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    Final Chronic Case Taking Proforma Final

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    sailesh sharma
    This document outlines the case record format for patients at the Bakson Homoeopathic Medical College & Hospital. The format includes sections for patient identification and history, physical examination findings, diagnostic considerations, case analysis and totality of symptoms, remedy selection, prescriptions and follow-up notes. Key elements covered are the patient's presenting complaints, medical, surgical, family and social history, physical and system-specific examinations, laboratory investigations, differential diagnosis, provisional diagnosis, miasmatic analysis and evaluation of symptoms to determine the totality for selecting the simillimum remedy.

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    Final Chronic Case Taking Proforma Final

    Uploaded by

    sailesh sharma
    56 views7 pages
    This document outlines the case record format for patients at the Bakson Homoeopathic Medical College & Hospital. The format includes sections for patient identification and history, physical examination findings, diagnostic considerations, case analysis and totality of symptoms, remedy selection, prescriptions and follow-up notes. Key elements covered are the patient's presenting complaints, medical, surgical, family and social history, physical and system-specific examinations, laboratory investigations, differential diagnosis, provisional diagnosis, miasmatic analysis and evaluation of symptoms to determine the totality for selecting the simillimum remedy.

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    This document outlines the case record format for patients at the Bakson Homoeopathic Medical College & Hospital. The format includes sections for patient identification and history, physical examination findings, diagnostic considerations, case analysis and totality of symptoms, remedy selection, prescriptions and follow-up notes. Key elements covered are the patient's presenting complaints, medical, surgical, family and social history, physical and system-specific examinations, laboratory investigations, differential diagnosis, provisional diagnosis, miasmatic analysis and evaluation of symptoms to determine the totality for selecting the simillimum remedy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    56 views7 pages

    Final Chronic Case Taking Proforma Final

    Uploaded by

    sailesh sharma
    This document outlines the case record format for patients at the Bakson Homoeopathic Medical College & Hospital. The format includes sections for patient identification and history, physical examination findings, diagnostic considerations, case analysis and totality of symptoms, remedy selection, prescriptions and follow-up notes. Key elements covered are the patient's presenting complaints, medical, surgical, family and social history, physical and system-specific examinations, laboratory investigations, differential diagnosis, provisional diagnosis, miasmatic analysis and evaluation of symptoms to determine the totality for selecting the simillimum remedy.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7

    BAKSON HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL

    Plot No. 36 B, Knowledge Park Phase-I, Greater Noida- 201306 (U.P.)

    (Session 2020-2022)

    CASE RECORD FORMAT

    1. INTRODUCTION
    IPD/OPD Registration No.: _________________________________ Date: _____________________
    Name of Patient: ___________________________________________________________________
    Age: ___________ Sex: ___________________ Religion: __________________________________
    Occupation: _______________________ Marital Status: ___________________________________
    Name of Father/Husband/Guardian: ____________________________________________________
    Address (Res.): ___________________________________________ Tel. No.:_________________
    Attending Physician: ___________________________Department/Unit: ______________________

    2. INTERROGATION

    2.1 Presenting Complaints (With reference to Duration, Location; Sensations/Character/ Pathology;


    Modalities; Concomitants &Extension of each complaint, write separately for each complaint)

    2.2 History of Present Complaints (In chronological order of their appearance; mode of onset-
    (sudden/insidious); probable immediate cause; course of illness, treatment adopted for each complaint and
    effect thereof)

    2.3 Past History (any major illness, surgery, accident, hospitalization, vaccination, drug reaction etc. in
    the past; age/year in which occurred, etc.)

    1 (Session 2021-2022)
    2.4 Personal History (marital status; development landmarks; diet (veg./non-veg.); habits/addictions;
    surroundings at home; any allergy; profession; relationship at home & workplace; history of illicit sexual
    contact; hobbies & educational status etc.)

    2.5 Family History (any chronic disease with blood relations, presently or in past; their present state of
    health; if dead, cause of death)

    2.6 Gynaecological & Obstetrical History

    2.6.1 Gynaecological History


    Menarche/Menopause(age) ,LMP( 1st day of last menstruation), Menstruation
    (Duration, Quantity ,Cycle (interval), Color: red/dark red/dark, Consistency: fluid/clotted/partly fluid
    &partly clotted ,Pattern of bleeding: regular/irregular,Any associated complaint(s), Any other vaginal
    discharge (quantity, color, odour, presence of blood, consistency, character, before during or after
    menses),Intermenstrual bleeding,Pelvic pain(site of pain, nature and relation to periods),Major
    gynaecological disorders in the past, Gynaecological treatment including surgery in the past.

    2.6.2 Obstetrical History GPAL( Gravida, Parity, Abortion and Live births),Major complications
    during past pregnancies, Mode of past deliveries: normal/cessarian/episiotomy/forceps, Abnormal
    presentations in the past pregnancies,Puerperal complications, Sexual History: discomfort, pain, bleeding
    during intercourse
    H/o contraceptive use:

    2.7 Treatment History (including outcome)

    2.8 Physical Generals


    2 (Session 2021-2022)
    Appetite
    Desire/Cravings
    Aversion
    Intolerance
    Thirst
    Taste
    Stool
    Urine
    Perspiration
    Sleep
    Dreams
    Sexual functions
    Sensations
    Thermals
    Side(s) of body
    affected
    General modalities

    2.9 Life Space (History of his/her family & social environment throughout his life till date i.e. accessory
    circumstances of his/her development)

    2.10 Mental (Will & Emotion; Intellect and Understanding; Memory)

    3. PHYSICAL EXAMINATION

    3 (Session 2021-2022)
    3.1 General Examination

    Level of consciousness Anaemia


    Physical attitude Jaundice
    Decubitus Pigmentation
    Facies Oedema
    Built Cachexia
    Gait Emaciation
    Deformity Respiratory rate
    Obesity Height
    Lymphadenopathy Weight
    Clubbing Temperature
    Nutrition Pulse
    Cyanosis BP
    Skin/hair/nails
    Scalp (dandruff, hair loss,
    discoloration, overgrowth)
    Oral (teeth, tongue , ulcers,
    discoloration)
    Neck (lymph glands, thyroid,
    pulsations)
    Axilla
    Groins
    Hands & Feet

    3.2 Systemic Examination

    3.2.1 Gastrointestinal System:


    Inspection-Shape of abdomen, swelling,
    condition of umblicus, dilated veins, movement
    with respiration, visible peristalsis, hernia etc.
    Percussion :Dullness, shifting dullness, fluid thrill
    etc.Auscultation: Bowel sounds, peristalsis,
    arterial bruit, venous hum etc.Special
    examination: Examination of rectum, if required
    3.2.3 Respiratory System:
    Inspection: Shape of chest, respiratory
    movements& any other conspicuous
    observation, Palpation :Chest movements,
    trachea, apex beat, tactile vocal fremitus etc.
    Percussion: Anterirorly, posteriroly,
    axilla→upper,lower, Auscultation: Breath
    sounds, added sounds (ronchi,
    crepitations,pleural rub), vocal resonance etc.
    3.2.4 Cardiovascular System:
    Inspection: Precordium, apex impulse,
    pulsations, scars, dilated veins/arteries & any
    other conspicuous observations, Palpation:
    Apex beat, left parasternal heave, diastolic surf,
    thrills, Percussion: Left border, right border(in
    case of pericardial effusion) Auscultation: Heart
    sounds: 1st, 2nd& 3rd sound; murmurs;
    pericardial friction rub & its radiation.
    3.2.5 Central Nervous System:
    Higher functions : Intellect, memory, speech, level of
    consciousness, Meningeal signs: Neck stiffness,
    photophobia, Kernig's sign ;Cranial Nerves : Individual
    nerve examination for 12 cranial nerves; Sensory

    4 (Session 2021-2022)
    functions : Spinothalmic sensation (pain, fine touch,
    temperature),Posterior column sensation (crude
    touch, position, vibration) Motor functions : Muscle
    strength & tone, gait, co-ordination, weakness on
    movement of muscle (UMN/ LMN lesions)
    3.2.2 Skeletal System:
    Inspection: Screen for GALS (Gait, Arms, Legs & Spine):
    deformed shape, swelling etc. Palpation:
    Temperature, tenderness, swelling etc.Joint
    movements: Active & Passive; Limitation of
    movement.

    4. LABORATORY INVESTIGATIONS
    Previous Investigations and reports Investigations advised

    5. DIFFERENTIAL DIAGNOSIS

    6. PROVISIONAL DIAGNOSIS

    7. CASE PROCESSING

    7.1 Analysis Of Case

    Sr.no. Symptoms Natural/ Causa Common


    Miasmatic Occasionalis Symptoms

    7.2. Evaluation of symptoms


    (According to different approach, i.e. Dr.Hahnemann, Dr. Bonninghausen & Dr. Kent, etc. )

    5 (Session 2021-2022)
    8. MIASMATIC ANALYSIS

    Sr. Symptoms Psora Sycosis Syphilis

    9. TOTALITY OF SYMPTOMS [Peculiar & characteristic features relating to Mind, Physical


    Generals& Particulars (PQRS); Causative factors (exciting, maintaining, fundamental) etc.

    10. SELECTION OF MEDICINE: Repertorial Method (Repertorial sheet to be


    attached) / Non- Repertorial Method (remedy selection with justifications)

    11. FIRST PRESCRIPTION (medicine, potency, dose, repetition)

    12. GENERAL MANAGEMENT

    SIGNATURE OF THE PHYSICIAN

    6 (Session 2021-2022)
    14. FOLLOW-UP

    Date Signs and symptoms Prescription Signature

    7 (Session 2021-2022)

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