clinical case sheet format for Dadru kushta/ Fungal Infections
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Transcript of clinical case sheet format for Dadru kushta/ Fungal Infections
Post Graduate Department Of Kãya Chikitsa Dr. BRKR Government Ayurvedic College & Hospital
Erragadda, Hyderabad. (Affiliated to Dr. NTR University of Health Sciences)
Special Case Sheet for the clinical evaluation of Dãrvãdi yoga and Kushţãdi lepa in the management of Dadru kushta
Name of the patient: Serial no:
Age/Sex: OPD/IPD reg No:
Religion: Date:
Education details: Diagnosis:
Marital status: Result:
Social status:
Occupation:
Address:
Phone no:
1
Chief complaints with duration: (Pradhãna Vedhana with Avadhi)
Associated Complaints: (Anubandha Lakshanas)
History of Present illness: (Roga Vruttãntam)
Mode of onset of lesion(s) -
Site of lesion(s) -
Characteristic of lesion(s) - Intermittent / Progressive
Earlier similar episodes (if present any) - Yes / No
H/o any aggravating / relieving factors - Yes / No If yes,
1. Food - veg / non veg
2. Season - rainy / winter / summer
3. Others - H/o Photo allergy/ any allergic skin reactions
History of Past illness: (Rogi Pũrva Vruttãntam)
Family History:(Parivãrika Ithihas)
2
Treatment History: (Chikitsa Vruttãntam)
Personal History: (Vyakti gata Charithra)
1. Diet - Veg / Non veg / Mixed
2. Addictions - Alcohol / Smoking / Others / No addictions
3. Appetite - Good / Average / Poor
4. Sleep - Sound / Disturbed
5. Micturition - Free / Dysuria / Polyuria / Oliguria
6. Bowels - Regular / Irregular / Constipated / Loose stools
Menstrual History:
Obstetric History: General Examination: (vitals) Systemic Examination: 1. BP - 1. CNS - 2. Pulse - 2. CVS - 3. Temp - 3. RS - 4. Resp.rate - 4. GIT -
5. Built - 5. GUS -
6. P/A - 6.MS /LS - Ashţa Sthãna Parĩksha: Dasha Vidha Parĩksha:
3
1. Nãdi - 1. Prakruthi -
2. Mala - 2.Vikruthi - Dosha: Dũshya: Srotas:3. Mũtra - 3. Satwa -
4. Jihwa - 4. Sãtmya -
5. Śabda - 5. Samhana -
6. Sparśha - 6. Sãra -
7. Dhruk - 7. Āhãra Śakti -
8. Ākruthi - 8. Vyãyãma Śakti -
9. Vayah -
10. Pramãna -
Examination of Integumentary System:
I. General Examination
SKIN (Twak) Texture:
Color:
NAILS (Nakha) Color:
Nature: Normal/ Onychomycosis/ Onycholysis HAIR (Kesha) Color: Distribution:
II. Local Examination
4
1) Site of lesion - (Pidaka Sthãna) Scalp/ Face/ Neck/ Hands/ Feet/ Trunk/ Groins/ Nails/ Others
(Flexor surfaces/ Extensor surfaces)
2) Distribution - (Vyãpti) Symmetrical/ Asymmetrical
3) Character of lesion -
(Pidaka Lakshanas) Size:
Color: Type: Maculae/ Annular scales/ Annular plaques with erythematous base/
Annular plaques with peripheral papules or vesicles
Arrangement: Single/ Grouped
4) Itching - Present /Absent (Kandu) Severity: Mild/ Moderate/ Severe (pruritic)
Time: Day/ Night/ Both
5) Inflammation - Present / Absent (Rãga) Severity: Mild/ Moderate/ Severe
6) Discharge - Present/Absent (Srãva)
5
Color: watery/white/red
Contents: blood/pus/clear fluid
7) Superficial Sensation on lesion - Anasthesia/ Parasthesia/Normal (Pidaka Sthãna Sparśha) Pain: Present/ Absent Swelling: Present/ Absent
Investigations:
1. Routine investigations: CBP, ESR, RBS, CUE
2. Special investigations: (Optional) Fungal Culture
Skin biopsy Woods Light examination
Treatment Schedule: (Chikitsa Krama)
Duration of treatment (trial) for 40 days -
1. Oral administration of “Dãrvãdi Yoga” 6gm, bid with Luke warm water (after food)
2. External application of “Kushtãdi lepa”
Review - Every 10 days
Clinical Parameters:
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Itching, Inflammation, Color, Nature of lesion, Size of lesion, Number of lesions.
Slno Parameter
BeforeTreatment
Review
After Treatment
10days 20days 30days 40 days
1. Itching
2. Inflammation
3. Color changes
4. Nature of lesion
5. Size of lesion
6. Number of lesions
Grading scale:
Sl. Parameter Grade Grade Grade Grade Grade Grade
7
no 0 1 2 3 4 5
1. ItchingNo itching
Occasionally mild itching
Mild itching
Moderateitching
Severeitching
Severe continuous itching
2. Inflammation
No inflammation
Mild inflammation
Moderate inflammation
Severeinflammation
Severe inflammation with prominent erythematous base
3. Color changes
No color change
Pink color
Pinkish red color
Red color
Black-is blue color
Black/Violaceous black color
4. Nature of lesion
No lesion
Mild visible lesion
Moderately visible lesion
Prominent visible lesion
Prominently evident lesion associated with discharge
5. Size of lesion (diameter)
Below 0.5/1cm
1 to 2cm
2 to 3cm
3 to 4cm
4 to 5cm
Above 5cm
6. Number of lesions
No lesion
Only 1lesion
2 lesions
3 lesions
4 lesions
More than 4 lesions
Results Assessment:
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Finally over all result is calculated by taking average of all parameter results.
Sl.no
Parameter Before treatment
After treatment
% of improvement
1. Itching
2. Inflammation
3. Color changes
4. Nature of lesion
5. Size of lesion
6. Number of lesions
Percentage Result Below 40 % - Poor 40 to 60 % - Average 60 to 80 % - Good 80 to 90 % - Very good 90 to 100 % - Excellent (Reduction from initial treatment)
Date of Commencement of treatment:
Date of Completion of Treatment:
Over all Response to Treatment: Poor/Average/Good/very good/Excellent
Signature of PG scholar Signature of Guide
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Consent Form
I ----------------------------- Son/ Daughter/ Wife of ------------------------ After being explained thoroughly the entire purpose of clinical trial and nature of treatment to my satisfaction, I hereby willingly agree to participate as a subject in the above clinical study of “Dadru Kushta”. I am aware of my right to opt out of the treatment schedule at any time during the course of clinical trial.
Signature of Witness Signature of Patient 1.
2.
10