CASE PRESENTATION

FINAL YEAR P.G. SCHOLARS

DEPARTMENT OF PG STUDIES IN KAYACHIKITSA

SKAMCH&RC

VIJAYANAGAR

BENGALURU1

ATURA VIVARANA

2

Name : Mr. P. K. Raju

Age : 55 Years

Sex : Male

Religion : Hindu

Socio economic status : Middle class

Marital status : Married

Occupation : Peon in BBMP

3

Address : Sunkadakatte

Bengaluru

Source of history : Patient

O.P No :E19392

I.P. No : 2445/17

Ward : Male General ward

Date of admission : 16/06/17

Date of discharge :

4

Case taken on : 30/06/17

Consultant doctor : Dr. Byresh A

PRADHANA VEDANA

5

C/O Pain in the neck region radiating to B/L upper limbs

Since 5 months.

Weakness in B/L upper limbs Since 5 months.

ANUBANDHA VEDANA

6

C/O burning sensation, numbness and tingling sensation in B/L upper

limbs and lower limbs.

Unable to do daily activities like taking bath, wearing shirt, holding

objects, eating etc., with respect to both upper limbs.

Increased frequency of micturition with increased volume, increased

thirst and sweating aggravated since 5 months

Constipation Since 5 months

C/O cyst over left eyebrow since 1 week

VEDANA VRITTANTA

7

The patient is a K/C/O DM since 8 years presented with a

history of sudden development of shocking type of pain in

the neck region radiating to both upper limbs while carrying

files at office 5 months before (Feb 2017). The pain was so

severe that he dropped the files and there was a sort of

sudden weakness in both upper limbs and couldn’t move the

hands. But there was no H/O fall/ LOC/ headache/ giddiness.

8

he found difficulty in walking also and there was increased

frequency of urination. For these complaints, he was

admitted in Sindhi hospital for a day and was later referred

to Sita Bhateja Hospital and was admitted for 10 days,

necessary investigations done and conservatively treated.

After discharge, the weakness of the upper limbs still

persisted, but was able to walk. The weakness of the upper

limb hampered his daily activities like taking bath, wearing

9

shirt, holding of objects, eating etc., Also he developed

constipation and disturbed sleep. Frequency of micturition

also persisted. So, he consulted a folklore practitioner in

Yentaganahalli where he was treated with some oil

application, coin and bandage application. But there was no

improvement noted.

Aggravating factors: The pain and numbness increases on

exposure to cold water , fan.

10

By the suggestion of their relative, he came to

SKAMCH&RC for further management. After admission,

he developed cyst over left eyebrow since 1 week.

POORVAVYADHI VRITTANTA

11

K/C/O DM since 8 years. Initially was on OHA for 5

years, on insulin for 3 years. Stopped Insulin 4 months

back and now only OHA.

H/O Surgery for low back ache - around 6 years back.

H/O cyst mid back ,done excision 4 years back

H/O of repeated cyst over left eyebrows – managed

with I&D since 2 years.

CHIKITSA VRITTANTA

1

2

In Sita Bhateja Hospital (7/2/17 to 16/2/17)

Diagnosis- Central cord syndrome, Uncontrolled DM, oral

candidiasis, LRTI

Treatment given: IV Fluids

Inj.Tramadol

Inj.C Tri

Inj. Dexa

Inj.Solumedrol

Inj.Optineuron

• Inj. Flucon

• Inj.H.Actrapid

• Inj.Human Insulin

• Tab.Ecosprin AV

• Tab. Glychek M forte

• Tab. Neurica M

• Tab. Janumet

• Tab.Wysolone

• Syp.Ambrolite

• Incentive Spirometry

• Asthalin Nebulization

• Duolin Nebulization

• Chest and limbs-

physiotherapy

13

ON MEDICATIONS

1

4

Tab.Ecosprin AV 0-0-1

Tab. Glychek M forte 1-0-1

Tab. Neurica M 75 mg 1-0-1

Tab. Janumet 50/500 0-1-0

KOUTUMBIKA VRITTANTA

15

All family members are said to be healthy.

VAIYAKTIKA VRITTANTA

16

Ahara : Non-Vegetarian ( Twice/week).

Mala Pravrutti : Once in 5 days

(Irregular, hard stools)

MutraVisarjana : 10-12 times / day

3- 4 times / night

Nidra : Disturbed due to pain and burning

sensation

VAIYAKTIKA VRITTANTA

17

Vyasana : Coffee (2-3 times /day)

Beedies- 20 since 20 years,

Cigarrete – 10-15 /day since 5 months

Alcohol – 250 ml/day since 15 years

ROGI PAREEKSHA

18

ATURA BHOOMI DESHA PAREEKSH

19

Jatatah : Sadharana

Samvardhitah : Sadharana

Vyadhitah : Sadharana

ASTHA STHANA PARIKSHA

20

Nadi :68/min

Mutra :10-12 times / day, 3-4 times / night

Jihva : Lipta

Mala : Once in 5 days (irregular, hard stools)

Sabdha : Prakruta

Sparsha : Anushna sheeta

Druk : blurrness in left eye

Aakruti : Madhyama

DASHAVIDA PAREEKSHA

21

1) Prakriti : Pitta kapha

2) Saara : Madhyama

3) Samhanana : Avara

4) Pramana : Madhyama (Height: 167cm, Weight :

78.7kg)

5) Saatmya : Vyamishra

6) Satva : Madhyama

7) Aahara Shakti :

Abhyavaran Shakti : Avara

Jarana Shakti : Avara Cont…

22

8) Vyayama Shakti : Avara

9) Vaya : Madhyama

10) Vikriti : pravara

Hetu : rooksha, virudhahara sevana,

vishamashana

Dosha :tridosha(vatapitta)

Dooshya : shareera kleda, lasika, Rasa, Rakta,

abadha Mamsa, abadhameda, vasa,majja,

ojas,Asthi

23

8) Desha : Sadharana

Bala : Avara

Kala :varsha

Prakriti : vikruti vishama samavaya

SAMANYA PARIKSHA (GENERAL PHYSICAL EXAMINATION)

24

Patient is conscious, alert, oriented to time, place and

Person.

Built : moderately built

Nourishment : Moderately -Nourished

Pallor : Absent

Oedema : Mild pitting oedema in b/l hands

Cyanosis : Absent

Nail : No clubbing or koilonychia

Icterus : Absent

Lymphadenopathy : Absent

25

Temperature : Afebrile

Pulse : 78 bpm.

BP : 130 / 90 mmHg.

R/R : 16b/min

Tongue :coated

Height :167cm

Weight :78.7

BMI :28.3

VISHISHTA PARIKSHA(SYSTEMIC EXAMINATION)

26

PER ABDOMINAL EXAMINATION

Inspection - Shape- distended

Umbilicus- Centrally placed, inverted

No Scar marks, No hyper pigmentation

Auscultation - Bowel sounds heard .

Palpation - Soft

No Tenderness

No organomegaly

Percussion - Tympanic

27

RESPIRATORY SYSTEM

Inspection –

Shape of chest –B/L symmetrical

Chest movements- Symmetrical

Respiratory rate-18/min

Palpation - Trachea - Centrally placed

Chest Expansion - Symmetrical

Tactile vocal fremitus - Normal

Percussion - B/L Resonant

Auscultation - B/L Normal Vesicular Breath Sounds heard

28

CARDIO VASCULAR SYSTEM

Inspection – No scar marks

Palpation - Apex beat felt @ 5th intercostal space lateral to

left mid-clavicular line

Percussion – Cardiac dullness noted

Auscultation - S1, S2 heard, No added sounds

LOCOMOTOR SYSTEM EXAMINATION

29

GAIT Normal

Inspection :

Shoulder ,upper limbs and hand muscle atrophy present

No scars seen over neck, shoulder and arms,

Swelling noted over bilateral hands

Palpation :

No tenderness, warmth, mass felt. Muscle atrophy felt

over shoulder, arm, forearm and hand muscle,

30

Shoulder joint :

All Range of movements

Restricted and painful

Spine examination:

Inspection

Old surgical scar seen over spinous

process of lumbar vertebrae, excision scar

over midback.

No scoliosis / lordosis/ kyphosis noted

31

Palpation

No Warmth, No mass, No Swelling

No tenderness

Range of motion

All cervical spine and lumbar spine motion

Possible and painless

CENTRAL NERVOUS SYSTEM EXAMINATION

32

(A)HIGHER MOTOR FUNCTIONS

Consciousness – Fully conscious

Orientation to -time, place and person is Intact.

Memory -immediate, recent and remote is Intact.

Intelligence- Intact

Hallucination & Delusion- Absent

Handedness-Right

33

(B) CRANIAL NERVE EXAMINATION

All cranial nerves Intact

(C) MOTOR SYSTEM

1)Involuntary movements – fasciculations Present over

upperlimbs

2)Muscle bulk – Rt Lt

Biceps 28.5cm 29cm

Forearm 22cm 21.5cm

Mid Thigh 44cm 46cm

Calf Muscles 33cm 32cm

3)Muscle tone Hypotonia present

34

Rt Lt

4)Muscle strength

a)Elbow -flexion 3/5 3/5

-extension 3/5 3/5

b)Wrist -flexion 3/5 3/5

-extension 3/5 /5

c) Finger abduction

d)Opposition of thumb not possible

e) Test of grip

35

Rt Lt

Hip -adduction 5/5 5/5

-abduction 5/5 5/5

-flexion 5/5 5/5

-extension 5/5 5/5

Knee -flexion 5/5 5/5

-extension 5/5 5/5

Ankle -dorsiflexion 5/5 5/5

-plantarflexion 5/5 5/5

36

5)Coordination

Finger nose test

Rapid alternative movements – not possible

Heel to shin test - possible

Intention tremor - absent

Tandem walking – rate-slow-Possible

Rhomberg test - Negative

Pronator drift – Absent, Rebound phenomenon – absent.

37

6)Gait- normal

7)Reflexes

Superficial Reflexes

a)Corneal -present

b)Abdominal -present

38

Rt Lt

Deep Reflexes (2 + indicates normal)

a)Biceps jerk +++ +++

b)Triceps jerk +++ +++

c)Knee jerk +++ +++

d)Ankle jerk - -

e)Clonus (ankle) Absent Absent

Plantar reflex - not able to elicit dorsiflexion

39

(D) SENSORY SYSTEM

1)Superficial:

a)Touch -Intact

b)Temperature -Intact

c)Pain - hyperasthesia present

2)Deep:

a)Vibration - present

b)Position sense -present

c)Pressure sense -present

INVESTIGATIONS

40

41

MRI cervical spine on 7th feb 2017

Impression :-

Long segmental focal T2 hyperintensity

involving the cord extending from c2 to c7

level ischaemic etiology ?

Posterior, central and b/l para central disc

protrusions at c4-c5 and c5–c6 level causing

moderate thecal compressions.

Posterior right para central disc protrusions at

c6-c7 level causing significant right lateral

recess nerve root compression.

ROGA PAREEKSHA

42

NIDANA PANCHAKA

43

Nidana – Madhumeha+ virudhahar, vishamashana

Purvaroopa - karapadadaha

Roopa- karmakshaya of bahu( gatisanga), balamamsa

kshaya in urdhwa shakha, sarvanga daha, suptata, harsha

Atisweda, trushna, aruchi, klama, mootraatipravruthi, vit

sanga

Anupasaya: sheeta jala, sheetavayu samsparsha

Tridosha

prakopa(vatapitta)

Madhumeha Amotpathi

Prameha pidakas,

prabhuta mootrata,

pipasa, swedadikyada,

indriyaupalepa

44

Circulates through

out the body

Sthanasamshraya over

trika sandhi

greevapradesha

Avarana

Nidana

Vikruthi in

tiryak gata

dhamanais

Sarvanga

daha,atisweda, supti,

harsha,klama

45

Sira,snayu,kandara

shosha

Kramaath shoola,

karmakshaya of bahu,

bahushosha Sparshajnana

vikruti,

Rasadeemshcha

upashoshayeth to greeva-

urdhwa shakha

Vishwachi,

bahusheershagata

vata

Hampers the

nourishment to the

kaphasthana-trika

sandhi

Samprapthi ghataka

• Dosha -Tridosha (vatapitta)

• Avaraka dosha- pitha and kapha

• Avrutha dosha- samana, vyana, apana

• Dooshya - shareeraja kleda, lasika rasa,rakta,

abadha mamsa, abadha meda, majja, asthi,

• Agni -Jataragni, dhatvagni

• Ama - Jataragnimandhyajanya

• dhathwagnimandhyajanya

46

• Srothas - rasavaha, raktavaha, mamsavaha,

medovaha, astivaha, mootravaha, udakavaha, swedavaha

• Srotho dushti prakara – sanga

• Udbava sthana -Amashaya and pakwashaya

• Vyaktha sthana - sarvashareerea

• Adhishtana - greeva and basti

• Marga - Madhyama

• Sadhyasadhyatha - kashtasadhya

47

VYAVACHEDAKA NIDANA

48

49

Vyadhi

Avabahuka bahupraspaditahar

a

kramaathshoola

vatarakta Vidaha, vedana,

sweda,

trushna,shosha

Tasya sthanam

karou

padavangulya,

sarvasandhi

Pakshagha

ta

Sira snayu

vishoshana,

sandhibandha

vimokshayan,

karmakshaya

Ardhakaya

akarmanya and

vichetana

50

Bahushosh

a

Amsabandhana

shosha, bahushosha,

savedana

Vishwachi Bahukarmakshaya,

kramathshoola.

Madhumeha

upadrava

Prameha pidakas,

trushna, daha,

dourbalya, arochaka,

avipaka

51

DIFFERENTIAL DIAGNOSIS

52

Radiculopathy Myelopathy

Pain, Burning, tingling,

numbness in neck region

with radiation into arm and

generally unilateral

associated with paresthesia

and weakness

Bilateral weakness with neck

pain

Paraesthesia in bilateral

upper limb and lower limb

Often with urinary

incontinence

Sudden onset

Deep tendon Reflexes

exaggerated with extensor

plantar response

53

Neuropathy Mechanical neck pain

Paresthesia

Weakness and atrophy more

distal than proximal

Sensory deficits commonly

in stock and glove pattern

Mostly distal parts of lower

limbs are involved

Deep tendon reflexes are

diminished

Neck pain

Muscle spasm, stiffness,

tightness in upper back and

shoulder lasting upto 6

weeks

No neurological deficits.

54

Multiple sclerosis Acute transverse

myelitis

Insidious over days to

weeks

Age of onset is 20-45 yrs

Common in females

Bladder dysfunction

Sensory disturbances

Ataxia, spastic paraplegia

Optic neuritis, scanning

speech

Neurological deficits are

seen

Symmetrical numbness

and weakness

With bladder dysfunction

55

Gullian barre syndrome Motor neuron disease

Weakness and muscle

wasting

Bilateral ascending motor

paralysis

Deep tendon reflexes are

absent

Self limiting and

recovery in 2-4 weeks

Wasting of muscles

Insidious onset

Deep tendon reflexes are

diminished in upper half

of body and exaggerated

in lower half of body

No sensory impairement

56

CVA

Reduced strength of b/l

upperlimbs,Deep tendon

reflexes exaggerated,

Babinski sign present

Presentation is

commonly hemiplegic

with altered gait, Spastic

plegia.

VYADHI NIRNAYA / DIAGNOSIS

57

Vishwachi, bahushosha, madhumeha upadrava

Cervical Myelopathy

Diabetic Neuropathy

DATE CHIKITSA OBSERVATION

19/06/1

7

•Continue same treatment

( Stop Sarvanga CPS with kottamchukkadi

churna and jadamayadi churna )

• Niruha basti with dashamoola kwatha 500ml

and gandharvhastyadi taila 100ml-stat

• sarvanga abhyanga with moorchita taila

followed by patra potli sweda (for 10 days)

C/o pain in the neck

region radiating to both

upper limb reduced 10

percent

Basti pratyagamana kala 5

min

Number of Evacuation 2 .

20/06/1

7-

26/6/16

Continue same treatment

Nasya karma

(mukha abhyanga with ksheerbala taila

followed by naadi sweda followed by nasya

with mahamasha taila 15 drops to each

nostril (for 10 days)

C/o pain in the neck

region radiating to both

upper limb persisting

disturbed sleep, fatigue

Bowel- not passed

58

DATE CHIKITSA OBSERVATION

16/06/1

7

to

18/06/1

7

1) Greeva basti with mahavishgarbha

tailam (for 10 days)

2) Sarvanga CPS with kottamchukkadi

churna and jadamayadi churna (for 5

days)

3) Dhandhanyadi kashayam 3tsf with 9

tsf water (7am and 6pm)

4) Cap – palsineuron (one cap tid)

5) Gandharvhastyadi taila and dashmoola

kwatha choorna

(1tsp kwatha choorna with 100ml water boil

and reduce to 50ml. Filter and add 2 tsp

gandharvhastyadi oil to be taken two

times daily.

Pain in neck region radiating

to both upperlimb associated

with tingling sensation,

burning sensation, reduced

strength in b/l upperlimb, not

able to hold any objects,

Incomplete evacuation- once

in 5 days, hard stools

Bladder- 10- 12 times day/ 3-

4 times at night

Reduced appetite

Disturbed sleep

59

DATE CHIKITSA OBSERVATION

27/06/17 Continue same treatment

• Refered to physiotherapy

• Referd to shalya dept

Nodular swelling over left upper

eyelid

Bowel- passed

Disturbed sleep

28/06/17 Continue same treatment Fatigue+

Radiating pain to b/l upperlimb

reduced by 25%

Burning sensation persisting all

over the body

29/6/17 Continue same treatment

Went to shalakya dept

Adviced excision of cyst

Stopped nasya

60

DATE CHIKITSA OBSERVATION

30/06/17 No panchkarma treatment

1) Dhandhanyadi kashayam 3tsf with 9 tsf

water (7am and 6pm)

2) Cap – palsineuron (one cap tid)

3) Gandharvhastyadi taila and dashmoola

kwatha choorna

(1tsp kwatha choorna with 100ml water boil

and reduce to 50ml. Filter and add 2 tsp

gandharvhastyadi oil to be taken two

times daily.

Pain in the neck region

both upperlimb

persisting

Cystic swelling not

operated

Bowel- passed

Sleep disturbance

61

DATE CHIKITSA OBSERVATION

1/07/17-

2/7/17

CST

Tab.hifenac p sos

Tab augumed cv 625mg bd A/F

Excision of cyst done in

shalya opd

Under local anesthesia

3/7/17 CST

Kamadugda rasa with mukta1-1-1 a/f

dressing done

Aruchi+

Fatigue

Burning sensation

Bowel not passed

62

PROPOSED TREATMENT PLAN

FIRST LINE OF TREATMENT

Sarvanga Parisheka with patoladi gana + dashamoola

ksheera paka 7 days

SHAMNOUSHADHI

• Dhanadanayanadi Kashaya + prasarynyadi Kashaya

2tsp each Kashaya+ 12 tsp water mrg and evg empty

stomach

• Gandharvahasta taila 20ml with ksheera 50ml at night.

63

SECOND LINE OF TREATMENT

Sarvanga Abhayanga triphala taila followed by shashtikashali pinda sweda for 7 days

• Dhanadanayanadi Kashaya + prasarynyadi Kashaya

2tsp each Kashaya+ 12 tsp water mrg and evg empty stomach

or

Bhadradarvyadi+ maharasnadi Kashaya

2tsp each Kashaya+ 12 tsp water mrg and evg empty stomach

Yavanna64

THIRD LINE OF TREATMENT

• Mukhabhyanga with Karpasathyadi thaila and Nasya

with ksheerabala 101 avarthi/ maharajaprasarini thaila

8 bindu pramana sayam kaala after food for 7 days

• Bhadradarvyadi+ maharasnadi Kashaya

2tsp each Kashaya+ 12 tsp water mrg and evg empty

stomach

• Trayodashanga guggulu

2-2-2 A/F

65

FOURTH LINE OF TREATMENT

• Madhutailika basthi for kala basthi

• Madhu – 80ml

• Moorchita tila Taila-80ml

• Saidhavalavana-12gm

• Kalka(shatapushpa kalka)-20gm

• Dashamoola kwatha- 300ml

• Anuvasana with moorchita tila taila- 40ml 66

• Bhadradarvyadi+ maharasnadi Kashaya

2tsp each Kashaya+ 12 tsp water mrg and evg empty

stomach

• Trayodashanga guggulu

2-2-2 A/F

Rasayana prayoga

Shilajathu prayoga- 12gms with milk

67

68