I. General Survey & II. Systemic Examination) I. General Survey 1. SAMANYA PAREEKSHA/ GENERAL EXAMINATION: Vital data/Vital Signs: Pulse: Respiratory rate: B P: Measured on left arm supine position. Temperature: General look/ Appearance: Healthy/Ill look/Depressed/Cheerful/Any other Weight: Height: Built/Build : Well-built/Poorly built/Giant/Dwarf/Tall stature Decubitus: Position of patient on bed. Nourishment/Nutrition: Average/ under nutrition/obese Cyanosis: Pallor/Anaemia : Mild/Moderate/severe Jaundice/Icterus: Neck vein/Jugular venous-engorgement, pulsation, pressure: Raised/Not raised Neck Artery/carotid arteries: Edema: Lymph nodes/Lymphadenopathy: Number, Site, Shape/Size-matted or discrete, Surface, Tenderness, Temperature, Consistency, Mobility, Discharge. Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 5
  6. 6. Scheme of case taking Clubbing: Koilonychia: Thyroid gland: 2. ASHTA STHANA PAREEKSHA 1. Nadi : 2. Mala : Baddha / Abaddha / Prakrata / Vikrita /min Atisara Pravahik Grahini Any other: 3. Mootra : Prakrita / Vikrita Frequency: Day: Night: Colour : Other associated complaints: 4. Jihva : Coated (lipta)/ Uncoated (alipta)/ Partially coated ( Alpalipta) Colour: Whitish/pinkish/blackish 5. Shabdha : Prakrita / Vikrita 6. Sparsha : Ushna: Anushna : Ruksha: khara : 7. Drik : Colour of conjunctiva : white/pink/red/yellow 8. Akrita Mrudhu : : Sthula /madhyama/heena 3. DASHAVIDHA PAREEKSHA 1. Prakruti 2. Vikruti 3. Sara Sharirika:V/P/K/ VP/ VK/ PK/ Sama Manasika:S/R/T Dosha: Dhatu: Mala: Twak /Rakta /Mamsa/ Meda /Asthi /Shukra/Majja /Satwa 4. Samhanana Susamhita/Madhyama samhita/ Heena Samhita 5. Pramana Supramanita /Adhika / Heena Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 6
  7. 7. Scheme of case taking 6. Satmya Ekarasa / Sarva rasa / Vyamishra /Rooksha satmya /Snigda satmya 7. Satva Pravara /Madhyama /Avara 8. Ahara Shakti a) Abhyavaharana shakti : P/M/A 9. Vyayam Shakti b) Jarana shakti : P/M/A Pravara /Madhyama/ Avara 10. Vaya Bala /Madhyama /Vrudda 4. VISHESHA PAREEKSHA SROTO PAREEKSHA: Srotas 1. 2. Pranavaha srotas Annavaha srotas 3. Udakavaha srotas Lakshanas Kupita abhikshana/ sashabha shoola ucchvasa. Anannabhilasha/ arochaka/ avipaka/ chardi Jihwashosha / talushosha/ oshtashosha/ kanta shosha/klomashosha/ Ati pravridha pipasa 4. Rasavaha srotas Asraddha / Aruchi / Asyavairasya / Arasajnata / Hrillasa / Gourava / Tandra / Angamar / dajwara / Tama / Pandutva / Srotorodha / Klaibya / Sada /Krishnangata / Agninasa / Akaalavali / Akaalapalitya/ Bhrama/ Glani/ Hritpida/ Trishna/ Shabda asahishnuta/ Kampa/ Shosa/ Rukshata. 5. Raktavaha srotas Tilakalaka /dadru /charmadala /switra /pama / kota /asramandala/ Amlaprartana / Sheetaprartana/ Tvak rukshata/ Tvak parushy/ Tvak sputana/ Shira shitilya/ Tvak mlanata/ Mukhapaka / Akshiroga / Vaivarnya / Agnimandya / Pipasadhikya / Gurugatrata / Santapa / Dourbalya / Aruchi / Shirashoola / Tiktaamlodhara / Vidahaannapanasya / Klama / Lavanasyata / Swedadhikya / Kampa / Swarakshaya / Tandra / Nidradhikya / Tamapravesha / Kandu / Pidaka / Pradara / Gudamedrasyapaka / pleeha / gulma /vidradi /neelika / kamala/ vyanga / piplava Others. 6. Mamsavaha srotas Sandivedana/ Rukshata/ Dhamanishitily/ Toda / Grivashuskata/ Urushuskata/ Gatrasadana / Spikshushkata /Adhi mamsa/ arbuda / keelaka/ gala shaluka/ gala shundika/ puti mamsa/ alaji/ galaganda/ Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 7
  8. 8. Scheme of case taking gandamala/ upajihwika 7. Medovaha srotas Asta nindita purusha lakshana/ Prameha purvarupa 8. Asthivaha srotas Adhyasthi/ Adhidantha/Dantha bheda/Asthi bhedha /Vivarnata/Kesha/loma/nakha/smashru dosha 9. Majjavaha srotas Ruk parvanam/Bhrama/Moorcha/Tama Dharshana/Arumshika/Sthoula parva 10 Sukravaha srotas Klaibhya/Aharshana 11 Mootravaha Kupitam/sashoola/bhahalam mootrayanti 12 Pureeshvaha Sashabdhashoola/ atidrava,/atigrathitam/ atibhahu 13 Swedavaha srotas Aswedana/ atiswedana/ parushanga/ atishlakshna anga/ paridaha/ loma harsha Vikruthi Pareeksha/Naidanika Samprapthi Pariksha: Nidana : Poorva Roopa : Roopa : Upashaya : Anupashaya: Samprapthi ghatakas: Dosha: K/P/V Dushya:Rasa/Rakta/Mamsa/Medha/… Agni:Jataragni/Dhatwagni Ama: Jataragni mandhyajaanita/Dhatvagni mandya janita Srotas:Medovaha/Rasavaha/Annavaha/Mamsavaha/Raktavaha Srotodushti prakara: Atipravrutti/Sanga/Vimarga gamana/Siragranthi Udbhavasthana:Amashaya/Pakwashaya Sanchari sthana: Vyaktasthana: Adhistana : Rogamarga: Sadhyasadhyata: Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 8
  9. 9. Scheme of case taking CARDIO VASCULAR SYSTEM/ CVS (Peripheral CVS and Central CVS) A. Peripheral CVS o Radial pulse: Rate Rhythm Volume Character Condition of arterial wall Redio-femoral delay o Other peripheral pulsations: o Blood pressure: o Sign of CCF: Raised JVP Tender hepatomegaly Pedal edema o Miscellaneous: Clubbing Cynossis Anaemia B. Central CVS  Inspection o Chest wall: Shape of chest / Shape of precordium: Look tangentially whether there is bulge or not. Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 9
  10. 10. Scheme of case taking o Apical impulse/Apex beat: Its best seen or best felt pulsation over the outer lower most precordium. o Other pulsations: Epigastric, Sternoclavicular, Sternal notch, cardiac artery pulsation in neck, pulmonary area, aortic area, other parts of precordium. o Abnormal bulges: Vessel distension, tumors, aortic dilation o Raised Jugular Venous Pressure  Palpation o Apex beat – (5th inter costal space ½ inch medial to mid clavicular line) Site –Detected in supine position of patient. Character-Described in left lateral position. Abnormal characters are Heaving,Forcible,Tapping. o Locate the tender areas o Pulsations in other area- Palpate pulmonary area,palpate aortic area ,palpate left parasternal area (Preferably by ulnar border). In normal Condition pulsations are not felt in these areas pulmonary,aortic and parasternal areas. o Thrills(Palpable murmers)-Systolic(Felt between first and second sound) , Diastolic(Felt after second sound),over mitral,pulmonary,aortic,tricuspid ares.  Percussion o It is rarely done. o Normally there will be dull note that means superficial cardiac dullness. o Stony dull note over precordium due to pericardial effusion. o Dullness in pulmonary area due to dilatation of pulmonary artery. o Dullness in the aortic area and upper sternum due to aneurysm of aorta. o Dullness over lower part of the sternum due to hypertrophied right ventricle. o Dullness lateral to right sternal border due to gross cardiomegaly and its due to shifting of right cardiac border to right lateral sternal border. Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 10
  11. 11. Scheme of case taking  Auscultation : (Position of patient: preferably sitting) o Listen the First and second Heart sounds (S1 and S2 ) in all four auscultatory areas o Added sounds : Murmurs- #In relation to systolic and diastolic. #Relation with natural respiration, whether better heard during inspiration or expiration. #Pitch of murmer-High or low #Site of conduction(Each murmers has specific site of conduction) o Pericardial rub: Sound resembling pleural rub heard over the precordium which is not releted to respiration. But related to cardiac cycle(Heard with each systole and diastole). Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 11
  12. 12. Scheme of case taking Respiratory System INSPECTION:  Nose: DNS, Turbinates, Mass, Inflammation,etc  Throat: Inflammation, tonsils,etc  Chest: o Movement /Type of breathing– Abdomino thoracic in Male and Thoracco abdomen in Female o Shape – Elliptical, Flat, Emphysematous(barrel shaped), Rachitic Chest, Rickety rosary (costochondral beading),Harrison’s sulcus, Pectus excavatum (funnel chest), Pectus carinatum (Pigeon chest),Kyphosis, Scoliosis, o Skin Lesions and Discoloration  Movement with respiration: Respiratory Rate & Rhythm. Normal respiration is regular rhythm Abnormal rhythm-cheyne stoke breathing  Symmetry of the chest: Normal chest is symmetrical  Cyanosis: Present/Absent. If present- Central/Peripheral.  Pursed-lip breathing:  Accessory muscle: Involved or not involved PALPATION: As you palpate the chest, focus on areas of tenderness and abnormalities in the overlying skin, respiratory expansion, and fremitus.  Chest Expansion/Movement with respiration: Are Normal and equal on both sides/Diminished.  Position of mediastinum- 1.Trachea 2. Apex beat  Respiratory expansion: Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 12
  13. 13. Scheme of case taking  Vocal fremitus/Tactile fremitus: Equal on both side.  Tenderness: In intercostal space  Sinus: Tenderness, Swelling. PERCUSSION: (Position of patient: preferably sitting)  Resonant-Normal  Superficial cardiac dullness-Normal  Liver dullness-Normal  Dullness in other field indicates -Pleural Effusion or Lobar Pneumonia  Hyper-resonance indicates - Pneumothorax or Emphysema AUSCULTATION: Breath Sounds –Vesicular breath sounds, Bronchovesicular, Bronchial breathing sounds-Tubular ,Cavernous ,Amphoric. Intensity of breathing sound- Normal /High / Diminished. Added Sounds/Adventitious sound – (Inspiration/Expiration, Polyphonic/Monophonic) 1. Wet-Crepitations-coarce,medium,fine 2. Dry- Rhonchi, Pleural rub, Crackles, Wheezes. Vocal resonance/ whispering pectoriloquy: Normal/High/Diminished Succession splash/Hippocratic succession: Coin test: Hydropneumothorax (This test is combination of percussion and auscultation) Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 13
  14. 14. Scheme of case taking PERCUSSION AND AUSCULTATORY AREAS/ LOCATIONS ON THE CHEST: Posterior chest Anterior chest Supraclavicular—above the clavicles Clavicular Infraclavicular—below the clavicles Anterior Mammary Bases of the lungs—the lowermost portions Upper, middle, and lower lung fields Suprascapular Infrascapular—below the scapula Interscapular—between the scapulae Posterior Infrascapular-Upper/Lower Axillary Infraxillary Dept Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 14
  15. 15. Scheme of case taking GIT / Gastrointestinal System / GI. System Oral cavity  Inspection : o Lips – Fissure or cracks or discoloration o Teeth – Dental caries o Tongue – Coating, Fasciculation, Cracks, Wasting o Tonsils – Enlargement Per Abdomen  Inspection: o Shape of abdomen o Umbilicus – Inverted / Everted o Movement with respiration o Pulsation o Visible blood vessels- Engorged veins in abdomen which are better appreciated with patient either sitting or standing than lying down position. o Visible swelling & erythema. o Scar/brand marks/ulcers/hypo/hyper pigmented areas describe their site size number etc. o Striae o Hernia orifices  Palpation o Tenderness –  Superficial–Try to identify tone of abdominal muscle, guarding, rigidity, tenderness, mass.  Deep –Evidence of enlarged liver, spleen, kidney, lymph nodes.  Bimanual –Kidney. Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 15
  16. 16. Scheme of case taking  Ballottement-  Dipping- In moderate and massive ascities where mass or organomegaly cannot be appreciated by deep palpation, so that fluid is displaced and underlying organomegaly or mass be felt. Abdominal aorta, caecum, sacral prominence, loaded descending colon. o Swelling : o Rebound tenderness :  Percussion: o Tympanic o Dull note. Normally percussion note is tympanic all over the abdomen. But over left hypochondrium and epigastric area may be resonant due to presence of air.  Auscultation :  Intestinal peristaltic sounds  Bruit over abdominal aorta  Bruit over the renal artery  Hepatic rub  Splenic rub Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 16
  17. 17. Scheme of case taking CENTRAL NERVOUS SYSTEM Higher function /Mental Status Examination:  Level of consciousness: Drowsiness, stupor, semi coma, coma.  Intelligence/ Intellectual level:  Memory:  Orientation of Time and Place:  Personal identity:  Mathematical ability:  General behavior:  Hallucinations(False impressions from sense organs) and delusions(false belief and idea):  Speech: Dysarthria/Dysphasia Gait: Gait problems are common. Basically, it's either musculoskeletal or neurological (UMN, LMN, Cerebellar syndrome, Extrapyramidal syndrome, Sensory ataxia). There are many patterns and types of gaits. The following patterns are recognized: Antalgic gait/Ataxic gait / Cerebellar gait / Festinating gait /Frontal(apraxic) gait /Hemiplagic gait/Helicopod gait / Hip extensor gait /High-stepping / Myopathic gait/ Paraplegic spastic gait/ Parkinsonian gait/Quadriceps gait/Scissor gait /Spastic gait /Sensory Ataxic /stiff-legged gait / Steppage gait / Stuttering gait/ Tabetic gait /Vestibular gait/ Waddling gait myopathic gait/etc Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 17
  18. 18. Scheme of case taking Examination of unconscious patient:  Stupor, obtundation, and other descriptions such as 'semiconscious' are non-quantitative descriptions of an altered mental state that is difficult to define precisely.  A rapid initial assessment of the unconscious patient should be performed to correct immediate threats to life and look for reversible causes of the unconscious state. Airway, breathing and circulation (ABC) can be rapidly assessed, and critical interventions made as required.  The Glasgow Coma Scale (GCS) / Glasgow Coma Score. It defines the degree of altered consciousness as an ordinal score between 3 and 15 - note that the lowest possible score is 3, not zero. Non-quantitative descriptions should be avoided. Eye-opening Best verbal response Best motor response Spontaneous 4 Oriented 5 Obeys commands 6 To speech 3 Confused 4 Localizes pain 5 To pain 2 Inappropriate 3 Normal withdrawal 4 None 1 Incomprehensible 2 Abnormal flexion 3 None 1 Abnormal extension 2 None 1 Cranial Nerve Examination:  Cranial nerve I/Olfactory: Parosmia (altered sense of smell) or Anosmia (loss of smell).  Cranial nerve II/Optic : Visual disturbances (Snellen chart), Visual fields , Colour disturbances  Cranial nerve III, IV, VI /Oculomotor, Trochlear, Abducent : Diplopia, Pupillary disturbances, Nystagmus  Cranial nerve V/Trigeminal: Mastication difficulties  Cranial nerve VII/Facial: Symmetry in smile, Nasal fold, Blowing of Mouth , Facial Expression  Cranial nerve VIII/Auditory: Hearing Disturbances, Romberg test Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 18
  19. 19. Scheme of case taking  Cranial nerve IX, X/Glosssopheryngeal ,vagus,: Sensation of Taste, Nasal twang to speech, Nasal regurgitation of food, Gag Reflex.  Cranial nerve XI/Spinal accessory: Difficulty while turning the Head & Shrugging Shoulder  Cranial nerve XII/Hypoglossal: Dysphagia, Tongue Tremor & Dysarthria Motor function test/Motor system:  Nutrition / Muscle Bulk :  Muscle Power / strength : Score Description 0 Absent voluntary/visible contraction 1 Feeble contractions that is unable to move a joint 2 Movement with gravity eliminated 3 Movement against gravity 4 Movement against partial resistance 5 Full strength  Muscle Tone: Hypotonia (Flaccidity) / Hypertonia (Rigidity)-Spasticity,Rigidity.  Co-ordination: UL-Finger nose test,finger test ,LL-Knee heal test,  Involuntary/abnormal movement: Fasciculation, Tremors, Chorea,Athetosis, Hemibalismus  Reflexes/Jerks: Primitive reflexes: Glabellar Tap Superficial reflex: Corneal and conjunctival reflex Palatal Pharyngeal Abdominal reflex-Upper, Middle ,Lower. Cremasteric reflex Plantar Reflex: Babinski’s sign Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 19
  20. 20. Scheme of case taking Deep Tendon Reflexes: Jaw jerk/reflex Supinator reflex Biceps reflex Triceps reflex Knee reflex Ankle reflex Scores for Reflexes: 0 Absent 1 Hypoactive or present only with reinforcement 2 Readily elicited with a normal response 3 Brisk with or without evidence of spread to the neighboring roots 4 Associated with a few beats of unsustained clonus 5 Sustained clonus Sensory system:  SuperficialTouch Pain Temperature  Deep Crude touch Vibration Joint sense Sense of position Sense of pressure  Cortical Tactile localization Tactile discrimination Tactile extinction Astereognosis Graphaesthesia Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 20
  21. 21. Scheme of case taking Cerebellar System: (Signs in disease of cerebellar system are due to hypotonia and inco-ordination) 1. Involuntary Movements 2. Nystagmus 3. Speech 4. Hyptonia 5. Intension tremor 6. Titubation 7. Rebount phenomenon 8. Pendular knee jerk 9. Tandom walking 10. Diadochokinesis 11. Cerebellar gait 12. Coordination Test:  Finger nose test  Heel Shin test  Heel toe walking  Neck stiffness  Kernig’s sign  Brudzunski’s sign Meningeal signs: Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 21
  22. 22. Scheme of case taking MUSCULOSKELETAL EXAMINATION / LOCOMOTORY In the Musculo skeletal examination, the physician should ask the patient about the pain according to Site, Onset, Character, Radiation, Associated factors, Timing (frequency, duration, periodicity), exacerbating features (exercise, use, etc.) and Severity Subsequently the affected joint should be examined for the inflammatory signs like Tenderness, Stiffness, Warmth, Swelling, and Range of movements. JOINT DISEASE: • A combination of pain and stiffness, leading to loss of function, is a classic feature of joint disease. • Usually one component predominates, as with stiffness in inflammation, and pain in mechanical joint problems. • Therefore, specific questions will establish whether symptoms are mechanical (e.g. degenerative joint disease or meniscal tear) or inflammatory (e.g. rheumatoid arthritis or gout). Features of Mechanical Joint Disease: In degenerative joint disease there may be a feeling of stiffness in the affected joint after resting which rapidly disappears with activity. This inactivity stiffness typically lasts only a few minutes and nearly always less than 30 minutes. Pain in the affected joint on activity, usually improving with rest, is typical. Features of Inflammatory Joint Disease: • Early morning stiffness : Early morning joint stiffness that persists for more than 30 minutes is an important symptom of active inflammatory joint disease. Ask about redness (rubor), warmth (calor), tenderness/pain (dolor) and swelling (tumour), the classic features of inflammation. • Recurrent attacks of joint pain : Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 22
  23. 23. Scheme of case taking • Episodic joint pain : • Flitting or migratory joint pains: EXTRA-ARTICULAR FEATURES OF JOINT DISEASE: Extra-articular features of joint disease:  Cutaneous nodules  Cutaneous vasculitic lesions  Lymphadenopathy Oedema  Tendon sheath effusions  Enlarged bursae  Ocular inflammation  Diarrhoea  Urethritis  Oro-genital ulcer  Gouty tophi caused by urate deposition  Rheumatoid nodules  Vasculitic nodules in SLE and systemic vasculitis  Xanthomataus deposition(hypercholesterolaemia) Types of subcutaneous nodule: Other soft tissue swellings: EXAMINATION OF INDIVIDUAL JOINTS: Examination of the joints can be summarized simply as 'look, feel and move', i.e. inspection, palpation, and range of movement Inspection: Inflammation is often associated with redness of the joint, and with tenderness and warmth. Look also for swelling or deformity of the joint. Note whether the distribution is symmetrical. 1. Spine deformities – Kyphosis, Scoliosis, Lordosis 2. Range of Movements according to the Joint:(Inspection and palpation) Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 23
  24. 24. Scheme of case taking Based on comparison with the normal side,or on the examiner's previous experience. For accurate description the actual range of movement should be measured with a protractor (goniometer). Both active and passive movement should be assessed. • Cervical Spine: Extension, flexion, rotation, abduction • Spine: Flexion, Extension, Lateral Flexion and Rotation. • Shoulders: External rotation and abduction, internal rotation and adduction, circumduction • Elbow: Flexion, extension, Pronation and supination • Wrist: Flexion, Extension, Adduction, Abduction and Circumduction. • Hip: Flexion, Extension, Adduction, Abduction, Medial Rotation and Lateral Rotation. • Knee: Flexion and Extension • Ankle: Plantar Flexion, Dorsi Flexion, Inversion and Eversion. Palpation: On palpation of a joint check first for tenderness and crepitus. Assessment of joint tenderness: Grade 1: The patient says the joint is tender Grade 2: The patient winces Grade 3: The patient winces and withdraws the affected part Grade 4: The patient will not allow the joint to be touched Local rise of temperature: Present/Absent CREPITUS: Tendon sheath crepitus: This is a grating or creaking sensation defined by palpating the tendon while the patient is asked to contract the muscle tendon complex involved. It is particularly common in the hand and is seen in rheumatoid arthritis and systemic sclerosis Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 24
  25. 25. Scheme of case taking Joint crepitus: This can be detected by feeling the joint with one hand while moving it passively with the other. This may indicate osteoarthritis, or loose bodies (cartilaginous fragments) in the joint space, but should be differentiated from non-specific clicking of joints. 1. Low Back Examination: o o Braggard's Test o Femoral nerve stretch test: o Flip Test o Cross SLR Test o Door bell sign: o Gaenslen's test o Sacro- iliac compression o Heel walking Test o 2. SLR/Lassegue’s Test Toe walking Test Reflexes : Deep tendon reflexes Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 25
  26. 26. Scheme of case taking Skin Morphology: Inspection and palpation(Use disposable gloves) o   Texture: Roughness / Smoothness  Temperature: Warm / Cold  Motility & Turgor: Thin/thick  Moisture: dryness / Oiliness/Dry/moist  Any visible sweat in general or local  o Color: Hypo / Hyper Pigmentation Elasticity of skin. Location /distribution/ Arrangement:   Cetripetal/centrifugal  Flexar/extensore  Exposed area of sun /unexposed area  o Symmetrical/asymmetrical Genitals involved or not Configuration of skin lesion/Types of Skin Lesion & its color: Once the morphology of individual lesion and their distribution has been established, it is useful to describe their configuration on the skin, means primary or secondary skin lesion. Primary skin lesion: 1 Macule 7 Bulla 13 Ecchymosis 2 Papule 8 Postule 14 Hemotoma 3 Plaque 9 Wheal 15 Poikiloderma 4 Nodule 10 Telangictasia 16 Erythema 5 Papilloma 11 Petechiae 17 Burrow 6 Vesicle 12 Purpura 18 Comedo Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 26
  27. 27. Scheme of case taking Secondary skin lesion: 1 7 Ulcer 2 Crust 8 Sinus 3 Excoriation 9 Scar 4 Lichenification 10 Keloid 5 Fissure 11 Atrophy 6 o Scale Erosion 12 Stria Some special and specific signs:  Kobner’s sign  Auspitz sign  Candle Greece sign  Nicole’s sign Nail  Color and Shape:  Lesion:  Nail Fold: Hair  Color:  Texture: Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 27
  28. 28. Scheme of case taking  Relevant investigation:  Summary of the case: (Construct two paragraphs; first: History, second: Brief Examination)  Differential diagnosis:  Provisional diagnosis: IMPORTANT: It’s just only the schematic outline on case taking, for further detailed reading please refer authentic and recent edition of clinical examinations/clinical methods books. @Mcleod's Clinical Examination. @Hutchison's Clinical Methods. @Bate's guide to physical examination. @Golwalla`s Physical Diagnosis. “Wherever the art of Medicine is loved, there is also a love of Humanity” - Hippocrates  Dept. Of P.G Studies in Roganidana, G.A.M.C Bangalore. ©Private Circulation Only© Page 28

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