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Case Sheet in Ayurveda
- 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?
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- 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 :
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- 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
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- 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 :
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- 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.
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- 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
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- 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/
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- 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:
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- 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.
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- 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.
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- 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).
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- 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:
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- 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)
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- 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
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- 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.
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- 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
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- 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
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- 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
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- 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
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- 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
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- 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:
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- 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 :
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• 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)
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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
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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
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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
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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:
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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
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