presented a case in final year of post graduation

1. WELCOME
TO
CLINICAL DISCUSSION
Dr. Kamal Kishore
PG Scholar,
Dept of PG Studies in Kayachikitsa,
SKAMCH&RC,
Bangalore.
1

2. Patient Bio-Data
Name : Mr. Manjunath
Age : 26 years
Sex :Male
Religion :Hindu
Socio-Economic status :Lower middle class
Marital status : Unmarried
Education : Graduate
Occupation : student
2

3. Date of Admission :12/04/2017
Ward :MGW
Source of History :Patient, Relative of patient
Case taken on :27/04/2017
Consultant Doctor :Dr. Byresh
OP No :E/2430
IP No :1520/1
Address : Mudden palya,
Magadi Road,
Banglore.
3

4. Pradhana Vedana / Chief
Complaints
 C/o difficulty in walking since 2 years
 C/o difficulty in speaking since 2 years.
4

5. Anubandha Vedana / Associated
Complaints
 Difficulty in activities of daily living since 2 years
5

6. Vedana Vrittanta / History of
Present Illness
Patient had an alleged history of Road traffic accident on
19/01/2015 near chandanpura Bengaluru. (hit by four
wheeler while crossing road) following which LOC and
bleeding from nose and ears was there. He was taken to
Sparsh hospital and imaging revealed bilateral temporal
subarachnoid haemorrhage with subdural haemorrhage,
fracture of left femur, nasal bone fracture and bilaterally
maxillary fracture.
6

7. He was managed in ICU. Decompressive craniotomy and
fixation of left femur was done. In ICU tracheostomy and
gastrostomy was done. After 3 months of hospital stay he
was discharged and was put on regular follow up with
physiotherapy. Post hospital stay he was unable to walk
and speech was also deranged. But memory and cognitive
functions were intact with no bowel bladder disturbance.
7

8. On 23/2/2016 left femur reconstruction adjustment was
done for the malunion in same hospital (Sparsh
hospital).
On 22/2/17 he was admitted to SKAMCH&RC in
preview of the above mentioned chief complaints and
was given treatment for one month. Finding significant
improvement in his ambulation, got admitted again on
12/4/17 for further management.
8

9. Poorva Vyadhi Vrittanta /
History of Previous Illness
No comorbidities noted.
9

10. Chikitsa Vrittanta / Treatment
History
Patient was managed conservatively and surgically in
preview of his head injury and left femur fracture
with various analgesics, diuretics, antiepileptics,
antibiotics etc.
10

11. Chikitsa Vrittanta / Treatment
history
Previously he was managed in SKAMCH&RC for one
month from 22/2/17 to 22/3/17 with
S. Abhyanga with Moorchita til taila f/b P.P.S
Bhadradarvyadi kashaya and dashmoolarishta (3 tsp each
bd) as abhyantara aushadhi.
Jihwa nirlekhana with vacha choorna.
Presently he is not on any allopathic medicine.
11

12. Koutumbika Vrittanta / Family
History
 All are said to be healthy.
12

13. Vayaktika Vrittanta / Personal
History
 Diet - Mixed, Nonveg – once/week
 Appetite - Moderate
 Sleep - Normal( 7-8 hrs/ day)
 Micturition - 3-4 times per day
2 times/ night,
 Bowel - once daily clear evacuation.
 Habits - none.
13

14. General Physical
Examination
 Built - Moderate
 Nourishment - Moderate
 Pallor - Absent
 Icterus - Absent
 Cyanosis - Absent
 Clubbing - Absent
 Lymphadenopathy - Absent
14

15.  Edema - Absent
 Tongue - not coated
 Pulse - 78 BPM
 B.P - 120/80 mm of Hg
 Temp - 98.6° F
15

16. 16
 Respiratory rate - 20 cycles/min
 Height - 170 cm
 Weight - 62kg
 BMI -21.4

17. Systemic Examination
 Cardiovascular System
S1 S2 heard.
 Respiratory System
Normal vesicular breath sounds heard with equal air entry.
 Abdominal System
Soft, non tender, no organomegally, bowel sounds present.
17

18.  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
(A) HIGHER MOTOR FUNCTIONS
18
Central Nervous System

19.  1.Olfactory
Smell sensation-Intact
 2.Optic
a)Visual acuity Intact
b)Visual field Intact
c)Pupils equal and reactive to light
 3.Occulomotor, 4.Troclear & 6.Abducent Nerve
a)Accomodation/convergence – NOT POSSIBLE
b) Nystagmus PRESENT ON RIGHT LATERAL GAZE
(B) CRANIAL NERVE EXAMINATION
19

20. c)Left divergent squint/ exotropia/
Incomitant squint with dysconjugate gaze PRESENT.
d)Bilateral drooping of eyelid PRESENT
(but does not obstruct the vision)
e)Eyeball movements:
Right left
OPTHALMOPLEGIA OF
MEDIAL RECTUS
OPTHALMOPLEGIA OF
MEDIAL RECTUS
OPTHALMOPARESIS OF
INFERIOR OBLIQUE
OPTHALMOPLEGIA OF
INFERIOR AND SUPERIOR
OBLIQUE
20

21. 21

22.  5.Trigeminal
Sensory-Touch, pain and pressure sensation- Intact
-corneal reflex-could not elicit
Motor-clenching of teeth -possible
-bilateral movement of jaw- possible
22

23.  7.Facial
a)Forehead frowning -possible, equal in both sides
b)Eyebrow raising - possible, equal in both sides
c)Eye closure - possible, equal in both sides
d)Teeth showing -possible
e)Blowing of cheek -possible
f)Naso labial fold -present on both sides
Taste sensation present on anterior 2/3 of tongue.
23

24.  8.Vestibulo-cochlear Rt Lt
Rinne’s test- Bone conduction Present Present
Air conduction ABSENT Present
Weber’s test- equal to both sides.
 9.Glossopharyngeal and 10.Vagus
Position of uvula- centrally placed
Taste sensation -intact, Gag reflex - not elicited
24

25.  11.Spinal accessory
Shrugging shoulder- possible against resistance
Neck movement -possible against resistance
 12.Hypoglossal
Protrusion of tongue -possible
Tongue movements -possible
Speech :- ATAXIC DYSARTHRIA PRESENT
25

26. 1)Involuntary movements – PRESENT(Intentional Tremors)
2)Muscle bulk – Rt Lt
Biceps 28.5cm 26.5cm
Forearm 23.5cm 22.5cm
Mid Thigh 45.5cm 44.5cm
Calf Muscles 30.5cm 28.5cm
3)Muscle tone
NORMOTONIC
(C) MOTOR SYSTEM
26

27. Rt Lt
4)Muscle strength
a)Elbow -flexion 5/5 5/5
-extension 5/5 5/5
b)Wrist -flexion 5/5 5/5
-extension 5/5 5/5
c) Finger abduction 5/5 5/5
d)Opposition of thumb 5/5 5/5
e) Test of grip 5/5 5/5
27

28. 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
28

29. 5)Coordination
Finger nose test - DYSMETRIA PRESENT (finger
overshoots more on left side)
Heel to shin test - DYSMETRIA PRESENT
Rapid alternative movements -
DYSDIADOCHOKINESIA PRESENT.
29

30. Intention tremor - PRESENT
Tandem walking - NOT POSSIBLE
Rhomberg test - Negative
Pronator drift - Absent.
Rebound phenomenon - PRESENT
30

31. 6)Gait- ATAXIC GAIT
7)Reflexes
Superficial Reflexes
a)Corneal -could not be elicited
b)Abdominal -could not be elicited
31

32. 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 - Flexor Flexor
32

33. 1)Superficial:
a)Touch -Intact
b)Temperature -Intact
c)Pain - present
2)Deep:
a)Vibration - present
b)Position sense -present
c)Pressure sense -present
(D) SENSORY SYSTEM
33

34. IMPRESSION :
1) Incoordinated movements
2)Cerebellar ataxic gait
3)Ataxic Dysarthria/scanning speech
4)Titubation (nodding of head)
5) Nystagmus
6) Intention tremors
7) Dysmetria present
8) Dyssnergia (small jerky clumsy movements)
34
“CEREBELLAR LESION”

35. Dashavidha pariksha
 Prakruti - Vata-Pitta
 Vikruti :-
Hetu - Abhightaja
Dosha -Vata, kapha pradhana tridosha
Dushya -Rakta, meda, asthi, snayu, sira
Prakruti - prakriti samasamaveta
Desha -Saadharana
Kaala - Varsha ritu
Bala -Madhyama
35

36.  Sara -Madhyama
 Samhanana -Madhyama
 Pramana -Ht-170 cm, Wt- 62 kgs
 Satmya -Madhyama
 Satva -Madhyama
 Ahara sakthi-
Abvyaharana sakthi -Madhyama
Jarana sakthi -Madhyama
 Vyayama sakthi - Avara
 Vaya -Yuva
36

37. 37
Shiro Marmabhighaata
Vyana vaata prakopa
Avarana by kapha and manifested
as Kapha avrita vyana vaata
Gati sanga
Difficulty in coordination
SAMPRAPTHI

38. Samprapthi ghataka
 Dosha -Vata, kapha pradhana tridosha
 Dooshya -rakta, meda, asthi, majja,
snayu, shira
 Agni -Jataragni,dhatvagni
 Srothas -Indriyavaha, medhovaha,
asthivaha, majjavaha.
 Srotho dushti prakara –Sanga, Athi pravruthi
 Vyaktha sthana - sarvashareera
 Adhishtana - Masthishka
 Marga - Madhyama
38

39. Vyavachedaka nidana
39
Disease Inclusion exclusio
n
Snayugata vata Kampa, snayu, kandara,
sira vikruthi.
Vepathu shirakampa
Udanavruta vyana Cheshtahaani,
nirnimeelanam,
Sheershakampa Nidana- moordhni
abhighata, sheershakampa,
karnahani, vacha vikara,
vepathu, moorcha, vistrut
netra kaneenika,
pakshahani

40. Vyadhi vinishchaya /
Diagnosis40

41. TREATMENT GIVEN
Date Treatment given
12/4/17-
17/4/17
1. Sarvanga agnilepa
2. Jihwa nirlekhana with vacha choorna
(1/2 tsp with 1 tsp honey twice daily)
3. Bhadradarvyadi kashayam 2 tsp tid with water
4. Dashmoolarishta 2tsp with water bd
5. Sarvanga abhyanga with dhanwantarum taila f/b
patra pinda sweda.
6. Physiotherapy
41

42. Date Treatment
18/4/17 1. Jihwa nirlekhana with vacha choorna
(1/2 tsp with 1 tsp honey twice daily)
2. Bhadradarvyadi kashayam 2 tsp tid with water
3. Dashmoolarishta 2tsp with water bd
4. Sarvanga abhyanga with dhanwantarum taila
f/b patra pinda sweda.
5. Physiotherapy
42

43. Date Treatment
19/4/17 –
30/4/17
1. Jihwa nirlekhana with vacha choorna
(1/2 tsp with 1 tsp honey twice daily)
2. Bhdradarvyadi kashayam 2 tsp tid with water
3. Dashmoolarishta 2tsp with water bd
4. Sarvanga abhyanga with dhanwantarum taila
f/b patra pinda sweda.
5. Physiotherapy
43

44. Date Treatment
19/4/17 –
30/4/17
6. Shiropichu with ksheerbala taila during day
time
7. Padabhyanga with ksheerbala taila during
night time
8. Mukhabhayanga with ksheerbala taila
followed by naadi sweda for nasya with anu
taila 15 drops to each nostril.
44

45. OBSERVATIONS
1. Muscle tone of lower limbs improved.
2. Can walk with one hand support as compared to
previous four legged walker support for walking.
3. Overall gait improved.
4. Can stand from bed without support.
5. Patient feeling well in sense of overall physical
performance.
45

46. Proposed line of treatment
1. Sarvanga abhyanga with ksheerbala taila followed by
shashtika shali pinda sweda
2. Matra basti with ksheer bala taila
3. Ksheerabala taila 101- 10 drops Bd
4. Marsha nasya with anutaila
5.Mahayogaraja guggulu 2-2-2 Bd A/f
6. Mahavatvidhwansa rasa 125mg bd
7. Balarishtam 3tsf bd
8. Ashwangdhaadi churna 2tsf bd with milk
46

47. Thank you
47