1.
Case Discussion
By Dr. Shashi Prabha Pandey
First Year MD- Clinical Yoga

2.
Content
Case History Disease Description Management

3.
CASE
HISTORY

4.
Preliminary data
•Name : Divya
•Age: 43 years
•Sex: Female
•Occupation : Home Maker
•Marital Status : Married
•Religion : Hindu
•Address : Bangalore
•D.O.A: 26-01-2023
History Taking

5.
Chief complaints
• C/O increased body weight since 2yrs.
• K/C/O pulmonary hypertension since 2 yrs.
• C/O lower back pain since 6 months.
• K/C/O sinusitis since 3 months.

6.
History of Chief Complaint
• H/C/O Increased body weight . The weight gain is gradual in
onset, due to sedentary lifestyle.
• PH on treatment from last 2 years.
• Low back pain since 6 months.
• Sinusitis since 3 months.

7.
• Not relevant.
Past History
Medical History
• Zoamet Nasal Drops - SOS
• Tab. Lasilactone 50 mg ½ - ½ - 0

8.
Surgical History
• No surgical history
Obstetric History
• G - 6
• P - 1
• L - 1
• A - 5
• C - 0

9.
Gynaec History
• Last menstrual period (LMP) -
15/01/2023
• Cycle length and frequency - 3/28
• Clots- Ab
• Dysmenorrhea - Ab
• Intermenstrual bleeding (IMB) - Ab
• Postcoital bleeding (PCB) - Ab
• Age of menarche- 14 yrs. of age
• Breast Tenderness- Present

10.
Family History
• Maternal –
Hypertension , CVD
• Paternal - Tuberculosis

11.
• Diet - Mixed
• Appetite - Good
• Thirst - Normal
• Micturition - Normal in
frequency
• Bowel - Regular
• Sleep - Disturbed
• Habit - Coffee, once daily
• Addiction - Nil
• Food allergy - Nil
Personal History Vital Parameters
• Blood pressure - 130/82 mm Hg
• Pulse rate - 84 bpm
• Respiratory rate - 16 cpm
• Temperature - Afebrile
• Height - 155 cm
• Weight - 94.1 kg
• BMI - 39.1 kg per meter square

12.
General Physical
Examination
• Built- Obese
• Nutrition- Vit. B12 and D deficiency
• Nails- Normal
• Conjunctiva- Clear
• Pallor- Absent
• Clubbing- Absent
• Tongue- Not coated
• Cyanosis- Absent
• Lymph nodes- Not enlarged
• Varicosity- Absent
• Icterus- Absent
• Edema- Absent
• Shape of spine - Normal

13.
Cardinal Symptoms
• Dyspnea – Present ( on exertion )
• Sweating - Present ( on exertion )
• Palpitations – Present ( on exertion )
• Cough - Absent
• Chest Pain - Absent
• Hemoptysis - Absent
• Syncope - Absent
• Chest tightness - Absent
• Blurred Vision - Absent

14.
Systemic
Examination

15.
 Respiratory system: Vesicular
breathing sounds heard.
 Abdominal Examination: p/a
soft, non-tender, no
organomegaly, bowel sounds
are heard.
 Central Nervous System:
Conscious, Well oriented,
Higher mental functions are
normal
 Locomotor system: Heel
Strike gait with an alignment.

16.
Cardio Vascular
Examination :
1) General
Examination(CVS)
2) Inspection
3) Palpation
4) Percussion
5) Auscultation

17.
General Examination
Pallor
• The pallor of anemia is seen in
the mucous membranes of the
conjunctivae, lips, tongue and
in the nail beds.
• Anemia can cause sinus
tachycardia, heart failure
(Hyperdynamic)

18.
General Examination
• Cyanosis
• Bluish discoloration of the skin and mucous
membranes caused by increased concentration of
reduced hemoglobin (5g/dl).
• Central cyanosis may result from the reduced
arterial oxygen saturation caused by cardiac or
pulmonary disease.
• Peripheral cyanosis may result when cutaneous
vasoconstriction slows the blood flow and
increases oxygen extraction in the skin and the
lips.

19.
General Examination
 Clubbing
• It is painless soft-tissue
swelling of the
terminal phalanges.
• Congenital cyanotic
heart disease, Infective
endocarditis.

20.
General Examination
 Edema
• Edema is tissue swelling due to an
increase in interstitial fluid.
• Pressure should be applied over a
bony prominence (tibia, lateral
malleoli, sacrum).
• Cardinal feature of congestive heart
failure.
• Prominent around the ankles in the
ambulant patient and over the
sacrum in the bedridden patient.

21.
• In advanced heart failure, edema
may involve the legs, genitalia
and trunk.
 Edema

22.
• Rate – 60-100bpm
• Rhythm
 Pulse
General
Examination

23.
 Blood
Pressure
General Examination

24.
1. Precordium
• It is the anterior aspect of the chest, which
overlies the heart.
• The subject should be examined in the
recumbent and sitting position, and in good
light.
• Bulging - 1. Enlarged heart 2. Pericardial
effusion 3. Mediastinal tumor 4. Pleural
effusion 5. Scoliosis
• Flattening - 1. Fibrosis of lung 2. Congenital
deformity
Inspection

25.
2. Apex Impulse
• Normally it is in the fifth left
intercostal space just inside the mid
clavicular line.
• Left lateral position.
• Not seen in case of obesity
emphysema and pericardial effusion.
Inspection

26.
3. Pulsations
• Check for abnormal pulsations in other parts of the chest.
• Ex. Left Parasternal- Left atrial enlargement, Aneurysm of aorta
etc.
• Epigastric : Right ventricular hypertrophy etc.
• On the right side of the chest - Dextrocardia, Right atrial
enlargement etc.
Inspection

27.
• Palpation for Apex Beat (Position and Character)
• Palpation for Position of trachea
• Palpation for Parasternal Heave, thrills
Palpation

28.
Apex Beat
• Position - Normally in the fifth left intercostal space, the mid-
clavicular line.
• Enlargement of the heart due to hypertrophy or dilatation may shift
the apex beat.
• Pulling or pushing of the mediastinum due to lung disease may shift
the position of the apex beat.
• May not be palpable in some cases- located behind a rib, obesity,
plural effusion, pericardial effusion, dextrocardia etc.
Palpation

29.
Parasternal Heave
• Position - Systolic impulse in the left parasternal region.
• Left ventricular enlargement.
• It is assessed by placing the ulnar border of the hand on the
left parasternal area, with the patient in supine position.
Palpation

30.
Percussion for Borders of the Heart
• Left Border - fourth and fifth space in the mid-
axillary region.
• Upper Border - in the second and third left
intercostal spaces in the parasternal
line. Normally there is resonant note in the
second space and dull note in the third space.
• Right Border of Heart - Right border of the
heart, which is formed by the right atrium, lies
behind the sternum.

31.
Auscultation
• Heart Sounds
• Murmurs

32.
Auscultatory Areas
• Aortic valve: second intercostal
space at the right sternal border.
• Pulmonary valve: second
intercostal space at the left sternal
border.
• Tricuspid valve: fourth
intercostal space at the left sternal
border.
• Mitral valve: fifth intercostal
space at the left midclavicular line.

33.
First Heart
Sound (S1), ‘lub’
• It is best heard at the apex, tricuspid
and mitral valve area.
• Prolonged – low pitched

34.
Second Heart
Sound (S2), ‘dup’
• It is caused by closure of the pulmonary and
aortic valves.
• At the end of ventricular systole and is best
heard at the left sternal edge.
• Shorter- High pitched.

35.
• Murmurs are abnormal heart sounds caused by
vibration of the valves or the wall of the heart or
great vessels.
• Develop due to alterations in blood flow.
• Systolic: occurs at or after S1, finishing before S2
• Diastolic: occurs at or after S2, finishing before S1
• Continuous Murmurs
Murmurs
Thomas SL, Heaton J, Makaryus AN. Physiology, Cardiovascular Murmurs. [Updated 2022 Jul 18].

36.
Investigations

37.
Imaging – To look for
PH
• Chest X-ray: to assess for
signs of underlying lung
disease or left ventricular
dysfunction (pulmonary venous
congestion). It may show
enlarged pulmonary arteries.
• Echocardiography: May
show
increase pulmonary arterial
pressure, enlarged right
ventricle.

38.
• Spirometry: to look for chronic lung disease.
• Ventilation/ Perfusion Scan: to look for
thromboembolic disease.
• Autoantibodies : To exclude autoimmune diseases.
Tests- for underlying causes

39.
• Right heart Catheterization : to measure the
pressure of blood vessels in the lungs.
To confirm PH

40.
Diagnosed only when other causes
have been rule out
• Aortic Stenosis
• Atrial Septal Defect
• Chronic Obstructive Pulmonary
Disease (COPD)
• Chronic Pulmonary Embolism
• Cardiomyopathies
• Emphysema
Differential Diagnoses
• Interstitial Lung Disease
• Mitral Regurgitation
• Mitral Stenosis
• Obesity-Hypoventilation
Syndrome
• Obstructive Sleep Apnea (OSA)
• Restrictive Lung Disease

41.
Provisional Diagnosis
• Grade II Obesity
• Pulmonary Hypertension
• Sinusitis
• Mechanical low back pain

42.
Pulmonary
Hypertension

43.
Definition
Classification
Pathology & Pathophysiology
Approach to diagnosis
Treatment
Table of Content

44.
Pulmonary Arteries
• The pulmonary arteries are the two major
arteries coming from right ventricle of our
heart.
• They carry low-oxygen blood from the
heart to the lungs.
• There oxygenation takes place and excess
carbon dioxide is removed.
• The blood is then pumped back into the left
atrium via the pulmonary veins.

45.
Definition
• By WHO - Pulmonary hypertension
(PH) is defined as mean pulmonary
arterial pressure (PAP) measured by right
heart catheterization ≥ 25 mm Hg at rest.
Leads to right sided heart failure.
• It is an umbrella term for many
different diseases which lead to
increased pressure in the pulmonary
arteries.
• Normal pressure is 14-18mmHg at rest
• 20-25mmHg on exercise.
Hoeper MM, Bogaard HJ, Condliffe R, et al.
Definitions and diagnosis of pulmonary
hypertension. J Am Coll Cardiol. 2013

46.
Signs and Symptoms
Initial -
• Difficulty
breathing
• Fatigue
• Weakness
• Chest Pain
• Dizziness
• Syncope
Later -
• Hemoptysis
• Hoarseness-
due to nerve
compression
in the chest

47.
Signs and Symptoms of
Untreated PH
• Right heart failure
• Ascites
• Liver enlargement
• Increase Jugular Venous
Pressure
• Cyanosis

48.
• Prevalence of about 1% of the global population, which
increases up to 10% in individuals aged more than 65 years.
• Left-sided heart and lung diseases have become the most
frequent causes of pulmonary hypertension.
• About 80% of the disease is associated with congenital
heart disease and various infectious disorders, including
schistosomiasis, HIV, and rheumatic heart disease.
• It is associated with clinical deterioration and a
substantially increased mortality risk.
Epidemiology and Risk factors

49.
Clinical
Classification
of Pulmonary
Hypertension
• Group 1: pulmonary arterial
hypertension (PAH)
• Group 2: PH due to left heart
disease
• Group 3: PH due to lung
diseases or hypoxia, or both
• Group 4: chronic
thromboembolic PH (CTEPH)
• Group 5: PH with unclear
multifactorial mechanisms.

50.
A global view of PA global view of pulmonary hypertension- The Lancet
hypertension

51.
• In this group of PH, the arteries and lungs are
not as thick or stiff as WHO Group 1, but there
are problems with how the heart squeezes or
relaxes, or problems with the valves on the left
side of the heart. Because of this, the left heart
is unable to keep up with the blood returning
from the lungs — causing a “backup” of blood
which raises pressure in the lungs.
2.Pulmonary Hypertension Due to
Left Heart Disease

52.
• Includes PH due to chronic lung disease and/or
hypoxia.
• Due restrictive lung diseases, lung cannot
expand fully which leads to high blood pressure
throughout the lungs.
3. Pulmonary Hypertension Due to
Lung Disease

53.
• WHO Group 4 is called chronic thromboembolic
pulmonary hypertension (CTEPH).
• This can lead to scar tissue in the blood vessels of the
lungs, which blocks normal blood flow and makes the
right side of the heart work harder.
4.Pulmonary Hypertension Due to
Chronic Blood Clots in the Lungs

54.
• PH is secondary to other diseases in ways that are not
well understood. These associated conditions include
sarcoidosis, sickle cell anemia, chronic hemolytic
anemia, splenectomy (spleen removal) and certain
metabolic disorders.
5.Pulmonary Hypertension Due to
Unknown Causes

55.
Conventional Management
1. Supportive Therapy
• Diuretics
• Supplemental Oxygen
• Anticoagulants
2. Specific Treatments – Vasodilators which work on following
pathways.
• Prostacyclin Pathway- Epoprostenol, treprostenol etc.
• Endothelin Pathway – Ambrisentan, Bosenten etc.
• Nitric Oxide Pathway – Sildenafil, tadalafil etc
3. Advanced – Double lung transplantation

56.
Naturopathy and
Yogic Management

57.
Yogic Diagnosis

58.
General
Measures
• Prohibit the physical strain that
causes shortness of breath, chest
pain, dizziness, and syncope.
• Patients with “cor pulmonale” it
is not recommended to stay in the
mountain areas above an altitude of
1200m.
• Airplane travel is also not
recommended if there is no
availability of oxygen inhalation in
emergency during flight.

59.
Aim of the Nature Cure and Yoga treatments.
TO REDUCE THE SEVERITY OF THE
SYMPTOMS ASSOCIATED WITH PAH.
TO PROMOTE PHYSICAL, MENTAL,
SOCIAL AND EMOTIONAL WELL-BEING.
TO IMPROVE THE QOL.

60.
Components of a healthy Yogic lifestyle
Achar – healthy physical activities
and exercise
 Vichar- right thought and right
attitude
 Ahar – healthy and nourishing diet
 Vihar – proper recreational
activities

61.
Achar
Achara - Interventions Rationale
Loosening practices.
Ankle stretch breathing
Hand in and out breathing
Tiger breathing
Ardhakati chakrasana,, Katichakrasana,
Vrikshasana, vakrasana.
Slow paced pranayama, Bhramari
Cyclic Meditation, Yoga Nidra
Reduces peripheral resistance hence
reduces BP.
Slow, deep breathing activates
parasympathetic nervous system which
decreases the heart rate and dilates blood
vessels, reducing overall blood pressure.
Chest expansion to improve cardiac and
lung health
Stress management, relaxation.

62.
Title Author Intervention Outcome
Development of a
modified yoga
program for
pulmonary
hypertension: a
case series
Rana Awdish et.al Three discreet yoga
programs were designed
with modifications
specific to PH patients:
• Chair yoga,
• Intermediate yoga with
a chair assist
• experienced yoga.
• Subjective and
objective effects on
clinical, physical
function, and
psychological
outcomes were
measured.
• Patients described
decreases in anxiety
and joint pain, with
improvements in
health-promoting
behaviors.

63.
Title Author Intervention Outcome
Effect of Yoga
Lifestyle in
Patients with
Heart Failure: A
Randomized
Control Trial
Ashish et.al Asana, Pranayama,
Meditation
• QOL as assessed by Minnesota
living with heart failure
questionnaire score improved
significantly in YG as compared
to CG
• There was a significant
improvement within YG in terms
of LVEF.
• CRP decreased by 49.3%
in YG and 35.8% in CG.

64.
Vichar- Interventions
• Avoid smoking, alcohol as it is associated
with an increased risk of heart and lung
diseases.
• Develop positive attitude, practice gratitude.
• Develop healthy sleep and relaxation habits.

65.
The review shows that early studies have investigated the presence of mental
disorders such as anxiety, depression, panic, and cognitive impairment. The
prevalence of mental disorders in PAH patients lies between 7.5% and 53%
for depression and 19% and 51% for anxiety and panic disorders.

66.
EFFECT OF SLOW BREATHING
• The changes of heart rate during the different phases of breathing may have a
positive influence on lung gas exchange via a more efficient ventilation/perfusion
matching.
• Controlled breathing has been shown to be beneficial in COPD, heart failure, and
high altitude hypoxia that are characterized by a gas exchange impairment.
• These studies demonstrated that slow and controlled breathing can improve vagal
activity and concomitantly reduce sympatho-excitation, with a favorable effect on
symptoms and prognostic variables. Furthermore, controlled breathing can have
a favorable psychological effect.

67.
Achar
Ahara - Interventions Rationale
Leafy green vegetables, Beetroot
Whole grains.
Berries
Omega 3 FA
Barley water
They are a great source of nitrates which
reduce blood pressure, decrease arterial
stiffness.
Reduces cholesterol levels.
Anthocyanins, which protect against the
oxidative stress and inflammation, which
might contribute to heart diseases.
Helps decrease triglycerides.
Diuretic
Nitrate-Rich Fruit and Vegetable Supplement Reduces Blood Pressure in Normotensive Healthy Young Males without Significantly Altering
Flow-Mediated Vasodilation: A Randomized, Double-Blinded, Controlled Trial

68.
Title Author Intervention Outcome
Effects of Oral
Supplementation With
Nitrate-Rich Beetroot Juice
in Patients With Pulmonary
Arterial Hypertension-
Results From BEET-PAH, an
Exploratory Randomized,
Double-Blind, Placebo-
Controlled, Crossover Study
Henrohn et.al Beet root Juice
which
contained (∼16
mmol nitrate )
for 7 days.
• BRJ administered for
1 week increases
pulmonary NO
production and the
relative arginine
bioavailability in
patients with PAH,
compared with
placebo.

69.
DASH Diet To Stop Hypertension
• Originated in the 1990s.
• Subjects included in the study were advised to follow just the dietary interventions and
not include any other lifestyle modifications to avoid confounding factors. It included-
• Vegetables: about five servings per day
• Fruits: about five meals per day
• Carbohydrates: about seven servings per day
• Low-fat dairy products: about two servings per day
• Lean meat products: about two or fewer servings per day
• Nuts and seeds: 2 to 3 times per week
• Results - They found that only the dietary intervention alone could decrease systolic
blood pressure by about 6 to 11 mm Hg.
Challa HJ, Ameer MA, Uppaluri KR. DASH Diet To Stop Hypertension. [Updated 2022 May 15].

70.
Vihar- Interventions
• Meditation and Relaxation techniques.
• Self-study.
• Nature walk
• Bhajans
• Educational lectures

71.
Title Author Intervention Outcome
Effects of Meditation versus
Music Listening on Perceived
Stress, Mood, Sleep, and
Quality of Life in Adults with
Early Memory Loss: A Pilot
Randomized Controlled Trial
Innes et.al Kirtan Kriya
Meditation (KK)
and music
listening (ML)
• Participants in both
groups showed
significant improvement
at 12 weeks in
psychological well-being
and in multiple domains
of mood and sleep
quality.
• KK group showed
greater gains in perceived
stress, mood,
psychological well-being,
and QOL-Mental Health.

72.
Nature Cure

73.
Title Author Intervention Outcome
Exercise and
respiratory
training
improve
exercise
capacity and
quality of life in
patients with
severe chronic
pulmonary
hypertension
Mereles et.al Nutrition,
Physical therapy
such as massages,
Counseling, and
muscular relaxation
without exercise.
• At week 15, patients in
the training groups had an
improved 6-minute walking
distance
• Exercise training was well
tolerated and improved scores of
quality of life
• Systolic pulmonary artery
pressure values at rest did not
change significantly after 15 weeks
of exercise and respiratory
training.

74.
Title Author Intervention Outcome
Repeated Waon
therapy
improves
pulmonary
hypertension
during exercise
in patients with
severe chronic
obstructive
pulmonary
disease
Megumi et.al Waon therapy at
60 °C in sauna for
15 min following
30 min warmth with
blankets outside of
the sauna room. This
therapy was
performed once a
day, for 4 weeks.
• Repeated Waon therapy
improved right ventricular
positive dP/dt, PH during
exercise, exercise tolerance and
the QOL in patients with severe
COPD.

75.
Title Intervention Outcome
Magnetic
stimulation of
carotid sinus as a
treatment for
hypertension.
Rongrong et.al
• The Optimum Magnetic
stimulator (MagPro X 100;
Tonica, DK, Farum, Denmark)
with a C‐100 circular coil was
used for magnetic stimulation.
• The subjects were instructed to
bend their necks backward
slightly with face turn left for
better exposing the right carotid
sinus. The center of the coil disk
was pointed to the right carotid
sinus.
• It was found that 1 Hz MSCS with
the intensity of 20% can lower SBP
(6.6 ± 0.4 vs −2.5 ± 0.4 mm
Hg, P < 0.0001) and HR (0.5 ± 0.5
vs −1.9 ± 0.3 beats/min, P = 0.002)
than sham stimulation.
• The nerve fibers with low resistant
inside carotid sinus are conductors
which can be stimulated by the
stimulation. Therefore, the
BP‐lowering effects of MSCS
observed in this study were supposed
to be the activation of carotid
baroreflex.

76.
Magnetic stimulation uses Faraday's law of induction to convert a time‐varying
magnetic field into induced electrical currents in tissues.The nerve fibers with low
resistant inside carotid sinus are conductors which can be stimulated by
the stimulation. Therefore, the BP‐lowering effects of MSCS observed in this study
were supposed to be the activation of carotid baroreflex.

77.
Acupuncture

78.
Title Author Intervention Outcome
Long-Lasting
Reduction of
Blood Pressure
by
Electroacupunc
ture in Patients
with
Hypertension:
Randomized
Controlled Trial
Pengli et.al Patients were
assessed with 24-
hour ambulatory
blood pressure
monitoring. They
were treated with 30-
minutes of EA at PC
5-6+ST 36-37 or LI
6-7+GB 37-39 once
weekly for 8 weeks.
Four acupuncturists
provided single-
blinded treatment..
• After 8 weeks, 33 patients treated
with EA at PC 5-6+ST 36-37 had
decreased peak and average SBP
and DBP, compared with 32
patients treated with EA at LI 6-
7+GB 37-39 control acupoints.

79.
• Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL,
Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th
ed. McGraw Hill; 2018
• P. J. Mehta’s practical medicine | nihar p. Mehta, s. P. Mehta, sr
joshi
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