2. PRELIMINARY DATA
NAME : MRS.PQRS AGE/SEX: 60/F
OCCUPATION: ACCOUNTANT MARITAL STATUS : MARRIED
PHONE NO.: 5345364876 ADDRESS: JAIPUR
ATTENDING PHYSICIAN: DR.RACHNA
SHRIVASTAV
SOCIOECONOMIC STATUS- UPPER
CLASS
3. PRESENTING COMPLAINT
PAIN IN HEELS FOR LAST TEN YEARS
DURATION: TEN YEARS
LOCATION: BOTH THE HEELS
SENSATION: NEEDLE LIKE PRICKING PAIN
MODALITIES: <MOTION, LONG STANDING
>RUBBING, COLD WATER APPLICATION
4. ASSOCIATED COMPLAINTS:
PAIN IN HEAD FOR LAST ONE MONTH
•LOCATION- WHOLE HEAD
•SENSATION- PULSATING TYPE OF PAIN
•<EMPTY STOMACH
•> PRESSURE
5. CONTINUED..
PAIN IN EPIGASTRIC REGION SINCE LONG
DURATION
•CHARACTER- BURNING
•BLOTTING IN WHOLE ABDOMEN
•< AFTER EATING OILY FOOD
6. PRESENTING ILLNESS
FEMALE PATIENT AGE OF 60 YRS CAME TO OPD
WITH COMPLAINT OF PAIN IN BOTH HEELS SINCE
TEN YEARS
NEEDLE LIKE PRICKING PAIN
PAIN AGGRAVATED BY MOTION, LONG STANDING
AMELIORATION BY RUBBING, COLD APPLICATION
SHE TOOK ALLOPATHIC TREATMENT WHICH GIVE
HER SLIGHT RELIEF
8. GYNAE/OBS HISTORY-
MENOPAUSE ATTENDED AT AGE OF 49 YEARS
COMPLAINTS AT THE TIME OF CLIMACTERIC
–
1)PAIN IN HEAD,
2) INCREASED IRRITABILITY,
3) DECREASE IN APPETITE
9. OBSTRETICS HISRTORY
NO.1
DATE OF DELIVERY- 4
TH
NOV 1993
COMPLAINTS DURING PREGNANCY- NO COMPLAINT
TYPE OF DELIVERY- NORMAL
BIRTH WT. OF CHILD- 3KG
ALIVE / DEAD - ALIVE
LACTATION HISTORY- 6
TH
MONTH
10. PHYSICAL GENERALS:
CONSTITUTION FAIR COMPLEXION, TALL, BLOND HAIR .
APPETITE 2 TIMES/DAY PREFERENCE IN LUNCH -
FRUIT AND JUICES
THIRST EXCESSIVE THIRST DRINK 5-6 LIT. OF
WATER/DAY
PREFER COLD WATER ONE GLASS AT A
TIME - EVERY HOUR
DESIRE
AVERSION
FRUITS AND GREEN VEGETABLE
OILY FOOD, SPICY FOOD, MILK
PRODUCTS
STOOL SATISFACTORY, REGULAR, ONCE IN A
DAY,NO STRAINING
URINE 6-7 TIME IN DAYS, NO BURNING, PALE
YELLOW COLOUR
SLEEP 6HOURS,UNREFRESHED DUE TO
COMPLAINT
11. Physical generals cont….
DREAM UNREMEMBERED
SWEAT SCANTY ON WHOLE BODY, NON
OFFENSIVE
THERMAL HOT, DESIRE COLD AND OPEN
ENVIRONMENT
12. MENTAL GENERALS:
ANGER PRESENT, WHEN EXPECTATION ARE NOT FULFILED.
PATIENT GETS IRRITABLE WHILE AN ARGUMENT.
> BY CONSOLATION.
FEAR OF BEING DROWNED.
RELIGIOUS
MEMORY SHARP.
TRAVELLING DESIRE
13. PHYSICAL EXAMINATION
CONSCIOUS SKIN: LOOSE SKIN
HEIGHT: 170 cm GAIT: STEADY
WEIGHT:58Kg B.P. : 130/80mmhg
PALLOR : NOT PRESENT PULSE: 75/min.
CYNOSIS: NOT PRESENT TONGUE: CLEAN, MOIST
OEDEMA: NOT PRESENT ANAEMIA: NOT PRESENT
LYMPHADENOPATHY: NOT PALPABLE
14. SYSTEMIC EXAMINATION
LOCOMOTOR SYSTEM- FOOT (BOTH)
INSPECTION :-A HIGH ARCH- NORMAL
PALPATION :-TENDERNESS ON TOUCH AT HEEL BONE
PAIN ON FLEXION OF FEET
ADVICE FOR
SKIA GRAM OF BOTH ANKLE JOINT AP OR LATERAL VIEW
16. CLASSIFICATION OF SYMPTOMS
ACCORDING TO JT. KENT’S REPERTORY.
MENTAL GENERAL PHYSICAL GENERAL PARTICULAR GENERAL
•Anger present, when
expectation not fulfilled
• patient gets irritable
while an argument
•> Consolation
•Travelling desire
•Fear of drowned
•Religious
•Aversion- oily food, spicy
food, milk product
•Excessive thirst, prefer
cold water
•Desire-fruits and
vegetable
•Pain in heels
Needle pricking like
sensation
< long standing
>rubbing, cold application
•Pain in whole head,
pulsating type of pain
<empty stomach
>Pressure
• Pain in epigastric region
Blotting in whole abdomen
< after eating oily food
17. TOTALITY OF SYMPTOMS
Pain in heels
Needle like pricking sensation
< long standing, motion
>rubbing, cold application
Pain in whole head, pulsating type of pain
<empty stomach
>Pressure
Pain in epigastric region
Burning sensation
Bloating in whole abdomen
< after eating oily food
18. CONTINUE
Desire-fruits and vegetable
Anger present, when expectation are not
fulfilled
patient gets irritable while an argument
> Consolation
Travelling desire
Fear of drowned
Religious
