parkinsons disease case presentation in ayurveda

CASE PRESENTATION

DR. VINAY TIWARI

2ND YEAR P.G. SCHOLAR

DEPARTMENT OF KAYACHIKITSA

SKAMCH & RC

VIJAYANAGAR

BANGALORE 1

ATURA PARICHAYA

Name : Md. Zaheeruddin

Age : 67 Years

Sex : Male

Religion : Muslim

Socio economic status : Middle class

Marital status : Married

Education status : 10th standard

Occupation : Provisional shop owner

Date of admission : 14/07/16

Date of discharge : 23/07/16

2

Ward : Semi Special Ward

Source of history : Patient & her wife

Case taken on : 18/07/16

Consultant doctor : Dr. Abdul Khader

O.P No : D – 21303

I.P. No : 3075/16

Address : # 13th cross Gowripalya

Bangalore.

3

PRADHANA VEDANA

C/O Tremors in right upper limb since 3 years

aggravated since 1 year.

Pain in both knee joints since 15 years and aggravated

since 1 year.

Low back ache since 1 year.

Swelling in both lower limbs since 1 year.

4

ANUBANDHA VEDANA

C/O Tendency to fall forward with difficulty in walking

since 1 year with slowness of movements.

Difficulty in writing, holding objects, and activity of

daily living since 1 year

Difficulty in passing motion (constipated) since 1 year.

5

VEDANA VRUTTANTA

•Patient was apparently healthy before 3 years, one day he

met with an accident and got injured on dorsal aspect of

foot with profuse bleeding for which he got operated in

St. Marthas Hospital Bangalore. After one week he

developed fever with chills for which he got admitted to

the same hospital and was managed conservatively. Next

day morning patient noticed tremor in his left hand which

got subsided by itself.

Continue….6

After 1 year patient gradually developed tremors in his

right hand and experienced difficulty in writing and

holding objects for which he consulted a Neurologist in

Rajarajeswari Medical College & Hospital, Bangalore

and diagnosed with Parkinson’s disease and was put on

medication( details of which are not known). After

continuing the same medicine for one year the patient

stopped the medication without any consultation.

Continue….7

Following which there was an increase in the symptoms

along with tendency to fall, slowness in movements,

bilateral lower limb swelling for which he consulted St.

Marthas Hospital, Bangalore and was advised CT scan

and was given some medications. Since 1 year he

developed constipated bowel movements along with

increased bilateral knee joint pain and low back ache .

So for the above mentioned complaints he approached

SKAMCH&RC for further management.

8

POORVA VYADHI VRUTTANTA

Known C/O Hypertension since 20 years

Ischemic Heart Disease since 5 years(on medication).

He is a not a known case of Diabetes mellitus, Asthma,

Tuberculosis .

9

CHIKITSA VRUTTANTA

Presently on

•Tab – Ecosprin 150 mg 0 – 1 - 0

• Tab – Clopilet 75 mg 0 – 1 – 0

• Tab – Pantop 40 mg 1 – 0 – 0 (B/F)

• Tab – Atorva 40 mg 0 – 0 – 1 After food

• Tab – Syndopa plus 1 - 0 – 1

• Tab – Parkin 2 mg ½ - ½ - ½

• Tab – Streepress XL 25 mg 1 – 0 – 0

10

KAUTAMBIKA VRUTTANTA

No history of similar complaints in the family.

11

PATIENT

67 Yr

WIFE

59 Yr

SON SON DAUGHTER SON DAUGHTER DAUGHTER

PATIENT

FATHERPATIENT

MOTHER

VYAKTIKA VRUTTANTA

Diet : Mixed (non veg 2 to 3 times in a week) .

Appetite : Reduced since 3 years(after surgery)

Sleep : Disturbed since 1 year

Bowel : 1-2 times/day, regular

constipated (incomplete evacuation)

Micturation : 4 to 6 times/day.

1 to 2 times/night.

Habits : Tea – 5 to 6 cups per/day.12

GENERAL PHYSICAL EXAMINATION

General Condition : Fair.

Built : Moderately built.

Nourishment : Moderately Nourished.

Pallor : Absent.

Oedema : Bilateral pedal oedema (pitting).

Nails : No clubbing

Cyanosis : Absent.

Icterus : Absent.

Lymphadenopathy : Absent.

Pulse :78 bpm.13

BP :130/90 mmHg.

R/R :18/minute.

Tongue : Coated.

Height : 1.88 m

Weight : 94 Kgs

BMI : 26.62

14

SYSTEMIC EXAMINATION

15

PER ABDOMEN EXAMINATION

Inspection -: Umbilicus centrally placed

-: No distension

-: No scar marks

Auscultation -: Bowel sounds heard

Palpation -: Soft, no tenderness

-: No organomegaly

Percussion -: Tymphanic sounds heard

16

RESPIRATORY SYSTEM

Inspection -: Shape of chest - bilaterally symmetrical

-: Respiratory rate -18/min

Palpation -:Trachea -Centrally placed

-: No tenderness

Percussion - : Resonant sounds heard except the

cardiac dullness.

Auscultation -: Normal Vesicular Breath

Sounds heard.

17

CARDIO VASCULAR SYSTEM

Inspection -: No distended blood vessels over

chest and neck

Palpation -: Apex Beat felt at 5th intercostal space9 cm from the mid sternal line.

Percussion -: Defined Area of cardiac dullness.

Auscultation -: S1S2 Heard

-: No murmurs

-: No added sounds heard

18

CENTRAL NERVOUS SYSTEM

Handedness- right

1.HMF

Conscious

Orientation to -Time

-Place Intact

-Person

Memory - Recent Intact

- Remote

Intelligence Intact

Hallucination & Delusion Absent

Speech disturbance

19

2. Cranial Nerve Examination

Olfactory -: Smell sensation - Intact

Optic -: a) Visual acuity - difficulty in

distant reading

b) Visual field -Not affected

c) Light reflex Not affected

d) Drooping of eye lids (Ptosis) -Absent

Occulomotor

Trochlear Eye ball movement – possible in

Abduvent Nerve all directions.

20

Pupil - Position

- Shape No abnormality detected

- Size

- Symmetry

Trigeminal Nerve

Sensory – Touch

Pain Present

Pressure sensation

Motor - Clenching of teeth Possible

- Lateral movements of jaw Possible

21

Facial Nerve

a) Forehead frowning - Present

b) Eyebrow raising - Possible

c) Eye closure against- Possible resistance

d) Teeth showing - No deviation of angle of mouth

e) Blowing of cheek - Not Possible

f) Nasolabial fold - Equal on both sides

Vestibulo cochlear

Rinne’s test - Negative

Weber’s test - Equal on both sides

22

Glossopharyngeal & Vagus nerve

Position of uvula - No deviation

Taste sensation - Intact

Accessory Nerve

Shrugging the shoulder - Possible against resistance

Neck movement - Possible against resistance

Hypoglossal Nerve

Protrusion of tongue - Possible

Tongue movements - Possible

23

3) Sensory system

Superficial

a) Touch - Intact

b) Temperature - Intact

c) Pain - Intact

Deep

a) Crude touch - Present

b) Position Sense & Pressure sense - Present

Cortical

a)Tactile localization - Present

b) Tactile discrimination - Present

c) Stereognosis - Present

d) Graphesthesia - Present 24

4) Motor system

Attitude of limbs

Upper limb : Normal

Lower limb : Normal

Muscle Bulk Right (in inches ) Left (in inches)

a) Upper limb

Arm 12.5 11.5

Forearm 9.5 9.5

b) Lower limb

Thigh 18 18

Calf 13 12.5

25

Tone - Upper limb & Lower limb - Normal

Power - Not affected

Coordination

Romberg sign- +ve

Upper limb- Finger nose test- Able to perform (slowly)

Lower limb-Knee heel test - not able to perform due to pain

Involuntary movements - Present

Right hand - Tremor

Gait-

–Parkinsonian/festinating gait

26

Reflex

a) Biceps jerk -++

b) Triceps jerk-++

c) Supinator jerk-++

d) Knee jerk-++

e) Ankle jerk-++

f) Clonus -Patella – absent

-Ankle- absent

g) Jaw jerk- ++

h) Babinski reflex - plantar flexion27

LOCOMOTOR SYSTEM EXAMINATION

Joints Tenderness Warmth Swelling Measurments Range of movements.

Ankle

joints &

foot

Rt & Lt

Absent

Rt-

Present

Lt-

Present

Rt- Present

Lt- Present

Rt – 10.8 inch

Lt – 10.8 inch

Flexion-Rt & Lt – Normal

Extension-Rt & Lt – Normal

Inversion – Rt & Lt Painful

Eversion- both normal

Knee

joints

Rt- ++

Lt- ++

Crepitus

present on

both joints.

Rt-

Present

Lt-

Present

Rt- Present

Lt- Present

Rt – 14.8 inch

Lt – 14.8 inch

Flexion- Painful

Extension- Painful

Internal rotation- Both Painful

External rotation-Both Painful

28

Joints Tenderness Warmth Swelling Range of movements

Hip joints Rt & Lt

Absent

Rt & Lt

Absent

Rt & Lt

Absent

Flexion - Painful

Extension - Painful

Abduction - Painful

Adduction - Normal

Int.Rotation - Painful

Ext Rotation – Normal

Thumbs Rt & Lt

Absent

Rt & Lt

Present

Rt & Lt

Present

Flexion- Both Normal

Extension-Both Normal

Abduction- Both Normal

Adduction- Both Normal

Opposition- Rt & Lt – Normal

29

30

Joints Tenderness Warmth Swelling Measurments Range of movements

Wrist joints Rt & Lt

Absent

Rt & Lt

Absent

Rt & Lt

Absent

Rt – 8.1 inch

Lt – 7.9 inch

Flexion -Normal

Extension -Normal

Adduction -Normal

Abduction - Normal

Hand grip – Normal

Elbow

joints

Rt & Lt

Absent

Rt & Lt

Absent

Rt & Lt

Absent

Rt – 11.2 inch

Lt – 10.8 inch

Flexion - Normal

Extension - Normal

Supination - Normal

Pronation - Normal

30

B/L

JointsTenderness Warmth Swelling Measurements Range of movements

Shoulder

joints

Rt & Lt

Absent

Absent Rt & Lt

Absent

Rt – 14.2 inch

Lt – 13.8 inch

Flexion- Rt- upto 90 degree,

Lt- upto 90 degree Normal

Extension- Both Normal

Int Rotation- Both Normal

Ext Rotation- Normal

Neck /

cervical

joint

Absent Absent Absent 16.5 inch Flexion - Normal

Extension - Normal

Rotation - Normal

Lateral Bending- Normal

31

आतुर भूमि देश परीक्षा जाततः - आनूप

संवदृ्धतः - आनूप

व्याधधतः - साधारण

32

DASHAVIDHA PARIKSHA

1) प्रकृतत -वात - कफ

2) ववकृतत

दोष : वात , कफ

दषू्य : रस , रक्ता, मांस , मेदा , अस्थि मज्ज, थनाय

देश : साधारण

बल : अवर

काल : वषाा33

3) सार : मध्यम4) संहनन : मध्यम5) प्रमाण : मध्यम6) सात्म्य : मध्यम7) सत्मव : मध्यम8)आहार शस्क्त

अभ्यवहरण शस्क्त : अवरजरणशस्क्त : अवर

9) व्यायाम शस्क्त : अवर10) वयः : मध्यम

34

NIDANA

Rookshaanna

Alpa anna

Abhojana

Vegadharana

Krodha

Bhaya

Divaswapna

Avyaayaama

Achinta

35

SAMPRAPTI

Nidana & Jara Kapha vruddhi by swanidana

Dhatukshaya Avarana of vata by kapha

Vata prakopa Vyana

(Gatisanga)

Affecting Affecting affecting udana

mastulunga snayu sandhi (gurugatratwa, aruchi)

Majja in

shira marma Kampa janu shula, Further anyonya avarana

katishula

Shakruth graha

Indriya hani(pani, Udanavruta vyana

pada) & Snayu dushti (chestani)

36

SAMPRAPTI GHATAKA

दोष : वात, कफ दषू्य : रस, रक्ता,मांस, मेदा, अस्थि,मज्ज, थनाय अस्नन : जठरास्नन,धात्मवास्ननआम : तद्जन्य स्रोतस ् : रस, रक्त, मेदो, अस्थि, मांस,मज्जावह स्रोतोद स्ष्ि प्रकार : सङ्ग , ववमागागमन उद्भव थिान : आम-पक्वाशय व्यक्त थिान : दक्षिण पाणण मागा : मध्यम साध्यासाध्यता : कृच्छ्र साध्य 37

VYAVACHEDAKA NIDANA

38

Provisional

diagnosis

Inclusion criteria Exclusion criteria

Kostha gata vata Mala nigraha

Hridya roga

Mutra nighara

Gulma roga

Arsha

Parswashoola

Pakvasaya gata

vata

Pureesha sangha Aanaha

Mutra kruchra

Udara shola

Trik pradesha

vedana 38

VYAVACHEDAKA NIDANA

39

Provisional

diagnosis


Kati shula Shula in kati

pradesha

sarvanga vata Sphutanthi va

sandhayaha

Gatra sphurana,

bhanjana

Mamsagata vata Guruanga Toda,

dandamushtihata

vedana 39

40

Provisional

diagnosis

Inclusion criteria Exclusion

criteria

Tandava roga Vida bibandha

Vepathu

Bala kshaya

Harshadikhata

Krimi sanchaya

Janu sandhi

gata vata

Vata purna dhriti sparsha

Sotha prasarna

aakunchana sa vedana

kampavata Vepathu

Peshikriya hani

Kara pada kampa nidra

bhanga

40

DIFFERENTIAL DIAGNOSIS

Provisional

diagnosis

Inclusion

criteria

Exclusion criteria

Dementia with

lewy bodies

•Slow movements

•Tremors

•Recurrent visual

hallucinations

•Mental decline

•Dementia

Multiple system

atrophy

•Incomplete

evacuation stools

•Tremor

•Hypotension

•Blurred vision

•Loss of muscle

coordination

•Lose of balance 41

Provisional

diagnosis


Ataxia •Gait impairment

•Tremor

•Visual blurring

•Uncontrolled or

repetitive eye

movements

•Head ache

•Behavioral changes

•Unclear speech

42

Provisional

diagnosis

Inclusion criteria Exclusion

criteria

Osteoarthritis Pain in weight bearing joint.

Functional restriction of

joints.

Crepitus present

43

Provisional

diagnosis


Parkinson’s

disease

•Tremor

•Slow movements

•Speech difficulty

•Incomplete

evacuation of

stools

•Fear of falling

•Sleep disturbance

44

VYADHI VINISCHAYA

Kampa vata with Sandhigata vata

Parkinson’s disease with Osteoarthritis

45

46

CHIKITSA

VRUTTANTA

47

DATE TREATMENT

14/07/16

To

21/07/16

1) Sarvanga abhyanga with dhanwantaram taila + Kottumchukkadi taila

followed by patra pinda sweda.

2) Sarvanga churna pinda sweda with Kottumchukkadi churna + Rasna

churna + Triphala churna

3) Tab – Bruhat vata chintamani 1-0-1

4) Cap – Neuro-XT 1-0-1

5) Syp – Dashmolarishta 3 tsp bd

6) Syp – Balarishta 3tsp bd

7) Syp – Aswgandharista 3tsp bd

8) Kapikachu churna 1 tsp OD with milk

9) Gandharva hastayadi taila 15 ml with 100 ml lukewarm milk @ bed time

in night.

10) Matra basti with Maha masha taila 80 ml. (20 & 21 july). 47

Later patient refused to basti treatment.

Date Adviced Observation

14/07/16

&

15/07/16

1) Sarvanga abhyanga with dhanwantaram taila +

Kottumchukkadi taila followed by patra pinda

sweda.

2) Sarvanga churna pinda sweda with

Kottumchukkadi churna + Rasna churna + Triphala

churna

3) Tab – Bruhat vata chintamani 1-0-1

4) Cap – Neuro-XT 1-0-1

5) Dashmolarishta 3 tsp bd

6) Balarishta 3tsp bd

7) Aswgandharista 3tsp bd

8) Kapikachu churna 1 tsp OD with milk

9) Gandharva hastayadi taila 15 ml with 100 ml

lukewarm milk @ bed time in night.

Patient feels better

Gatragurutha reduce

20%

Appetite- reduced

Bowel- constipated

Pain and tremors

persisitiing

48


16/07/16

&

17/07/16

Continue same

treatment (1 to 9)

C/O Tremor reduced by

20 %

Sleep improved

18/07/16

&

19/07/16

Continue same

treatment (1 to 9)

Patient feels better

C/O Tremor reduced by

40 %

Able to hold objects

without any involuntary

movements for 5 minutes

Bowel – irregular,

complete evacuation

Appetite improved.

Sleep – sound 49

Pain in joints reduced 30%


20/07/16

&

21/07/16

Continue same treatment

1 to 9

Along with Matra basti with

Maha masha taila 80 ml.

Patient feeling 60%

improvement in

tremors.

Improvement in

slowness in

movements.

Constipation relieved.

Able to do his daily

routine activities.

Pain in joints 30%

reduced.

50

DISCHARGE MEDICINES

Tab – Bruhat vata chintamani gold 1 – 0 – 1 (A/F)

Cap – Neuro – XT 1 – 0 – 1 (A/F)

Dashmoolaristha 3ts bd.

Bhadradarvyadi Kashaya 3 tsp bd.

Balaristha 3 tsp bd.

Kapikachu churna 1 tsp with milk OD

Nimbamruthadi eranda thaila 2 tsp +1/2 cup hot water at

bed time. 51

PATIENT CONDITION ON DISCHARGE

Patient got considerable relief in symptoms by the time of

discharge.

Tendency to fall forward & Tremor relieved by 60 to 70

% as per patient words.

Pain in joints 30% relieved.

Appetite improved.

Bowel regularized.

Review after 20 days. 52

THANK YOU

53