OPD -iâgyoË ITf
Case Record Form : Gcncral Format
Date of case taking :
UHID No/ OPD No.
27l02|2024 Casc n0 : o|
IP No/ Dt....
Name: XYZ
Age : 76 yg Sex : Fernale
Address with phone no :
Oceupation : House Ife Ineome : No income
Maritalstatus : MMorried Education : 7th Gtd
Name of nearest Relative with phone no:
Date & Time of Admission:
Date & Time of Discharge :
Present Complaints :
clo - Raktavanni Twak dushti
and Mandal utpatt1
Raag and kancu on BIL Foregrms months
Total Duration :
8 months
Ilistory of present liness : "The above patient
SymtomLess Was
before g mont hs. But as the
Geen the patient had taken Symptoms Were
but as the patient hot got allopathie treatment
Came to dyu oPD. relief the patient
Ilistory of past Illness with treatment :
No history of any major medlicinal and
Gurgical ilness.
Treatment llistory of present llness : Tab Aul 25 mg
Der ma TTR Cream LA I month
Family History: Father - HTN
Personal llistory:
Fetal History:
Birtlh History:
Menstrual History: (in the case of woman): Menopaus
Obstetric History: (in the case of woman): G,To P, H3
Diet : (Commonly included ingredients &any notable points oa Virudhahara)
Milk + Banana Fating cund at nght
Miik + ickle
Habits : Addictions:
Mode of work: Houseoife
Sleep/ rest pattern:
Daily Diwaswap 20-25 yIS
General Examination:
Physical Eaxmination:
Temp: 9-4°P Heart Rate: 76Imin Resp. Rate: 20| min B.P
Body Weight: 18 kg5 Koshta: 13UH Akruthi: E 130)3omm
Systenic Eaxmination:
SoFt, non tendey
P|A - No organomegaly Cardio Vascular S15, Normol
Gastro Intestinal Syste:
System:Chest bilaterally
Respiralory System: No added Sounds Skin &Apendages: 5ymmetrical
Others:
Lo cal examinat
Trachea centrally placed
]5ite of tension - B}L Fore arm Colou-Reddish
2)Distribuhon - circule
1TDAammation - V
3|Tching - Mila kandu Present {Dischauqi - ahsent
2
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All otheS - HET
Dashavidha Parccksha:
Dushyam: Dosham: Bhurn:
'Desant:. Dcha:
Dhatu: Balan: Rog: Rogam:
Malam.
Kalam: Kanadi: lyadhividbi:
Chikitsa: lyadhyavasha:
Anala: Prakruthi @,45fyrte Vaya qEZ1421| Satva: 1E
Satmya:JAhara: Vihara
Ahara s Jaranasakthi: 4e Ablyavaharanasakthi:
Ashtasthana Parccksha: (Observations. Doshas involved)
kapha - Jilwa: Tghat Malam: Sq mygk Mutram: Samyak
Nadi: prttaja 50am
Drik: Prakrut Sabdam: Sparsam: Mrudy Akzuthi: 5thool
Spashta
Routine &Specific Laboratory Investigations:
Blood: ’ CBC
Urine:
Stool:
Sputum:
Other:
Provisional Diagnosis:
Analvsis of the Case:
Doosheevisha / Garavisha /Vishopama)
Vishabheda: (Sthavara / Jangama /Kritrima/
Sthavara vishabheda: Nil
Signs &Synmptoms:
Saamanya lakshana:
Vega Lakslhana:
Anubandha Upadrava:
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Jangama vishabl1eda: NI
1.
2.
Chancters of snakc:
Placc of bitc
3, (Dansa sthanna)
Timc of bile
4. (Dannsa sanaya):
Timc clapscd
S. Part of body
btween bite &Admission:
6. aflccted:
Naturc of bite
7. Signs &Sympt(Damsasya
oms
blhaava):
8. Samanya Lakshana: (Damsa lakshanaani):
9. Vega lakshanaani:
10. Anubandha upadravaani:
11. Arishta lakshanaani:
Kritrimavislhabheda: Ni
Signs& Symptoms:
Saamanya Lakshanaani:
Kritrimavisha pratiniyata lakshanaani:
Doosheevisha: hogta va hng factors of Dushivish
Lakshanaani: a]Desh - Anup
Doosheevishajanya roga: b] kal - Vansha Htu
Anubandha upadrava: c] Anng -
Indriya pareeksha: Almost caly congumption of
Stale foDd
d Nidra - Daily5ince past 20-25 yrS
Vislhopama Samprapti: 20-25 dinOsWap
yrs. 5ince past
Virudhabara: Almost
Bnona dailymilkconsumpt
Eat1ng cuHd at+ pickleor : milk and
Type of virudinara : of
Factors involved:
Samanya Lakshana: night.
+ 3prerfiZ
4
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Ama
Doshadbikya:
Samanya Lakshana.:
Dosha & Vikruta akshanaani:
Dooshya& Viknita lakslananni:
Stotas & Dushti lakshanaani:
Vvandlhyadhishtaanan:
Vyadhi Margam:
Diagnosis:
Differential (with reason):
Actal: Dushi vishajanya kotha
Treatment:
Chaturvimsl1ati upakrama:
Saamanyachikitsa:
Sodhanachikitsa:
Samana chikitsa: Tnternally and externally
Details of Treatnment
Medicines/Proccdure Dose/ Time Duration
Date Observations
Dushivigh Agad Bo days
Chobrra before m ea
RakBg Pqchak choor Ugm H dayS
|23 /02/2 nQ BÁote meal 30
|Laghu manjish th-gm FH
betore meal B0 days
28lczBe4
HulT - LukeaMm wde
Eladi Tel - Apply it 9 fimes a day on affected pavt
5
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Ahara:
Vihara:
Apathya: S1rietly avoid vruddhah y likt MAk+ Bahanc1
Alara: Gtrictyqvoid eating Mik+ Rice +Pickle
stale tood
Vilhara:
Stridiy aveid dis aaqp Eatng cuyd d night
Chikitsaphalam:
decreases Rakta dyshti
Advice given at the time of discharge:
Sr.No
Medicine Dose Duration
Anupana
Dushivishai Agacl LukewcHr)
walet
2- Rakta pachak hoornagm H
3 Lag Chn1stadi
|gm
lo cal
Eladi tel
follow up was taken qiey Tih Hh
day.
Signature of Student
29le42024
Signature of Teacher
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