DEPARTMENT OF ROGA NIDAN

SAM COLLEGE OF AYURVEDIC SCIENCES &

HOSPITAL, RAISEN

Long case sheet

Patient Name: Case No:

Age: Sex: M / F Date of Admission:
Religion: H / M / S / Ch Date of Discharge:
Marital Status: M / U M / D / W / S OPD / IPD:
Education: U E / P / M / H / G / P G / Ward / Bed No:
Doctoral /Professional
Occupation: Consultant:
Socio Economic Status: V P / P / L M / Provisional
M/UM/R/VR Diagnosis:

Address: Final Diagnosis:

Mukhya Vedana (Chief Complaints with Duration in

Chronological order):

Chief Complaints Duration

1)
2)
3)
4)
5)

Anubandha Vedana (Associated Complaints):

1)
2)
3)
4)
5)

Pradhana Vedana Vrittanta (History of Present Illness):

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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

Purva Vyadhi Vrittanta (History of Past Illness):

Past History:

Treatment History:

Kautumbika Vrittanta (Family History):

Father: Brother:

Mother: Sister:

Diseases having Genetic Spouse:

Predisposition:
Children:

Vaiyaktika Vrittanta (Personal History):

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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

(A) Aaharaja:

a) Types of Diet: Vegetarian / Mix

b) Dominance of Rasa in Diet: Madhur / Amla /
Lavana / Katu / Tikta / Kasaya
c) Dominance of Guna in Diet: Usana / Sheet / Guru /
Laghu / Snigdha / Ruksha
d) Dietary Habits: Samasana /
Adhyasana / Vishamaasana
Regular /
Irregular
e) Supplementary Diets: Tea / Coffee / Cold
drinks / Others
Quantity:
f) Vyasana (Habit): Tobacco (Smoking /
Chewing) / Alcohol / Sedative / Other
Quantity:

(B) Viharaja:

a) Vyayama: Regularly / Irregularly /

No / Less / Proper / Excess
b) Vishrama (Rest): Hrs. / Day
Hrs. / Night
c) Abhyanga: Yes / No
d) Snana: Daily / Irregular
e) Nidra: Samyaka / Asamyaka
(Alpa / Prabhuta)
Hrs. / Day
Hrs. / Night

(C) Koshtha – Bowel :

a) Agnibala: Visham / Manda /

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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

Teekshna / Sama
b) Koshtha: Mradu / Madhyam / Krur
c) Mala: Santushta / Asantushta /
Saama/ Nirama/Kathina
/Drava /Sakashtam
/Vivarna/Alpa/ Muhurmuhur
Frequency: Time /
Day
d) Apana Vayu (Flatus):

(D) Mootra Pravritti – Micturition:

a) Mootra: Samyaka/ Asamyaka

(Kruchchha /Vaivarnya/Daaha/Alpa/Prabhutta
Frequency: time / Day
time / Night

(E) Artava Pravritti – Menstrual History:

a)

b) Menarche / Menopause
c) Regular / Irregular
d) L. M. P.
e) Use of contraceptive - Oral Pills/Copper-
T/Injectable/Vaginal Pessary/ Vaginal Pills
/others

(F) Prasava – Obstetric History:

a)
b) Last Delivery:
Physical Examination
Decubitus Height
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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

Icterus Weight
Pallor Temperature
Cyanosis Pulse
Pigmentat Blood
ion Pressure
Clubbing Respiratory
Rate
Oedema Heart Rate
Lymph
Nodes

Respiratory System
Inspection Shape

Symmetry

Respiratory
Movements
Obvious
Swellings

Palpation Trachea Centrally Placed / Deviated

Vocal
Fremitus

Percussion

Auscultation Breath
Sounds

Vocal
Resonance

Adventitious
sounds

Cardio-Vascular System

Inspection Superficial Veins

Movement With
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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

Respiration
Palpation Apex Beat
Percussion
Auscultatio Auscultatory
n Areas
- Aortal Area
- Pulmonary
Area
- Tricuspid
Area
- Mitral Area
S1, S2 Heart
Sounds
Adventious Murmurs
Sounds

Gastro-Intestinal System

Inspecti Contour Of The

on Abdomen
Skin
Umbilicus
Movement Of
Abdomen
Visible Peristalsis
Superficial Veins
Auscult Peristaltic Sounds
ation
Palpatio Consistency of The
n Abdomen
Tenderness
Lump
Liver
Gall Bladder
Spleen
Kidneys
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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

Percuss Fluid Thrill

ion
Shifting Dullness
Puddle’s Sign

Uro-Genital System

Inspection

Palpation

Central Nervous System

1 Consciousness

2 Higher Functions

3 Intellectual Capacity

4 Memory

5 Cranial Nerve
Examination

6 Straight Leg Raising Test

(SLR)

7 Motor Functions
1. Bulk of Muscles
2. Tone of Muscles
3. Strength of Muscles
4. Reflexes
A. Superficial Reflex
B. Deep Reflex
5. Co-Ordination of
Movement Spastic (Hemiplegic Gait) /

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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

6. Gait Scissor /Ataxia (Wide

based ataxia, Drunken
ataxia, Friedreich’s ataxia,
Ataxia of cerebellar disease)
/ Festination / Steppage
(Foot drop) /Waddling
7. Involuntary
(Myopathic)
Movements

Grading of weakness
Gradation
Grade 0: Total Paralysis
Grade 1: A Flicker of contraction
Grade 2: Normal movement with gravity
eliminated
Grade 3: Normal movement against gravity not
against additional resistance
Grade 4: Full normal movement but overcomes
by resistance
Grade 5: Normal power

Detailed Examination of System Involved

Sroto-Pariksha

S.No Srotas Observation

.
1 Pranvaha
srotas

2 Udakavaha
srotas
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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

3 Annavaha

4 Rasavaha

5 Raktavaha

6 Mansavaha

7 Medovaha

8 Asthivaha

9 Majjavaha

10 Shukravaha

11 Mutravaha

12 Purishavaha

13 Swedavaha

14 Artavavaha

Dashavidha Pareeksha

1 Prakriti K / P / V / VP / VK / KP / VPK
.
2 Saara Twak / Rakta / Mansa / Meda / Asthi
. /Majja / Sukra / Satva

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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

3 Samhanan Pravara / Madhyama / Avar

. a
4 Pramana Pravara / Madhyama / Avar
.
5 Satmya Pravara / Madhyama / Avar
.
6 Satva Pravara / Madhyama / Avar
.
7 Aharashak Pravara / Madhyama / Avar
. ti
8 Vyayamas Pravara / Madhyama / Avar
. hakti
9 Vaya Bala / Madhya / Jirna
.

Vikriti Pariksha (Samprapti Vighatana)

Dosha: Vriddhi/Kshaya
Dushya
Saptadhatu: Vriddhi/Kshaya
Upadhatu:
Mala:
Vriddhi/Kshaya
Sharirika mala
Saptadhatu mala
Agni
Jatharagni : Manda, Vishama, Tikshna
Dhatvagni : Manda, Vishama, Tikshna
Bhutagni : Manda, Vishama, Tikshna
Ama
Jatharagnijanya
Dhatvagnijanya
Bhutagnijanya
Srotas(Name the involved srotas)
Srotodusti
Sangha
Vimargagamana
Atipravritti
Siragranthi
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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

Adhisthana
Sancharasthana

Vyaktasthana

Udbhavasthana

Svabhava

Prabhava

Rogamarga

Rogabheda

Hetu

Desha

Assessment of Dashvidha Pareeksha

Rogi bala Pareeksha : Pravara Madhyam

Avar
Roga bala Pareeksha : Pravara Madhyam
Avar

Prayogashaliya Pariksha (Ancillary Investigations)

Heamatological –

Serological –

Biochemical –

Urine Analysis –

Radiological -

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 DEPARTMENT OF ROGA NIDAN
SAM COLLEGE OF AYURVEDIC SCIENCES &
HOSPITAL, RAISEN

Other Relevant Investigations -

Sambhavita Roga (Provisional Diagnosis):

Upashaya & Anupashaya:

Vyavachedaka Nidana (Differential Diagnosis):

Vyadhi Vinischaya (Final Diagnosis):

Upadrava

Arishta

Sadhyasadhyata (Prognosis)

Management

Signature of the Student

Signature of the Teacher

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