Ayurvedic Case Sheet
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DR
Dr. Smith

Ayurvedic Case Sheet

MediCore Ayurveda Clinic • Case No. CS-2026-1042

Date

May 15, 2026

Patient Information

Name

John Carter

Age / Gender

42 yrs / Male

Patient ID

P-1042

Phone

+91 98765 43210

Prakriti

Vata-Pitta

Vikriti

Vata Pradhana

Agni

Vishamagni

Occupation

Software Engineer

Chief Complaint

Chronic lower back pain (Kati Shoola) for 6 months, aggravated by prolonged sitting and cold weather. Associated with constipation and disturbed sleep.

Ashtavidha Pariksha

ExaminationFindings
Nadi (Pulse)Vata pradhana — irregular, fast, thread-like (Tantu), 78 bpm
Jihva (Tongue)Dry, brownish coating in posterior third, cracked margins
Drika (Eyes)Sunken, slight redness, frequent blinking, poor luster
Sparsha (Touch)Skin cold and rough to touch, reduced sweating
Akriti (Build)Lean, stooped posture, restless movements, dry skin
Shabda (Voice)Weak, hoarse at times, talks rapidly
Mutra (Urine)Scanty, dark yellow, occasional burning
Purisha (Stool)Dry, hard, irregular — every 2–3 days, painful defecation

Dosha Assessment

Vata65%
Pitta30%
Kapha15%

Diagnosis (Roga Nidana)

Nidana (Causative Factors)

Prolonged sitting (Asana), late night work (Ratri Jagarana), irregular meals, excessive intake of dry/cold foods, stress.

Samprapti (Pathogenesis)

Vata Prakopa → Apana Vayu obstruction → Asthi Dhatu Kshaya → Kati Shoola. Vata vitiation in Pakvashaya causing Mala Baddhata.

Roga: Kati Shoola (Vataja Pradhana) with Vibandha (Constipation)

Dosha: Vata Pradhana, Anubandhi Pitta

Dushya: Asthi, Mamsa, Purisha

Srota: Purishavaha Srotas, Vatavaha Srotas

Treatment Plan (Chikitsa)

Medicines
MedicineFormDoseAnupanaDuration
Trayodashanga GugguluTablet1 tab BDWarm water30 days
Mahanarayana TailamOil10 ml BDWarm milk30 days
Eranda SnehanaOil20 ml HSWarm water7 days
Hingvastak ChurnaChurna3 gm BDGhee + Warm water15 days
Ashwagandha ChurnaChurna3 gm BDWarm milk60 days
Panchakarma / Procedures
  • Kati Basti with Mahanarayana Tailam — 7 days
  • Pinda Sweda with Dashamoola — 7 days
  • Sneha Basti with Eranda Taila — 3 days (alternate)
  • Abhyanga (full body) with Dhanwantharam Tailam — Daily
Diet & Pathya (Do's)
  • Warm, freshly cooked meals. Avoid cold/refrigerated food.
  • Include ghee, sesame oil, and warm soups in diet.
  • Soaked raisins (5–6) and figs in warm water daily.
  • Warm milk with Ashwagandha at bedtime.
  • Drink warm water throughout the day.
Apathya (Don'ts)
  • Avoid dry, cold, and light foods (salads, popcorn, crackers).
  • Avoid late night meals and staying awake past 10 PM.
  • Avoid prolonged sitting — take breaks every 45 minutes.
  • Avoid suppression of natural urges (urges of stool, urine, sleep).
  • Reduce caffeine and aerated drinks.
Lifestyle Recommendations
  • Practice Bhujangasana, Pavanmuktasana, and Setu Bandhasana daily.
  • Pranayama: Nadi Shodhana 10 min, Bhramari 5 min — morning & evening.
  • Abhyanga (self-massage) with warm sesame oil before bath.
  • Regular sleep schedule: 10 PM – 6 AM.

Follow-up

Next Visit

May 29, 2026

Review After

14 days

Re-assessment

Nadi, Bowel habits, Pain scale

Examined By

Dr. Rajesh Sharma (BAMS, MD Ayurveda)

Reg. No. AY-78432 • MediCore Ayurveda Clinic

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