Ardita ( bells palsy ) case presentation

ardita is considered as facial palsy. here is a case presentation on ardita. for more info feel free to contact at [email protected]

1. Case presentation Kamal Kishore 2nd year PG Scholar Dept. of PG studies in Kayachikitsa SKAMCH&RC BENGALURU

2. ATURA VIVARANA Name : Mr. P. N. Marilingaiah Age : 59 Years Sex : Male Religion : Hindu Marital status : Married Socio economic status : Middle class Education status : PUC Occupation : Supervisor in Horticulture Dpt. Date of admission :16/08/16 Date of discharge :26/08/16 1

3. Ward : Semi Special ward 2 Source of history : Patient Consultant doctor : Dr. Byresh A. O.P No : D24757 I.P. No : 3509/16 Case taken on : 17 th August 2016 Address : #49, 1 st main, 7 th cross, near Gayathri temple, K.G. nagar , Bangalore. 2

4. Pradhana vedana Dakshina Mukhardha vakrata / Deviation of Face towards right side since 12/08/2016 3

5. Anubandha Vedana Vaam Akshi nimesha hrasa / Loss of complete closure of left eye Ashru srava from vama netra / Lacrimation from left eye L alasrava / Dribbling of saliva on left angle of mouth. Vaak Aspashtata / slurred speech since 13/08/2106 4

6. Adyatana Vedana Vrittanta Patient was apparently normal up to 12/08/2016. After his post lunch sleep for two hours, when he woke up his son noticed slight deviation of mouth to Right side/ Dakshina Mukhardha vakrata . Patient did not experience any difference but was taken to hospital. At NIMHANS he was advised to take the consultation at Victoria hospital. In Victoria after initial check up, he was advised to follow up next day. 5

7. Adyatana Vedana Vrittanta Next day the patient noticed Difficulty in Closure of left eye/ Vaam Akshi nimesha hrasa , Watering from left eye/ Ashru srava from vama netra , Dribbling of saliva on left angle of mouth/ lalasrava , slurred speech/ Vaak Aspashtata & consulted a different hospital . 6

8. Adyatana Vedana Vrittanta He also approached a folklore practitioner in Andhra Pradesh. On the advice of his relative he approached SKAMCH. The patient presented with the following symptoms at the time of admission on 16/08/2016. Mukhardha vakrata towards dakshina bhaga , nimesha hrasa of vama akshi , ashru srava from vama akshi , lalasrava from vama bhaga of mukha , vak aspastata . Patient did not c/o shiro ruja , bhrama , karna nada or drushti hrasa , sparsha hani , rasa gyan hrasa . 7

9. Poorva Vyadhi Vrittanta Patient was admitted & treated for acclerated blood pressure for 6 days from 31 st July 2016 as he presented with features of giddiness, imbalance & vomiting. 8

10. Chikitsa vrittanta On 13/08/2016 at Spandana hospital on OPD basis Tab. Losar H 1 O.D. Tab. Omnacortis 10mg 2-2-0 for 1 week 2-1-0 for 1 week Tab. Sompraz 40mg 2 B.D for 2 weeks Tab. Ecosprin gold 1 O.D for 2 weeks Tab Axovir 800mg 1tid for 1 week Oflox Eye drops 2dros tid for 1 week Inj Rejunex 1amp 1B.D. for 1 week & Physiotherapy for one week. Patient took 1 – 2 dose of the above & stopped it. Took folklore treatment after this. (details of medication – NA) 9

11. Koutumbika Vrittanta HTN from past 11 days 10 All family members are said to be healthy.

12. Vayaktika Vrittanta Diet : Mixed, Non veg once in a week (chicken, fish) Appetite : Good Bowel : once/day (regular) complete evacuation. Micturition : 5-7 times/day once/night Sleep : Good Addictions : None 11

13. ROGI PAREEKSHA 12

14. Atura Bhoomi Desha Pareeksha Jatatah : Sadharana Samvardhitah : Sadharana Vyadhitah : Sadharana 13

15. ASHTA STHANA PAREEKSHA Naadi-78 bpm Mootra - 5-7times a day, once at night occasionally. Mala- Once a day, Jihwa - Alipta Shabda - Vikrita ( Aspashta vaak ) Sparsha – Anushnasheet a Drik - vaambhaga a kshi nimilana Hrasa Aakriti - Madhyama 14

16. Prakriti :- Vata Kapha Prakriti Saara :- Madhyama Samhanana : Madhyama Pramana : Madhyama Ht : 1.67m, Wt : 55 kg Saatmya : Madhyama Satva : Madhyama Aahara Shakti : Abhyavaran Shakti : Madhyama Jarana Shakti : Madhyama Vyayama Shakti : Madhyama Vaya : Madhyama DASHVIDHA PAREEKSHA 15

17. Vikriti :- M adhyama Hetu :- Aaharaja & viharaja nidaana . Dosha :- kapha ( bodhak,tarpak ) Vaata ( prana & udana,vyan ), Dooshya :- Meda , Rakta , sira , snayu . Desha:- Sadharana Bala :- Madhyama Kaala :- Ritusandhi ( Varsha-Sharat ) Prakriti :- vikriti vishama Samasamveta 16

18. SAAMANYA PAREEKSHA Patient conscious , alert, oriented to time , place and Person. Built : Moderate Nourishment : Moderate Pallor : Absent. Cyanosis : Absent. Nail : Normal Icterus : Absent Oedema : Absent Lymphadenopathy : Absent. 17

19. Temperature: 98.6 degree Fahrenheit BP :130/90 mm of Hg. R/R :20 cycles/minute. Tongue : Uncoated. Height : 1.67m Weight : 55Kg BMI : 19.72 18

20. Respiratory System Examination Shape of chest -bilaterally symmetrical. Trachea -centrally placed Normal vesicular breath sounds heard. No added sounds. Cardiovascular Syste m Examination S1 S2 heard, no murmurs . 19 VISHISHTA PAREEKSHA

21. Per Abdomen Examination Inspection – Scaphoid Umbilicus – Inverted Auscultation -Peristaltic sounds heard , Palpation – Soft, No tenderness. No organomegaly Percussion – dull over liver area, Resonant otherwise. 20

22. Local Examination Inspection Deviation of mouth towards right Left eyeball moves upwards and in wards when the patient attempts to close it along with incomplete closure of eyelid. (Bells phenomenon) Lacrimation from left eye. Dribbling of saliva on left angle of mouth & food contents during eating. Nasolabial fold loss on left side. 21

23. Central nervous system Examination 1. Higher Motor Functions Consciousness- Conscious Orientation to- Time, place, person- Intact Memory - Recent -not affected Remote- not affected Intelligence- Intact Hallucination & Delusion - Absent Speech - S low and words are mumbled Handedness - Right 22

24. 2. Cranial Nerve Examination CN1 – Smell sensation - Intact CN II- Optic – a)Visual acuity - Not Affected b)Visual field - Not affected c)Light reflex - Not affected d)Drooping of eye lids (Ptosis)-Absent 23

25. CN III Occulomotor , CN IV Trochlear , CN VI Abducens Nerve – Pupil - position , size, shape, symmetry- no abnormality detected Eyeball movement - Possible in all directions CN V Trigeminal Nerve Sensory –Touch, pain and pressure sensation – intact Motor - Clenching of teeth – Possible Jaw movement against resistance decreased Jaw jerk- Normal 24

26. CN VII Facial Nerve a) Forehead frowning - not possible on left side b) Eyebrow raising - not possible on left side c) Eye closure - not possible in left eye d) Teeth showing - not possible in left side denture e) Blowing of cheek - not Possible in left side 25

27. Nasolabial fold - decreased on left side Taste perception - not affected Dribbling of saliva – left corner of mouth present. Bells phenomenon – present on left side . 26

28. CN VIII Vestibulocochlear nerve Rhinne’s test - AC > BC Weber’s test -Equal on both sides CN IX, CN X Glossopharyngeal and Vagus nerve Speech – no Dysarthria or Dysphonia noted Position of uvula - Centrally placed Taste sensation -Intact Gag reflex - normal 27

29. CN XI Accessory Nerve Shrugging the shoulder - Possible against resistance Neck movement -Possible against resistance CN XII Hypoglossal Nerve Protrusion of tongue - Possible Tongue movements - Possible 28

30. 3. Motor system Muscle Bulk Right (in cms ) Left (in cms ) Upper limb Arm 24 25 Forearm 17.5 18 Lower limb Thigh 46.5 45 Leg 29.5 29 29

31. Muscle tone B/L Upper limb and lower limb- Normal Muscle power Rt Lt Upper limb 5/5 5/5 Lower limb 5/5 5/5 Reflexes Biceps jerk- ++, Triceps jerk- ++ Supinator jerk- ++, Knee jerk- ++ Ankle jerk- ++, Plantar reflex- ++ 30

32. Co-ordination Upper limb Dysdiadokinesia - absent Finger to nose test- possible Pronator Drift- Possible Fine movements- No abnormality detected Lower limb Tandem walking- Possible Heel shin test- Possible Heel walk- Possible 31

33. Toe walk- Able to do Rhomberg’s sign- negative Pronator drift - negative 4 . Sensory system Superficial a) Touch - Intact b) Temperature - Intact c) Pain - Intact 32

34. Deep Vibration sense- intact Joint position sense- intact Cortical a)One point localization - intact b) Two point discrimination - intact c) Stereognosis - Present d) Graphesthesia - Present 33

35. FINDINGS OF CNS EXAMINATION :- Peripheral lesion (LMN) of 7 th Cranial nerve. 34

36. ROGA PAREEKSHA 1 35

37. NIDANA PANCHAKAS Nidana – ? Diwaswapna , Sheetala vayu sevana . 1 36

38. SAMPRAPTI 1 37

39. NIDANA PANCHAKAS Purvaroopa - Mukhardha vikriti . Roopa – Dakshina Mukhardha vakrata / Deviation of Face towards right side , Vaam Akshi nimesha hrasa of / Loss of complete closure of left eye. Ashru srava from vama netra / Lacrimation from left eye. Lalasrava /Dribbling of saliva on left angle of mouth. 1 38

40. SAMPRAPTI GHATAKAS Dosha – Vaat pradhana kapha Dushya – Rasa, R akta , Meda , . Srotas – R asavaha , Raktavaha , Medovaha . Sroto dushti - Sanga,vimargagamana . Agni - Jatharagni and Dhatvagni mandya 1 39

41. Udbhavasthana – Aamashaya,Pakwashaya Sancharasthana – Rasayani Vyaktasthana – Mukhaarda Adhishtana – Shiras, Indriya Rogamarga – Madhyama Sadhya-Asadhyata – Kricchra Sadhya 1 40

42. VYAVCHEDAK NIDAAN Pakshavadha Pakshaghaata Ardita ( Charakokta ) Ardita ( Sushrutokta ) 1 41

43. Disease Inclusion Exclusion Pakshavadha Dakshina mukhardha ardhakaya akarmanyo Pakshaghaata Vaakstambha , mukhardha cheshta nivritti . Cheshta nivritti in ardhakaya , ruja in sharirardha , hastpada sankocha Ardita ( charak&vaghbhataokta ) Mukha vikruthi . sareerardha vikruthi . Ardita ( Sushrutokta ) Mukhardha vikruthi 4 2

44. DIFFERENTIAL DIAGNOSIS CVA Facial palsy (LMN)/Bell’s Palsy Facial palsy (UMN) 43

45. Disease Inclusion Exclusion CVA Loss of functions of face Loss / reduced strength of half of body is generally seen Facial palsy (UMN) Loss of functions of lower half of face of affected side Intact functions of upper half of face of affected side Facial Palsy (LMN) / Bell’s Palsy Loss of functions of half of face of affected side 44

46. VYADHI NIRNAYA Ardita ( Sushrutokta ) Facial Palsy/Bell’s palsy 1 45

47. SADHYA ASADHYATA Kricchra Saadhya 46

48. CHIKITSA DATE TREATMENT GIVEN OBSERVATIONS 16/8/16 Nasya Karma Mukhabhyanga with ksheerbala taila followed by bala moola saadhita ksheer dhooma Nasya with maha masha taila 15 drops to each nostril 2. Deviation of mouth towards right. Left eyeball moves upwards and outwards when the patient attempts to close it along with incomplete closure of eyelid. (Bells phenomenon) Slurred speech 47

49. DATE TREATMENT GIVEN OBSERVATIONS 2.Dhandhanyadi kashayam 3tsp with 9 tsp water at 7am & 6pm. 3.Ashwagandha choorna (mix with water to apply to left half of face once daily) 4.Idli prepared out of Masha with navneeta for breakfast. Lacrimation from left eye. Forehead frowning not possible on left side. Dribbling of saliva on left angle of mouth & food contents during eating. Nasolabial fold loss on left side. CHIKITSA 48

50. DATE TREATMENT GIVEN OBSERVATIONS 17/8/16 – 18/8/16 CST 1-4 5. Vacha Choorna Mix ¼ tsp powder with ½ tsp honey &rub over tongue for 3-5 min (twice daily) 6. Cap. Palsineuron (one Cap. Tid ) Deviation of mouth towards right. Left eyeball moves upwards and outwards when the patient attempts to close it along with incomplete closure of eyelid. (Bells phenomenon) Slurred speech. CHIKITSA 49

51. DATE TREATMENT GIVEN OBSERVATIONS Lacrimation from left eye. INCREASES WHILE MUKHABHYANGA. Forehead frowning not possible on left side. Dribbling of saliva on left angle of mouth & food contents during eating. Nasolabial fold loss on left side. CHIKITSA 50

52. CHIKITSA DATE TREATMENT GIVEN OBSERVATIONS 19/8/16 CST 1-6 Deviation of mouth towards right. DECREASED BY 10 PERCENT . Left eyeball moves upwards and outwards when the patient attempts to close it along with incomplete closure of eyelid. (Bells phenomenon) Slurred speech. 51

53. CHIKITSA DATE TREATMENT GIVEN OBSERVATIONS Lacrimation from left eye. DECREASED. Forehead frowning not possible on left side. Dribbling of saliva on left angle of mouth & food contents during eating. Nasolabial fold loss on left side. 52

54. DATE TREATMENT GIVEN OBSERVATIONS ON 22/8/16 20/8/16 to 22/8/16 CST Deviation of mouth towards right. DECREASED BY 25 PERCENT . Left eyeball moves upwards and outwards when the patient attempts to close it along with incomplete closure of eyelid. (Bells phenomenon) IMPROVED. Slurred speech. MILDY IMPROVED 53

55. DATE TREATMENT GIVEN OBSERVATIONS ON 22/8/16 Lacrimation from left eye. DECREASED. Forehead frowning not possible on left side. Dribbling of saliva on left angle of mouth & food contents during eating. ABSENT Nasolabial fold loss on left side. 54

56. DATE TREATMENT GIVEN OBSERVATIONS 23/8/16 CST Deviation of mouth towards right. DECREASED BY 50 PERCENT . Left eyeball moves upwards and outwards when the patient attempts to close it along with incomplete closure of eyelid. (Bells phenomenon) MODERATELY IMPROVED . Slurred speech. MODERATELY IMPROVED 55

57. DATE TREATMENT GIVEN OBSERVATIONS Lacrimation from left eye. DECREASED. Forehead frowning possible MILDLY on left side. Dribbling of saliva on left angle of mouth & food contents during eating. ABSENT Nasolabial fold VISIBLE on left side. 56

58. DATE TREATMENT GIVEN OBSERVATIONS ON 26 /8/16 24/8/16 TO 26/8/16 CST Deviation of mouth towards right. DECREASED BY 75 PERCENT . Left eyeball moves upwards and outwards when the patient attempts to close it along with incomplete closure of eyelid. (Bells phenomenon) IMPROVED . Slurred speech. IMPROVED 57

59. DATE TREATMENT GIVEN OBSERVATIONS ON 26 /8/16 24/8/16 TO 26/8/16 CST Lacrimation from left eye. REDUCED COMPLETELY. Forehead frowning possible MODERATELY on left side. Dribbling of saliva on left angle of mouth & food contents during eating. ABSENT Nasolabial fold VISIBLE on left side. 58

60. BEFORE TREATMENT AFTER TREATMENT Deviation of mouth towards right side. Bells phenomenon present. Deviation of mouth reduced by 75%. Dribbling of saliva on left side of mouth. Dribbling of saliva stopped. Watering of left eye. Watering of left eye stopped. Not able to close Left eye. Able to close left eye. Nasolabial fold not present on left side. Nasolabial fold visible on left side. 59

61. ADVISE ON DISCHARGE Rx Dhanyanadi kashayam 3tsp with 9 tsp water at 7am & 6pm . Cap. Palsineuron ( one Cap. Tid ) Pratimarsha nasya with maha masha taila 2 drops to each nostril . L/A of ashwagandha choorna lepa on face L/A of vacha choorna on tongue Review in OPD after 15days. 60 for 15 days

62. Pathya - Apathya 61

63. Pathyas Milk Meat soups masha Navaneetha 63 62

64. Varjas by arditha rogi Sheeta jala Snana Dantha dhaavana Vata prakopakara ahara and viharas 63

65. Thank you !