aamvaat case presentation

1. DR. VINAY TIWARI
I YEAR PG SCHOLAR
DEPT., OF PG STUDIES IN KAYACHIKITSA
SKAMCH&RC, BANGALORE
1
CASE DISCUSSION

2. PREMILINARY DATA OF PATIENT
 Name : Mr. Armugam
 Age : 45 Years
 Sex : Male
 Religion : Hindu
 Socio economic status : Lower class
 Marital status : Married
 Education status : Uneducated
 Occupation : Labour
 Date of admission :12/03/15
 Date of discharge : 25/04/15
2

3.  Ward : Male General Ward
 Source of history : Patient
 Case taken on : 17/04/15
 Consultant doctor : Dr. Baidyanath Mishra
Dr. Abdul Khader
 O.P No : C-7013
 I.P. No : 1090/15
 Address : # 92 Venkatashwamappa
lane chikkamavelli.
Bangalore.
3

4. PRADHAN VEDANA
 Pain (shoola) in multiple joints (sarva sandhi) associated
with difficulty in walking (gamana ashakatata) since 3
months.
 Swelling (shotha) in both legs (pada) since 2 months.
4

5. ANUBANDHA VEDANA
 Tingling sensation (chimchimayana) over right foot
(dakshina pada) since 2 months.
 Loss of appetite (arochaka) since 1 month.
 Constipation since (baddha mala) 1 month.
 Burning micturation (mutra daha) since 1 month.
5

6. VEDANA VRUTTANTA
Patient was apparently normal 3 months back where he
noticed pain in knee joints (janu sandhi shoola) after
walking long distance on a pilligrimage. Gradually with
in a span of 10 days he noticed pain in multiple joints
pricking type in nature with bodyache (angamarda)
associated with difficulty in movement. He was treated
at various hospitals with little relief. He was admitted at
St. Johns hospital after one and half months of onset of
above complaints.
6

7. At that time along with above complaints he had
difficulty in movement of right foot & tingling sensation
in right foot (pada). After detailed investigation he was
diagnosed as Sero-negative arthritis, ? Foot drop, fatty
liver, Vitamin-D deficiency & treated conservatively for
the same. He was discharged after 12 days with
considerable relief in pain. Patient didn’t continue
medication after discharge and noticed aggravation of
pain in multiple joints with in few days.
7

8. So he approached SKAMCH&RC after one week. At the
time of admission patient presented with pain and
stiffness in multiple joints with difficulty in walking,
heaviness in the body (gaurava), swelling in both legs
(sotha), loss of appetite (arochaka), incomplete
evacuation of stools (vibandha/anaha) & burning
micturition, tingling sensation in right foot with restricted
movement in right foot.
8

9. Patient complains of severe pain during morning hours with
restricted movements (stambha) upto 2 to 3 hours, warmth in all
joints, feverish feeling, reduced appetite does not feel like
consuming food (arochaka), hard stools with incomplete evacuation
of bowel once in four days, burning micturition was more during
morning hours & used to subside after 2 to 3 evacuations.
Swelling in legs was said to be more during morning hours & use to
reduce gradually. Patient is not able to recollect about the onset of
restricted movement in right foot (? foot drop) but said that he
noticed it during admission to St.John hospital. 9

10. POORVA VYADHI VRUTTANTA
 Patient had similar set of complaints 10 years
back and was treated symptomatically (by self
medication of pain killers tablets).
 Patient is not a k/c/o Diabetes Mellitus,
Hypertension, Tuberculosis.
10

11. TREATMENT HISTORY
IN ST.JOHNS HOSPITAL (21/02/15 to 04/03/15 )
Tab – Wysolone 10 mg (1-0-0) for 7 days.
Tab – Wysolone 5 mg (1-0-0) for 7 days.
Tab – Methotrexate 10 mg (once a week).
Tab – Folic acid 5 mg (once a week).
Tab – HCQ 200 mg (1-0-1) for 7 days.
Tab - Shelcal 500 mg (0-1-0) for 7 days.
Tab – Pan 40 mg (1-0-0) for 2 weeks.
Vit-D sachet 60000 units (once a week).
11

12. FATHER MOTHER
BROTHER BROTHER PATIENT BROTHERSISTER SISTERSISTER
WIFE
SON
KAUTAMBIKA VRUTTANTA

13. KAUTAMBIKA VRUTTANTA
 Father was suffering from Diabetis mellitus. (Died).
 Mother was suffering from Carcinoma, detail not
available (Died).
 Patient has 4 brothers & 3 sisters.
 Patient is married and has 1 child.
 No history of similar complaints in the family.
13

14. VYAKTIKA VRUTTANTA
 Diet : Mixed (non veg 3 to 4 times in a week)
since 3 months taking only veg.
 Appetite : Reduced.
 Bowel : Hard stools once in 4 days, irregular,
incomplete evacuation.
 Bladder : 4 to 5 times/day. Burning micturation
2 to 3 times/night.
 Sleep : Disturbed due to pain.
 Addiction : Alcohol :100 to 120 ml whisky/day. Since
: Smoking : Beedi :15 to 20 per/day. 25 yrs
:Tea – 5 to 6 per/day. 14

15. GENERAL PHYSICAL EXAMINATION
 General Condition : Fair.
 Built : Moderately built.
 Nourishment : Moderately Nourished.
 Pallor : Absent.
 Oedema : Bilateral legs (pitting).
 Nails : No clubbing / Koilonychia.
 Cyanosis : Absent.
 Icterus : Absent.
 Lymphadenopathy : Absent.
 Pulse :78 bpm. 15

16.  BP :120/80 mmHg.
 R/R :18/minute.
 Tongue :Coated.
 Height : 1.86 m
 Weight : 84 Kgs
 BMI : 24
16

17. PER ABDOMEN EXAMINATION
 INSPECTION
 Shape – Scaphoid
 Umbilicus inverted
 No visible peristalsis, No scars.
 Area of Hyper pigmentation around the
Umbillicus observed.
17

18.  PALPATION
 Soft, Non Tender and no organomegaly.
 PERCUSSION
 Tympanic sounds heard except the area of Liver
dullness.
 AUSCULTATION
o Bowel sounds heard.
18

19. RESPIRATORY SYSTEM
 INSPECTION
 Shape of chest - Bilaterally symmetrical
 PALPATION
 Trachea - Centrally placed
 Tactile Vocal Fremitus -Normal
 PERCUSSION
 Resonant sounds heard except the cardiac dullness.
 AUSCULTATION
 Normal Vesicular Breath Sounds heard
19

20. CARDIO VASCULAR SYSTEM
 INSPECTION - No scar, No swelling .
 PALPATION - Non tender, Apex Beat felt at 5th
intercostal space 9 cm from the mid sternal line.
 PERCUSSION - Defined Area of cardiac dullness.
 AUSCULTATION - S1 and S2 heard.
No added sounds heard.
No murmurs heard.
20

21. LOCOMOTOR SYSTEM EXAMINATION
21
Joints Tenderness Warmth Swelling Measurments Range of movements.
Ankle
joints &
foot
Rt- +++
Lt- +++
Rt-
present
Lt-
present
Rt- present
Lt- present
Rt – 11.8 inch
Lt – 9.4 inch
Flexion-Rt- painful, Lt-
painful
Extension-Rt- painful, Lt-
painful
Inversion – Rt- painful, Lt-
painful
Eversion- both normal
Knee
joints
Rt- ++
Lt- ++
Rt-
present
Lt-
present
Rt- present
Lt- present
Rt – 14.8 inch
Lt – 14.1 inch
Flexion- both normal
Extension-both normal
Internal rotation- both
painful
External rotation- both
painful

22. 22
Joints Tenderness Warmth Swelling Range of movements
Hip joints Rt- ++
Lt- ++
Rt-
present
Lt-
present
Rt- present
Lt- present
Flexion- both painful
Extension- both painful
Abduction-both painful,
Adduction- both Normal
Int.Rotation- both painful
Ext Rotation- both normal
Thumbs Rt- ++
Lt- ++
Rt-
present
Lt-
present
Rt- present
Lt- present
Flexion- both painful
Extension-both normal
Abduction- both normal
Adduction- both normal
Opposition- Rt-normal, Lt- painful

23. 23
Joints Tenderness Warmth Swelling Measurments Range of movements
Wrist joints Rt- +++
Lt- +++
Rt-
present
Lt-
present
Rt-
Present
Lt- Absent
Rt – 7.5 inch
Lt – 6.9 inch
Flexion- painful
Extension-painful
Adduction-painful
Abduction- painful
Hand grip – Normal
Elbow
joints
Rt- ++
Lt- ++
Rt-
present
Lt-
present
Rt-
Present
Lt- Absent
Rt – 10 inch
Lt – 9.5 inch
Flexion- painful
Extension-normal
Supination- normal
Pronation- normal

24. 24
B/L
Joints
Tenderness Warmth Swelling Measurements Range of movements
Shoulder
joints
Rt- ++
Lt- ++
Present
on both
Rt - Present
Lt – Absent
Rt – 14 inch
Lt – 12.8 inch
Flexion- Rt- upto 90
degree, Lt- upto 50 degree,
painful
Extension- both upto 20
degree, painful
Int Rotation- both painful.
Ext Rotation- not possible
in both.
Neck /
cervical
joint
- Present Absent Flexion- normal
Extension- painful
Rotation- Painful
Lateral Bending- painful

25. SUMMARY OF LMS EXAMINATION
 Pain in all the joints
 Tenderness & warmth in all the joints.
 Mild swelling over right half of the body.
 On examination of right ankle joint and foot there was no
foot drop.
25

26. DASHAVIDHA PARIKSHA
1) प्रकृ ति: –: Vata Pittaja.
2) सारतः –: Madhyama.
3) संहनि –: Madhyama.
4) प्रमाणतः –: Height - 1.86 m
- : Weight - 84 kgs.
5) सात्म्यि –: Madhyama.
26

27. 6) सत्मवि –: Madhyama
7) आहर शक्ति -: अभ्यवहरण शक्ति – Avara
-: जरण शक्ति – Avara
8) व्यायाम शक्ति –: Avara
9) वयः –: Madhyama
10) ववकृ ति –: Pravara
27

28. NIDANA PANCHAKA
NIDANA : Viruddhahara, mandagni, ati vyayama after
snigdha bhojana, ati madya pana.
SAMPRAPTI GHATAKA:
 Dosha : Kapha and Vata pradhana tridosha.
 Dushya : Rasa, Mamsa, Snayu, Asthi.
 Srotas : Annavaha, Rasavaha, Pureeshva, mootravaha,
mamsavaha, astivaha
 Sroto dusti : Sanga, Vimargamana.
 Agni : Jatharagni, Dhatvagni
 Ama :Jatharagni & Dhatwagni mandhya janya ama
 Udbhava sthana : Amashaya.
 Sanchara sthana : Dhamni.
 Vyakta sthana : Sandhi.
 Roga marga : Madhyama
28

29.  Vyadhi Svabhava : Chirakari.
 Sadhya asadhyata : Krichra sadhya.
29

30.  Nidana sevana Agnimandya + Vata Dusti
Ama utpatti
Pravruddha ama propelled by vitiated vayu
 Undergoes Vidhagdha and Results in Tridosha
Prakopa and Enters Dhamani
30

31. Lodges in sandhi, amashaya causing srotoavarodha
Produces symptoms like Angamarda, gourava, dourbalya,
jwara, shotha, shoola, stabdhata
Amavata
31

32. POORVAROOPA - Could not be elicited
ROOPA
 Pain in hast, pada, gulfa, trik, janu sandhi pradesha.
 Sotha in sandhi & pada.
 Pricking type of pain in joints (Vruschika damsavat).
 Aruchi, agnimandya, gaurava, anaha,
 Stabdhata in sandhis.
 Trushna.
 Bahumootrta.
 Vida vibandhata (Constipation).
 Jwara.
 UPASAYA : Analgesics.
 ANUPSAYA: Exposure to cold climate. 32

33. VYAVACHEDAKA NIDANA
33
Lakshana/
Parameters
Sandhivata vatarakta Amavata
Dosha Vata predominant Vata,rakta pradhana
tridoshaja
Vata kapha pradhana
tridoshaja
Dushya Rasa, asthi dhatu Rasa, rakta dhatu Rasa dhatu
Vyadhi Udhbhava In weight bearing joints In smaller joints First in smaller joints, later
in bigger joints
Ruja, shotha Only ruja( vata purna
druti sparsha)
Both ruja (Aku
Vishavat) and shotha
present
Initially both, in later stages
only pain. (vrischika
damshavat vedana)
Jwara Absent Absent Present (often/episodes)
Effect of sthanika
snehana
useful useful In initial stages causes
aggravation, in later stages
useful

34. Lakshanas /
parameter
Vatakantaka Khnaja Pangu Khalli
Dosha Vata
predominant
Vata
predominant
Vata
predominant
Vata
predominant
Dushya Asthi Asthi, Khandara Asthi, Khandara Asthi, snayu
Vyadhi udhwava Gulpha
masritvam
Kati pradesha &
gulpha
pradesha
Kati pradesha &
gulpha
Pradesha
Pada, jangha,
uru, kara, moola
Ruju sotha Ruja sotha Ruja Ruja Ruja
Jwara Absent Absent Absent absent
34

35. •Osteo arthritis •Gouty arthritis • Rheumatoid arthritis
•Age > 45 yrs (often 60)
•Insidious onset over months or
years.
•Mainly related to movement
and weight-bearing, relieved by
rest.
•Only brief(< 15 min ) morning
stiffness and reduced after rest.
•Usually one or a few joints
painful(not multiple origin)
•Inflamation is not a prominent
feature.
Full blood count, ESR, CRP are
normal.
•In almost all attacks a single distal
joint is affected.
•The first MTP joint is affected in over
50% cases.
•Podagra (seizing the foot).
•The axial skeletal and large proximal
joints are rarely involvedand never as
the first site..
•Extreme tenderness.
•Marked swelling with overlying red,
shiny skin
•Self limiting over 5 to 14 days, with
complete return to normalaty.
•Starts with great toe.
•Raised uric acid level on laboratory
examination.
•Morning stiffness(> 1 hr).
•Arthritis of 3 or more joint
areas.
•Arthritis of hand joints.
•Symmetrical arthritis.
•Rheumatoid nodules.
•Rheumatoid factor.
•Raised ESR & CRP.
•Typically presentation with
pain,joints swelling,
stiffness affecting the small
joints of the handfeets and
wrists. Large joints
involvement.
•Stiffness more than 6
weeks for diagnosis.
35

36. LAB INVESTIGATIONS
36

37. 37

38. 38

39. 39

40. 40

41. 41

42. DIAGNOSTIC CRITERIA CONFIRMING RA(AS PER
2010 AMERICAN COLLEGE OF RHEUMATOLOGY)
 Joint Involvement:
 1 large joint 0
 2-10 large joints 1
 1-3 small joints 2
 4-10 small joints 3
 10 joints(atleast 1 small joint) 5
 Serology:
 Negative RA factor 0
 Low positive RA factor 2
 High positive RA factor 3 42

43. Acute phase Reactants:
Normal ESR and normal CRP 0
Abnormal ESR or Abnormal CRP 1
Duration of symptoms:
< 6 weeks 0
≥ 6 weeks 1
Score of ≥ 6/10 is needed for confirming as RA.
In this pt score is - 7/10.
43

44. VYADHI VINASCHAYA
 Amavata.
 Rheumatoid arthritis
44

45. CHIKITSA VRUTTANTA
DATE LAKSHANA CHIKITSA OUTCOME
12/03/15 Pain in multiple joints with
swelling.
Non passage of bowels.
Fever.
Tingling sensation over the rt foot.
Burning micturation.
Pedal Oedema
1. I.V.F – Ringer lactate .
2. Syp. Renalka 2tsf -0-2tsf.
3. Cap. Palsineuron 1- 0-1
4. D – Protein
2tsf – 0 2tsf
13/03/15 Pain in multiple joints with
swelling.
Non passage of bowels.
Fever.
Tingling sensation over the rt foot.
Pedal Oedema .
Burning micturation.
1. I.V.F – Ringer lactate .
2. Syp. Renalka
2tsf – 0 - 2tsf.
3. Cap Palsineuron
1 - 0 -1
4. D – Protein
2tsf – 0 - 2tsf 45

46. DATE LAKSHANAS CHIKITSA OUTCOME
14/03/15 Pain in multiple joints with
swelling, Non passage of
bowels, Fever, Burning
micturation, Tingling
sensation over rt foot,
Pedal Oedema
(Opinion of
Dr. Shankarlingaiah)
1. I.V.F – Ringer lactate .
2.I.V.F – Normal Saline with
inj. optineuron
3.Syp. Renalka 2tsf – 0 - 2tsf.
4. Cap. Palsineuron 1 - 0 -1
5. D – Protein 2tsf – 0 - 2tsf
6. Dashanga Lepa.
7. Inj. Xone 1 Gram IV Bd.
8. Inj. Dexona IV Bd.
9. Inj Tramadol IV Bd.
10. Proctolysis enema
15/03/15 Pain in multiple joints with
swelling, Non passage of
bowels, Fever, Burning
micturation, Tingling
sensation,
Pedal Oedema
1. I.V.F – Ringer lactate .
2.I.V.F – Normal Saline with
inj. Optineuron
3.Syp. Renalka 2tsf – 0 - 2tsf.
4. Cap. Palsineuron 1 - 0 -1
5. D – Protein 2tsf – 0 - 2tsf
6. Dashanga Lepa.
7. Inj. Xone 1 Gram IV Bd.
8. Inj. Dexona IV Bd.
9. Inj Tramadol IV Bd.
•Pain in all joints
reduced.
•Fever reduced.
•Pedal oedema
reduced.
•Bowel passed after 8
days. Complete
evacuation.
• Burning micturation
reduced.
46

47. DATE LAKSHANA CHIKITSA OUTCOME
16/03/15 Pain in multiple
joints with
swelling, Non
passage of bowels,
Fever, Tingling
sensation,
Pedal Oedema
1. I.V.F – Ringer lactate with inj
M.V.I.
2.I.V.F – Normal Saline with
inj. optineuron
3.Syp. Renalka 2tsf – 0 - 2tsf.
4. Cap. Palsineuron 1 - 0 -1
5. D – Protein 2tsf – 0 - 2tsf
6. Dashanga Lepa.
7. Inj. Xone 1 Gram IV Bd.
8. Inj. Dexona IV Bd.
9. Inj Tramadol IV Bd.
•Pain in all joints
reduced.
•Fever redced.
•Pedal oedema reduced
17/03/15 Pain in multiple
joints with
swelling.
Difficulty in
defecation.
Pedal Oedema.
Fever.
Added.
10. Syp. Liv-52 10 ml (tid).
11. Triphala choorna 3 gram with
half glass luke warm water (Bd)
before food.
12. Syp. Saraswataristam 3 tsf
(tid).
13. Tab. Rumalya forte 1-1-1
14. Syp. Maharasnadi quatha
15 ml (tid).
•Pain in multiple joints
and swelling reduced.
47

48. DATE LAKSHANA CHIKITSA OUTCOME
18/03/15 Pain in multiple joints with
swelling, Difficulty in
defecation, Pedal Oedema
Continue same treatment Pedal Oedema
reduced.
Bowel not passed.
19/03/15 Pain in multiple joints with
swelling, difficulty in
defecation, Pedal Oedema,
pain in hip join increased.
Continued same treatment
Added-
15. Kati basti with
murivenna taila and
Sahacharadi taila.
16. Adhosakha abhyanga
with murivenna taila.
Pedal Oedema
reduced.
Bowel not passed
20/03/15 Pain in multiple joints with
swelling, Pedal Oedema, pain
in hip join increased.
Continued same treatment
Added-
I.V.F – D.N.S instead of
N.S.
17. Amruta guggulu 2-2-2
with hot water.
18. Sthanika valuka sweda.
Bowel passed once ,
hard stool,
incomplete
evaquation.
Pain, swelling,
oedema reduced.48

49. DATE LAKSHANA CHIKITSA OUTCOME
21/03/15 Pain in multiple joints
with swelling, Pedal
Oedema, pain in hip
joint.
Continue same treatment •Hip joint pain
reduced.
•Patient able to stand
with support.
22/03/15 Pain in multiple joints
with swelling, Pedal
Oedema, pain in hip
joint.
Continue same treatment •Patient feeling better
able to walk.
23/03/15 Pain in multiple joints
with swelling, Pedal
Oedema, pain in hip
joint.
Continue same treatment •Patient feeling better
able to walk.
49

50. DATE LAKSHANA CHIKITSA OUTCOME
24/03/15 Pain in multiple joints with
swelling, Pedal Oedema, pain
in hip joint.
Inj. Xone 1 gram iv
stopped.
Other continued as
same.
25/03/15 Pain in multiple joints with
swelling, Pedal Oedema, pain
in hip joint, difficulty in
defecation.
Continued same
treatment
Bowel not passed
26/03/15 Pain in multiple joints with
swelling, Pedal Oedema, pain
in hip joint, difficulty in
defecation.
Continued same
treatment
Bowel not passed
27/03/15 Pain in multiple joints with
swelling, Pedal Oedema, pain
in hip joint, difficulty in
defecation.
Continued same
treatment
Bowel passed, hard
stools incomplete
evaquation.
28/03/15 Stiffness of ankle joint
persisting
Continued same
treatment
Oedema reduced
50

51. DATE LAKSHANAS CHIKITSA OUTCOME
29/03/15 to
04/03/15
Pain in multiple
joints with swelling,
Pedal Oedema, pain
in hip joint, Stiffness
of ankle joint
persisting
Continued same treatment Pain,swelling,oedema,stif
fness is reduced to 95%.
Bowel habit regular,
incomplete evaquation .
05/04/15 Pain in multiple
joints, fever 100
degree F.
Stopped All old treatment Pain Increased with fever
.
06/04/15 Pain in multiple
joints, fever 100
degree F.
1. Inj Inac IM (SOS) Pain and fever reduced
07/04/15 to
16/04/15
Pain in multiple
joints, fever 100
degree F.
1. Inj Inac IM (SOS) Pain and fever reduced
17/04/15 Pain in multiple
joints
Burning micturation
1. Inj Inac IM (SOS)
2 Tab. Rumalya forte 1-1-1(A/F).
3.Tab Reosto 2-0-0 (B/F)
4. Tab Rasnadi Guggulu 2tid
5. Syp Maharasanadi quatha 30 ml (tid)
6. Sthanika abhyanga with karpooradi
taila & murivenna taila followed by Patra
51

52. DATE LAKSHANA CHIKITSA OUTCOME
18/04/15 Pain in multiple joints
Burning micturation
ADDED-
7. Crape bandage for right
ankle.
8.Sthanika valuka sweda.
9.Tab Amrutha guggulu
2(tid) b/f.
10. Tab. Cystone 2 bd after
food.
Burning
Micturation
Reduced.
19/04/15 Pain in multiple joints. Continued same treatment
20/04/15 Pain in multiple joints. Continued same treatment
21/04/15 Pain in multiple joints
Burning micturation
Continued same treatment Pain reduced.
Burning
micturation
improved.
22/04/15 Pain in multiple joints Continued same treatment Pain reduced.
Burning
micturation
improved.
52

53. 53