AYURVEDA

1. CASE SHEET Dr. Chandu
PRELIMNARY DATA
Register number [IPD/OPD] :- Education :-
DOA – DOD :- Address :-
Name :-
Age :- Occupation :-
Gender :- Religion :-
Marital status :- Consultant :-
Diagnosis :- Reference :-
प्रधान वेदना एवं अवधध -
अनुबन्ध वेदना एवं अवधध –
वेदना वृत्तान्ता - Patient was said to be apparently healthy before ______________ and came to hospital
with the complaint for better treatment in ______________________________________________ and detail
description of वेदना is mentioned below .

2. पूववव्याधध वृत्तान्ता - (with treatment) Surgeries
RED FLAG SYMPTOMS (DEATH SIGN) –
धिधित्सा वृत्तान्ता –
Drug history & hosp history
Dosage
ADR , Symptoms & side effects
Allergy & Management
Illicit drug use & over counters
Vaccinations

3. िौटुम्बिि वृत्तान्ता –
Common symptoms [if] & family description Pedigree
सामाधिि वृत्तान्ता –
Upbringing
Home life and House
Domestic circumstances & Animal interest
Community and Social issue
Psychological & psychiatric issue
Sexual history
Leisure hobby and activities

4. आधथवि वृत्तान्ता – High / Moderate / Low
वृधत्त वृत्तान्ता - Occupation :-
Type of work Physical stress Mental work
Duration of work
Place of work
Mode of travel
प्रसूधि एवं स्त्रीरोग वृत्तान्ता – G P L A APH PPH
Type of delivery
Complications
Age during pregnancy
Foetal defect & complications
Age during - Menarche Menopause
Menstrual cycle - Duration Quantity
Associative complication -

5. वैयम्बिि वृत्तान्ता –
आहार Type of food
क्षुद प्रवृत्ति [A] Quality Quantity
मल प्रवृत्ति [B] Colour Consistency Time (day __ / night __)
Complications
मूत्र प्रवृत्ति [M] Time ( day __ / night __ ) Colour
Complications
त्तनद्र [S]
व्यसन [Habits & Addictions ]
General physical examination
Height US LS AS Total Weight BMI
Pallor Lower palpable conjunctiva Icterus
Oral cavity
Above tongue Sub lingual mucosa
Nail beds Skin
Palms & soles Bulbar sclera
Oedema Site
Unilateral Bilateral
Pitting ( fast slow ) Non pitting

6. Cyanosis Peripheral (p) Central (p+) Mixed(p+c)
Tips of finger Tip of tongue
Palms & soles Inner Lips
Ear lobules
Clubbing Angle of obliteration Uniformity of fingers
Fluctuation test Schromoth test – Parrot beak
Hypertrophic osteo arthopathy
(Unidigital / multidigital ) ( Unilateral / Bilateral )
Heart rate Pulse
BP
Temperature
Resp rate (chest wall movt )
Muscle bulk
Bulk Right left (cm)
ARM
F. ARM
THIGH
CALF
ARTERY RIGHT LEFT (b/m)
TEMPORAL
RADIAL
CAROTID
BRACHIAL
INGUINAL
DORSALIS
PEDIS
FEMORAL

7. Lymph edenopathy Hydration Status
Skin fold
On oral cavity
Urine output
Subcutaneous fat
OTHER PHYSICAL EXAMINATIONS
LYMPH RIGHT LEFT
SUBMENTAL
SUB MANDIBLE
TONSILLAR
PRE
AURICULAR
POST
AURICULAR
OCCIPITAL
CERVICAL
SUPRA
CLAVICULAR
AXILLARY
EPI -
TROCHLEAR
INGUINAL
POPLITEAL

8. SYSTEMIC EXAMINATION
GASTRO INTESTINAL TRACT
SYMPTOMS
Dysphagia Flatulence
Heart burn Hiccough
Indigestion Diarrhoea
Vomiting Constipation
Altered bowel Bleeding
Abdominal Pain Jaundice
INSPECTION
Shape - Flat Globular Scaphoid Others
Symmetry - Localised Generalised (5F) _____________
Surface - __________________________
Linear mark / scar mark_________
Branding mark __________ Straie ____________
Cullens sign ___________
Umbelicus _________________________________
Peristalisis Veins & arteries
Movement of Abdominal wall - Abdomino thoracic Thoraco abdominal

9. PALPATION
SUPERFICIAL DEEP
Muscle guarding LIVER :-
Muscle rigidity
Tenderness- rebound shifting reffered/crossed GALL BLADDER :- MURPHY BOAS
KIDNEY :- RIGHT LEFT SPLEEN :-
URINARY BLADDER :- AORTA :-
Urge to pass urine _______
PERCUSSION NOTE :- AUSCULTATION
Gaseous distension Bowel sound
Puddle sign
Horse shoe dullness
Shifting dullness Bruits
Fluid thrill
Ascities
Spleen Succussion splash
Kidney
Liver

10. LOCOMOTARY SYSTEM
SYMPTOMS (Please mention active A / passive P for movements of joints )
Pain Triggering
Stiffness Deformity
Redness Impaired movement
Swelling Muscle wasting
Effusion Extra articular features – (GALS )
Locking
Synovial thickening Crepitus
Subluxation Dislocation WRIST
SHOULDER JOINTS
MOVEMENT RIGHT LEFT
FLEXION 180
EXTENSION
50-60
ADDUCT 45
ABDUCT 180
FRACTURE
WINGING
MOVEMENT RIGHT LEFT
EXTEND 10
PALMAR
FLEXION 70
RADIAL
DEVIATION
30
ULNAR 20
WRIST DROP

11. ELBOW FOREARM
FINGERS F E
Flexion F Able to perform
Extension E Not able
ABLE NOT ABLE HANDS
• STONE
• PAPER
• SCISSOR
• OK
Any upper limb note
M0VEMENT RIGHT LEFT
FLEXION 160
HYPER
EXTENSION
180
PRONATE 90
SUPINATE 90
GOLFER /
TENNIS /
STUDENT
ELB0W
MOVE -
MENT
RIGHT LEFT
PRONATE
80
SUPINATE
80
ABNORMALITY RIGHT LEFT
CLAW HAND
OSLER NODE
JENVER NODE
BOUCHARD
NODE

12. HIP JOINT KNEE JOINT
• Anterior drawer sign
• Posterior drawer sign
• Medial meniscus
• Lateral meniscus
• Squat test
MOVEMENT RIGHT LEFT
FLEX 70-80
ABDUCT 45
ADDUCT 30
ELEVATE 30
ROTATION
40-50
TEST RIGHT LEFT
FLEX 180
EXTEND 180
ANT. PAIN
Thomas test
Tendenburg
sign
Bakers cyst
Ripple test
Patellar tap
Muscle wast
Collateral
Cruciate
Swelling

13. ANKLE JOINT FOOT
SPINE CURVATURE ____________________________________
• Deformity
• Gibbus Any lower limb note
• Spondoylosis
• Spondylolosis
• Retrolisthesis
• Spondylolisthesis
MOVEMENT RIGHT LEFT
DORSI FLEX 20
PLANTAR FLEX
50
INVERSION 30
EVERSION 30
ACHILLES
TENDON
THOMSON TEST
MOVEMENT RIGHT LEFT
FLEXION 40
EXTEND 40
EVERSION 15
INVERSION 5
FLEXION 90
CLAW TOE

14. ROOT COMPRESSION TEST
MOVEMENT CERVICAL THORACIC LUMBAR
FLEXION 45
EXTENSION 45
LATERAL MOVT 40
ROTATION 70
CURVATURE
NERVE ROOT / TEST RIGHT LEFT
FEMORAL (L2-L4)
TIBIAL (L4-S3)
FLIP TEST
SLR (with degree)
LASEQUE TEST
SCHOBER TEST
FAIR TEST