| Presenting complaints | Severity | Chronicity | EpD | OTT |
|---|---|---|---|---|
|
1. Heaviness on shoulders |
H |
1 year |
- |
N |
|
2. Heaviness on neck |
H |
1 year |
- |
N |
|
3. Headache |
H |
>1 year |
- |
|
Integrated Summary
Mrs.N.J aged 35 years c/o heaviness on her head associated with headache. She was also having heaviness on her shoulder region since 1 year. So she came to Ayurvaid hospital for root cause analysis and appropriate management.
Past Medical History:
Dry eye syndrome
| Condition At The Time Of Start Of Treatment On 3.6.2019 | |
|---|---|
|
GC: Fair |
P0 E0 N0 C0 I0 L0 |
|
GENERAL FINDINGS: |
|
|
Appetite: Good |
Bowel:Clear, regular |
|
Micturition: Normal |
Sleep: Sound |
|
Vitality: Moderate |
Stress: Present |
|
Wellbeing: Moderate |
Blood pressure: 130/70 mm of Hg |
|
Pulse: 83/min |
|
|
CLINICAL EXAMINATION: |
|
|
PA: Soft, non tender |
CVS: S1, S2 heard |
|
RS: NVBS heard |
MS: NAD |
DIAGNOSIS: Sinusitis
PRAKRITI: Vata-Kapha
RISK FACTORS:
GENERAL: Aggravation of the above symptoms
Treatments Done:
| Condition At The Time Of Start Of Treatment On 3.6.2019 | |
|---|---|
|
GENERAL FINDINGS: |
|
|
Appetite: Good |
Bowel:Clear, regular |
|
Micturition: Normal |
Sleep: Sound |
|
Vitality: Moderate |
Stress: Moderate |
|
Wellbeing: Moderate |
Blood pressure: 120/70 mm of Hg |
|
Pulse: 82/min |
|
|
CLINICAL EXAMINATION: |
|
|
PA: Soft, non tender |
CVS-S1, S2 heard |
|
RS: NVBS heard |
MS: NAD |
Outcome
| Outcome parameter | Metrics | Before treatment 3.6/.2019 | During treatment | After treatment 21.6. 2019 |
|---|---|---|---|---|
|
Headache |
VAS(0-10) |
10 |
4 |
0 |
|
Heaviness on head |
H/M/L |
H |
M |
M |
|
Giddiness |
Present/Absent |
Present |
Present |
Absent |
|
Ear block |
H/M/L |
H |
M |
Absent(on and off) |
|
Tinnitus |
H/M/L |
H |
H |
Absent |
|
Light sound sensitivity |
H/M/L |
H |
M |
Absent(on and off) |
|
Heaviness on shoulder region |
H/M/L |
H |
M |
M |
Standard Outcome Scale
| Scale with Min-Max Score | Before Treatment 3/6/2019 | After Treatment 21/6/2019 | Impression |
|---|---|---|---|
|
HIT |
65 |
48 |
Moderate improvement (only on & off headache present ; headache frequency and intensity reduced ) |
|
RHINO SINUSITIS |
MAGNITUDE-40.6% IMPORTANCE-37.1% |
MAGNITUDE-9% IMPORTANCE-0% |
Marked improvement |
Conclusion
Mrs. N.J has completed the entire hospital course without any adverse events. All her vitals were monitored regularly which were within normal limits.