Clinical case SHEET format for DADRU KUSHTA/ fungal infections

BY

DR. PUCHAKAYALA JYOTHI, P.G. SCHOLAR, KAYA CHIKITSA DEPARTMENT, DR.BRKR. GOVT.AYURVEDIC MEDICAL COLLEGE, HYDERABAD.

UNDER THE GUIDANCE OF

DR. S. RAMALINGESHWAR RAO, SENIOR LECTURER, P.G DEPARTMENT OF KAYA CHIKITSA, DR.BRKR. GOVT.AYURVEDIC MEDICAL COLLEGE, HYDERABAD.

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:

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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)

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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:

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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

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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)

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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

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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.

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