kaamla and jalodara Case presentation

Jaundice/ kaamla/ jalodara case presentation in @and year MD kayachikitsa 2016
SKAMCH&RC Bangalore

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

2. ATURA VIVARANA Name : Mr. Yogesh Age : 23 Years Sex : Male Religion : Hindu Marital status : Bachelor Socio economic status : Middle class Education status : PUC Occupation : Shopkeeper Date of admission :05/05/16 Date of discharge :18/05/16

3. Ward : Male General ward Source of history : Patient Consultant doctor : Dr. Supreeth /Dr. Kiran M. Goud O.P No : D 14095 I.P. No : 2090/16 Case taken on : 14 th May 2016 Address :Sh. Annapoorneshwari , sira Tumkur Karnataka

4. Pradhana vedana Ubhaya adhogata shakha shotha ( dakshina > vaama ) Krishna varna , kandu , fluid filled eruptions with erosions on extensor surface on Rt leg Udara utsedha Peeta varna Akshi Haridra varna mootrata Since 20 days Since 1 month

5. Anubandha Vedana Difficulty in ambulation Tiredness ( shrama ) Reduced appetite Discomfort in sitting Since 1 month

6. Adyatana Vedana Vrittanta The above said patient was diagnosed with Wilson Disease 8 years back. He was asymptomatic 40 days back, when he experienced fever followed by loose stools(2-3 watery episodes) for which he visited a clinic nearby and was managed with some I.V Fluids and Oral medications ( details of which are not known) following which the symptoms came down. 30 days back he noticed simultaneous swelling in b/l lower limbs ( Rt >Lt) which was same throughout

7. the day. Gradually he developed blackish discoloration, itching on b/l lower limbs( Rt >Lt) and fluid filled eruptions with erosions on extensor surface Rt leg. This hampered the ambulation of patient as he started developing tiredness after walking more than 5 min. 20 days back he noticed yellowish discoloration of sclera, dark yellow urine and gradual distension of abdomen with discomfort in sitting and reduced appetite. Bowel and bladder were said to be regular.

8. For these complaints he went to General Hospital where the consulting physician advised him some tests and referred him to visit an Specialist consultant nearby, so the patient went there and took the consultation . Along with this the patient also went to an Ayurvedic clinic and took medication following which his swelling and itching reduced. The same Ayurvedic doctor advised him to approach SKAMCH&RC for further management.

9. Poorva Vyadhi Vrittanta Patient was diagnosed with Wilson disease 8 years back. He is on following medication from Indira G andhi Institute of Child Health Hospital B’lore . 1.Tab. Pencillamine 250mg 2-0-2 2.Tab. Zincovit 0-0-1

10. Chikitsa vrittanta Rx From General Physician since past twenty days 1. Urosolol 150mg 1-0-1 2. Lasilactone 50mg 1-1-0 3. Aldactone 25mg 2-2-0 Rx From Ayurvedic Clinic (from 22 nd april to 2 nd May) 1. Udaramrith juice 15ml b.d . (B/F) 2. Syp . Cardorium plus 10ml b.d . (A/F) 3. Tab. Immunocin 1tab b.d . (A/F) 4. Tab. Shiva Gutika 1tab b.d . (A/F)

11. Koutumbika Vrittanta HTN & T2DM Since 8 years (on med) HTN Since 5 years (on med) Wilson disease since 8 years

12. Vayaktika Vrittanta Diet : Vegetarian diet Appetite : Good Bowel : once/day (regular) complete evacuation. Micturition : 5-7 times/day once/night Sleep : Good Addictions : None

13. SAAMANYA PAREEKSHA Patient was conscious, alert, oriented to time , place and Person . Built : Medium Nourishment : M oderate Pallor : Absent. Cyanosis : Absent. Nail : Normal Icterus : Present Oedema : Absent Lymphadenopathy : Absent.

14. Temperature: Afebrile Pulse : 78 bpm. BP :120/80 mmHg. R/R :20/minute. Tongue : UnCoated . Height : 160cm Weight : 60Kg BMI : 23.4

15. ASHTA STHANA PAREEKSHA Naadi -78 bpm Mootra - 5-7times a day, once at night occasionally. Mala- Once a day, Jihwa - Alpalipta Shabada - Prakruta Sparsha – Prakruta Drikka - Prakruta Aakriti - Madhyama

16. Prakriti :- Pitta pradhana Vaata Vikriti :- Pravara Hetu :- beeja Dushti , Aaharaj Nidaana Dosha :- Pitt Vriddhi , Vaat vriddhi , Kapha Vriddhi Dooshaya :- Rasa , Rakta , Maansa Desha:- Saadharana Bala :- Madhyama Kaala :- Greeshma Prakriti :- Prakriti SamSamveta Saara :- Avara DASHVIDHA PAREEKSHA

17. Samhanan : Madhayama Pramana : Madhayama Ht : 160cm Wt : 60 kg Saatmaya : Sarvrasa satmaya Satva : Avara Aahara Shakti : Madhyama Abhyavaran Shakti : Madhyama Jarana Shakti : Madhyama Vyayama Shakti : Madhyama Vaya : Madhyama

18. ROGI PAREEKSHA

19. Atura Bhoomi Desh Pareesha Jatata : Sadharana Samvardhita : Sadharana Vyadhita : Sadharana

20. VISHISHTA PAREEKSHA P/A EXAMINATION Inspection – *Distended *Umbilicus – I nverted Auscultation -Peristaltic sounds heard , 2-3 / min Palpation – * Soft, No tenderness. * organomegaly not elicited. Percussion – Shifting dullness noticed. Abdominal Girth - 65cm

21. CVS S1 S2 heard, no added sounds/murmurs. RS Shape of chest -bilaterally symmetrical. Trachea -centrally placed Normal vesicular breath sounds heard. No added sounds.

22. EYE EXAMINATION VA 6/6 in both eyes sclera slight yellowish K.F rings present in b/l cornea SKIN EXAMINATION Color : blackish discoloration of extensor surface of b/l Leg, yellowish discolration of sclera. Moisture: Dryness Texture: Rough Turgor: normal Temperature: equal to body temp (98.6 f) Lesions :Vesicular eruptions on rt extensor surface of leg with erosions

23. INVESTIGATION

24. INVESTIGATIONS

25. ROGA PAREEKSHA

26. NIDANA PANCHAKAS Nidana – Beeja dushti Aharaja – Katu amla lavana rasa pradhana bhojana,vidaahi ahara ( excessive masala food,curds ), Guru aahara Purvaroopa - Roopa – Ubhaya adhogata shakha shotha ( dakshina > vaama ) Krishna varna , kandu , pidika ( dakshina adhogata shakha ) Udara utsedha Peeta varna Akshi Haridra varna mootrata

27. SAMPRAPTI JALODARA Shyava kandu sarava yukta Pidika

28. Upashya – Vishraama . Anupashaya – Guru, Vidahi , Ati ambu sevana .

29. SAMPRAPTI GHATAKA Dosha – pitt pradhana tridosha Dushya - Rasa,Rakta,maansa Srothas – Rasa,Rakta,maansa Sroto dusti - Sanga , vimarga gamana Agni - Jatharagni and Dhatvagni mandya

30. Udbhavasthana - Aamashya Sancharasthana – Rasayani , Ambuvaha Strotas Vyaktasthana – Udara , Adhosakha , Adhishtana – Aamashaya Rogamarga – Abhyantara Sadhya-Asadhyata - kruchra sadhya

31. VYAVCHEDAK NIDAAN Plihodhara Yakritodara Jalodhara Kostha ashrita kamala Shakha ashrita kamala Kumbha kamala Haleemaka Panaki

32. Disease Inclusion Exclusion Plihodara Udara abhinivartyati , arochaka , daurbalya Spleenomegally Yakritodhara Udara abhinivartyati Arochaka,daurbalya

33. DISEASE INCLUSION EXCLUSION Asruja yonivyapat / Rakta yonivyapat Ati pravartana of rakta from yoni marga . No daha , No osha , choshadi pitta lakshana`s Lohitakshara yoni vyapat Rakta ksharana No Osha , chosha , jwara , daha Disease Inclusion Exclusion Jalodhara Annanaakansha Dourbalya Gudsrava Shifting dullness Panaki Santapa , Bhinnavarchasa , peeta Panduta netraraga Haleemaka / laghava / alasa Mridu jwara Balo utsaha kshaya Mandagani aruchi Angamardha,varna , breathlessness Bhrama , harita shyava peeta varna , Tandra , shwasha , trishna

34. DISEASE INCLUSION EXCLUSION Asruja yonivyapat / Rakta yonivyapat Ati pravartana of rakta from yoni marga . No daha , No osha , choshadi pitta lakshana`s Lohitakshara yoni vyapat Rakta ksharana No Osha , chosha , jwara , daha Disease Inclusion Exclusion Pandu Daurbalya Jwara shrama Akshikoota shotha Shishir dweshi Atinidra , bhrama Shativan Pidikodweshtana Shakha Ashrita kamala Daurbalya Jwara , Hikka Parshava shoola shwasha shweta varchasa Aatopa , vishtambha , Kostha Ashrita kamala Aruchi Daurbalya Netra peetata Shakrit peetata Kumbha kamala Kaalantrat kharibhoota , aruchi , Jwara . Shoona / Shootha krishna Peeta shakrut mutra parvbheda

35. DIFFERENTIAL DIAGNOSIS Haemochromatosis Hepatitis A/E Hepatitis B/C/D Liver cirrohosis

36. DISEASE INCLUSION EXCLUSION Asruja yonivyapat / Rakta yonivyapat Ati pravartana of rakta from yoni marga . No daha , No osha , choshadi pitta lakshana`s Lohitakshara yoni vyapat Rakta ksharana No Osha , chosha , jwara , daha Disease Inclusion Exclusion Hamachromatosis Metallic hue/ pigmentation over legs Liver disorders Fatigue, weakness, Serum Iron levels were found to be normal Hepatitis A/E Spreads by faeco oral route, Fever, anorexia, splenomegally , jaundice after 1-2 week of fever Recovery occur in 3-6 weeks Severe elevations of AST,ALT (>300U/L) Hepatitis B/C/D Fever, anorexia, splenomegally , jaundice Spread of route is percutaneous or sexual contact Severe elevations of AST,ALT (>300U/L) Transmitted by intravenous route, sexual Cirrohosis of liver Shrunken liver Jaundice Ascites

37. VYADHI NIRNAYA Liver cirrohosis with mild Ascites Jalodara Wilson disease

38. SADHYA ASADHYATA Krichha Saadhya

39. CHIKITSA DATE TREATMENT GIVEN OBSERVATIONS 5/5/16 – 12/5/16 1.Gomutra haritaki 6gm haritaki +30ml of Gomutra On empty stomach before breakfast. 2.Tab. liv52DS 2tid 3.Nirocil Syrup 3tsp tid 4.Vasa Guduchyadi kwatha 6tsp tid p.t.o Pada shotha Vaivarnya in pada Udara Utsedha

40. CHIKITSA DATE TREATMENT GIVEN OBSERVATIONS 5. Mukta Bhasma 2gm Godanti bhasma 40gm Guduchi Satva 50gm Mixed and given 1tsp tid During the entire course of treatment patient was advised to take Rice and milk diet only.

41. CHIKITSA DATE TREATMENT GIVEN OBSERVATIONS 13/5/16 – 19/5/16 1.Gomutra haritaki 6gm haritaki +30ml of Gomutra On empty stomach before breakfast On alternate days. 2.Rest medicine continued same.

42. BEFORE TREATMENT AFTER TREATMENT Pada shotha Pada shotha absent Krishna Vivarana in pada with kandu Krishna Vivarana in pada with kandu reduced Udara Utsedha Udara utsedha reduced Peeta vivarana of akshi Peeta vivarana of akshi reduced to a greater extent Vesicular eruptions with erosions Vesicular eruptions have changed into crusts, erosions absent

43. BEFORE TREATMENT Investigations 21 April 2016 AFTER TREATMENT Investigations Total Bilirubin 4.65 3.31 ▼ Direct 2.86 1.03 ▼ Indirect 1.79 2.28 Total protein 5.9 7.9 ▲ Albumin 2.84 2.6 Globulin 3.06 5.3 Ag Ratio 0.93 0.5 SGOT/ALT 46.8 18.9 ▼ SGPT/AST 116.8 31.8 ▼▼ Alkaline Phosphatase 89.5 93.8 Gamma Glutyl Transferase 40.8 33.3 ▼

44. Kayser –Fleischer ring

45. Kayser –Fleischer rings

46. RIGHT LEFT During Treatment

47. RIGHT LEFT After Treatment

48. ADVISE ON DISCHARGE 1.Gomutra haritaki 6gm haritaki +30ml of Gomutra On empty stomach before breakfast on alternate days. 2.Tab . liv52DS 2tid 3.Nirocil Syrup 3tsp tid

49. 4.Vasa Guduchyadi kwatha 6tsp tid 5 . Mukta Bhasma 2gm Godanti bhasma 40gm Guduchi Satva 50gm Mixed and given 1tsp tid Breakfast with milk diet only. Regular meals for Lunch and Dinner. Avoid fatty and spicy food items. Follow up after 30 days.

50. Proposed line of treatment Shamana Gomutra haritaki 6gm haritaki with 30ml gomutra b.d B/f Darvyadi choorna 1tsf tid with Water B/f Vasa guluchyadi kashayam 3tsf tid with water A/f Kalyanaka gudam 5gm b.d with milk A/f Shodhana Virechana with Trivrit avleha & Triphala kwatha

51. Rasayana Shilajatu rasayana 1 tab tid with Gomutra a/f Pipali vardhmana Rasayana for 13 days (max dose 5gm for 5 days ) Swarna makshika bhasma 1 ratti with Madhu A/f

52. Pathya - Apathya

53. Pathya Apathya Cereals Old rice, wheat, barley Fried and difficult to digest articles of food Pulses Pigeon pea ( arahara ), green gram ( mudga ), masura Peas, black gram Fruits and vegetables Papaya, banana, potato, amalaki , pomegranate, grapes, anjira , apple, paravala , mango, Others Cow milk, buttermilk Excessive use of oil and clarified butter, mustard oil, betel, spices, rye, hingu , sesame, heavy food

54. Pathya Apathya Lifestyle vegdharana , maithuna , diwaswapna,atapa sewana , Vyayama , krodha , atichankramana , ati ambu paana

55. Thank you !