Case presentation

Kamal Kishore2nd year PG Scholar Dept. of PG studies in KayachikitsaSKAMCH&RCBENGALURU

ATURA VIVARANA

Name : Mr. P. N. MarilingaiahAge : 59 YearsSex : MaleReligion : HinduMarital status : Married Socio economic status : Middle classEducation status : PUCOccupation : Supervisor in Horticulture Dpt.Date of admission :16/08/16Date of discharge :26/08/16 1

Ward : Semi Special ward 2Source of history : PatientConsultant doctor : Dr. Byresh A.O.P No : D24757I.P. No : 3509/16Case taken on : 17th August 2016Address : #49, 1st main, 7th cross,

near Gayathri temple, K.G. nagar, Bangalore.

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Pradhana vedana

Dakshina Mukhardha vakrata / Deviation of Face towards right side

since 12/08/2016

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Anubandha Vedana

Vaam Akshi nimesha hrasa / 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.

Vaak Aspashtata/ slurred speech

since 13/08/2106

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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.

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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.

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Adyatana Vedana VrittantaHe 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

Poorva Vyadhi Vrittanta

Patient was admitted & treated for acclerated blood

pressure for 6 days from 31st July 2016 as he

presented with features of giddiness, imbalance &

vomiting.

8

Chikitsa vrittantaOn 13/08/2016 at Spandana hospital

on OPD basis 1. Tab. Losar H 1 O.D.2. Tab. Omnacortis 10mg 2-2-0 for 1 week

2-1-0 for 1 week3. Tab. Sompraz 40mg 2 B.D for 2 weeks4. Tab. Ecosprin gold 1 O.D for 2 weeks5. Tab Axovir 800mg 1tid for 1 week6. Oflox Eye drops 2dros tid for 1 week 7. 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

Koutumbika Vrittanta

HTN from past 11 days

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All family members are said to be healthy.

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/nightSleep : GoodAddictions : None

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ROGI PAREEKSHA

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Atura Bhoomi Desha Pareeksha

Jatatah: SadharanaSamvardhitah: SadharanaVyadhitah: Sadharana

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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–Anushnasheeta

Drik- vaambhaga akshi nimilana Hrasa

Aakriti - Madhyama 14

Prakriti :- Vata Kapha PrakritiSaara :- MadhyamaSamhanana: MadhyamaPramana : Madhyama Ht: 1.67m, Wt: 55 kgSaatmya : Madhyama Satva : MadhyamaAahara Shakti : Abhyavaran Shakti : Madhyama Jarana Shakti : MadhyamaVyayama Shakti : MadhyamaVaya :Madhyama

DASHVIDHA PAREEKSHA

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Vikriti :- Madhyama 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

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SAAMANYA PAREEKSHAPatient conscious, alert, oriented to time, place and

Person.Built : Moderate Nourishment : Moderate Pallor : Absent. Cyanosis : Absent.Nail : NormalIcterus : Absent Oedema : Absent Lymphadenopathy : Absent.

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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

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Respiratory System Examination Shape of chest -bilaterally symmetrical. Trachea -centrally placed Normal vesicular breath sounds heard. No added sounds.

Cardiovascular System Examination S1 S2 heard, no murmurs.

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VISHISHTA PAREEKSHA

Per Abdomen ExaminationInspection – Scaphoid

Umbilicus – Inverted Auscultation -Peristaltic sounds heard, Palpation – Soft, No tenderness. No organomegaly Percussion – dull over liver area, Resonant

otherwise. 20

Local ExaminationInspection

Deviation of mouth towards right Left eyeball moves upwards and inwards 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

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 - Slow and words are mumbled

Handedness - Right

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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

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CN III Occulomotor , CN IV Trochlear , CN VI Abducens Nerve –

Pupil - position , size, shape, symmetry- no abnormality detected

Eyeball movement - Possible in all directionsCN V Trigeminal Nerve

Sensory –Touch, pain and pressure sensation – intact

Motor - Clenching of teeth – Possible

Jaw movement against resistance decreased

Jaw jerk- Normal24

CN VII Facial Nerve a) Forehead frowning - not possible on left sideb) Eyebrow raising - not possible on left sidec) Eye closure - not possible in left eyed) Teeth showing - not possible in left side denturee) Blowing of cheek - not Possible in left side

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f) Nasolabial fold - decreased on left sideg) Taste perception - not affected h) Dribbling of saliva – left corner of mouth present.i) Bells phenomenon – present on left side.

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CN VIII Vestibulocochlear nerve Rhinne’s test - AC > BC Weber’s test -Equal on both sidesCN IX, CN X Glossopharyngeal and Vagus nerve

Speech – no Dysarthria or Dysphonia noted

Position of uvula - Centrally placed

Taste sensation -Intact

Gag reflex - normal

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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

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

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Muscle tone B/L Upper limb and lower limb- NormalMuscle power Rt LtUpper limb 5/5 5/5Lower limb 5/5 5/5 ReflexesBiceps jerk- ++, Triceps jerk- ++Supinator jerk- ++, Knee jerk- ++Ankle jerk- ++, Plantar reflex- ++ 30

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

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• Toe walk- Able to do • Rhomberg’s sign- negative • Pronator drift - negative

4. Sensory systemSuperficial

a) Touch - Intact

b) Temperature - Intact

c) Pain - Intact

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Deep

Vibration sense- intact

Joint position sense- intactCortical

a)One point localization - intact

b) Two point discrimination - intact

c) Stereognosis - Present

d) Graphesthesia - Present

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

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ROGA PAREEKSHA

135

NIDANA PANCHAKAS

Nidana – ? Diwaswapna, Sheetala vayu sevana.

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SAMPRAPTINidana Sevana

Kapha prakopa and rakta dushti

Aavarana to vaata

Vaata prakopa

Sthana samshraya in vaama mukhardha bhaaga

Mukhardha vikriti

Vyaktavastha

Ardita137

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.

138

SAMPRAPTI GHATAKAS

Dosha – Vaat pradhana kapha Dushya – Rasa, Rakta, Meda, .Srotas –Rasavaha, Raktavaha, Medovaha.Sroto dushti - Sanga,vimargagamana.Agni - Jatharagni and Dhatvagni mandya

139

Udbhavasthana – Aamashaya,PakwashayaSancharasthana – RasayaniVyaktasthana – MukhaardaAdhishtana – Shiras, IndriyaRogamarga – MadhyamaSadhya-Asadhyata – Kricchra Sadhya

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VYAVCHEDAK NIDAAN

PakshavadhaPakshaghaataArdita (Charakokta)Ardita (Sushrutokta)

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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

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DIFFERENTIAL DIAGNOSIS

CVAFacial palsy (LMN)/Bell’s PalsyFacial palsy (UMN)

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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

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VYADHI NIRNAYA

Ardita (Sushrutokta)Facial Palsy/Bell’s palsy

145

SADHYA ASADHYATA

Kricchra Saadhya

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CHIKITSADATE TREATMENT

GIVENOBSERVATIONS

16/8/16 1. Nasya KarmaMukhabhyanga 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

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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

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DATE TREATMENT GIVEN

OBSERVATIONS

17/8/16 – 18/8/16

CST 1-45. 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

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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

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CHIKITSADATE TREATMENT

GIVENOBSERVATIONS

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.

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CHIKITSADATE 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.

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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 IMPROVED53

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.

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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 IMPROVED55

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 foldVISIBLE on left side.

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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. IMPROVED57

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

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

ADVISE ON DISCHARGERx 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.

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for 15 days

Pathya -Apathya

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Pathyas

Milk Meat soups masha Navaneetha

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Varjas by arditha rogi

Sheeta jala Snana Dantha dhaavana Vata prakopakara ahara and viharas

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Thank you !