This document contains details about a 42-year-old female patient presenting with joint pain and swelling in multiple joints for 4 years. She reports chief complaints of pain and swelling in all joints, aggravated for 15 days along with fever and loose motions for 4 days. On examination, she has pain, tenderness, warmth and swelling in both ankles, knees, hips, fingers, thumbs, wrists, elbows and shoulders. Laboratory tests show elevated ESR and CRP. The document provides a summary of the patient's history, examinations, investigations and considers differential diagnoses.

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2. Name : Mrs. Jabeena
Age : 42 yrs/ F
Address : Shamanna gardens,
Bangalore.
Occupation : Agarbathi maker
Religion : Muslim
Marital status : Widow
Education : Uneducated
Socio economic status : Poor
Source of history : Patient
2
Treating Doctor : Dr. Byresh.A
 OPD No : C4212
 IPD No : 827/15
 DOA : 23/2/15
Case taken on : 11/3/15 ,
Photographs taken on :
PATIENT DETAILS

3. Clinical Case Presentation 19th March 2015 Page No.
प्रधान वेदना - CHIEFCOMPLAINTS :
C/O of sarva sandhi shoola, shotha since 4 yrs,
aggravated since 15 days.
Along with jwara and chardi since 4 days.
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4. Clinical Case Presentation 19th March 2015 Page No.
अबन्धध वेदना –ASSOCIATED COMPLAINTS :
 C/o Trishna , Alasya since 1 year, aggravated since 1
month.
 C/o Burning sensation( daha) in the epigastric region and
Apaka since 4yrs. Sometimes associated with shira shoola.
Now aggravated since 4 days.
 C/o Raga and daha in jihwa, aruchi, mukha vairasyata –
on and off since 1 year. Increased since 4 days.
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5. Clinical Case Presentation 19th March 2015 Page No.
HISTORYOF PRESENT ILLNESS
 Patient was apparently normal 5 yrs back. She had an attack of chikungunya
fever. After fever subsided, she noticed pain in b/l ankle joint first for which
took OTC medicines and found relief. After few days she again noticed pain
in b/l ankle joints, knee jt, elbow jt, shoulder jt and other smaller joints
associated with shotha of respective joints, which gradually aggravated. Pt
also c/o stabdhata of sandhi (Morning stiffness) for more than 1 hour.
 She first visited a nearby clinic, later consulted various hospitals and was
given some medications(oral and IM injections) for the same which she
continued for 4 yrs and the symptoms were under control with medication.
Cont.5

6. Clinical Case Presentation 19th March 2015 Page No.
HISTORYOF PRESENT ILLNESS
 She stopped the medications abruptly before 4 days(before coming to OPD)
after which the symptoms like sarva sandhi shoola and shotha got
aggravated restricting her daily activities. She was unable to walk without
support. She also had jwara, aruchi, apaka and chardi- non projectile in
nature, containing food particles since 4 days. Patient was not getting much
relief with NSAID’s, So she came to SKAMC&RH for treatment on 12.2.15
on OPD basis.
 She was advised to get some investigations done and was put on internal
medications.
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7. Clinical Case Presentation 19th March 2015 Page No.
PAST HISTORY
 Had an attack of chikungunya fever 5 yrs back.
 Not a k/c/o DM/ HTN/TB
 Had # of rt hand 7 yrs back .
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8. Clinical Case Presentation 19th March 2015 Page No.
TREATMENT HISTORY
 Initially when patient noticed sandhi shoola and shotha 4 yrs back, took
treatment in a nearby clinic , victoria hospital and later in Bowring
hospital. ( details of the treatment not available with patient).
 Also she used to get some IM injections and tablets in a clinic nearby her
home. (Details not available).
 And also was taking OTC medicines.
 On 12/2/15 , the patient approached the OPD of SKAMC&RH for
treatment and was advised the following medications ( did not complete
the course).
1. Sarvanga valuka sweda for 7 days
2. Vyoshadi guggulu 2-2-2
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कौटुम्बिक वृत्तान्त -FAMILY HISTORY:
 Paternal grandmother had similar complaints.
 Both parents are apparently said to be healthy.
 Has 5 younger sisters, 2 younger brothers, all are said to
be healthy.
 Husband: Died after 7 months of their marriage.
 1 Daughter: said to be healthy.
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वैयम्िक वृत्तान्त–PERSONALHISTORY:
Diet – Mixed (Non veg once/day) , since 3 months taking only veg.
Sleep – Disturbed (due to pain)
Appetite – Poor
Micturition – 4-5 times/ day, 2-3 times/ night
Bowel – once/ day / Incomplete evacuation
Habits – Tea - 10 cups/ day.
Menstrual History- Menarche- 14 yrs of age.
M.C- Irregular cycle since 1 yr. Had 2 cycles in the past 1 yr. 4-5 days/ cycle.
Obstetric History: G1P1L1A0, FTND.
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GENERAL PHYSICALEXAMINATION :
 Built – moderately built
 Nourishment – under nourished
 Pulse – 78/ min, regular.
 BP – 120/80 mm of Hg
 R/R –16 /min
 Tongue – Dry, Redness+
 Pallor - Present
 Edema – Absent
 Nails – Normal
 Clubbing – Absent
 Icterus - Absent
 Lymphadenopathy - Absent
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SYSTEMIC EXAMINATION:
 RS - B/L NVBS, No added sounds.
 CVS - S1,S2 Heard, No added sounds.
 P/A – soft, distended, No organomegaly noted. Mild tenderness over
the epigastric region present.
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LOCOMOTOR SYSTEM EXAMINATION
13
Joints Pain Tenderness Warmth Swelling ROM
Ankle jt &
foot
Rt- +++
Lt- +++
Rt- +++
Lt- +++
Rt- present
Lt- present
Rt- present
Lt- present
Flexion- Rt- painful, Lt- painful
Extension-Rt- painful, Lt- painful
Inversion – Rt- painful, Lt- painful
Eversion- both normal
Knee jt Rt- ++
Lt- ++
Rt- ++
Lt- ++
Rt- present
Lt- present
Rt- present
Lt- present
Flexion- both normal
Extension-both normal
Int rotation- both painful
Ext rotation- both painful
Hip jt Rt- ++
Lt- ++
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 upto 50 degree, painful
Ext Rotation- both normal

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LOCOMOTOR SYSTEM EXAMINATION
14
Joints Pain Tenderness Warmth Swelling ROM
Fingers Rt- ++
Lt- ++
Rt- ++
Lt- ++
Rt- present
Lt- present
Rt- present
Lt- present
Flexion- both hands painful and restricted
Extension- both hands normal
Abduction- both hands normal
Adduction- both hands normal
Thumbs Rt- ++
Lt- ++
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
Wrist jt Rt- +++
Lt- +++
Rt- +++
Lt- +++ Rt- present
Lt- present
Rt- present
Lt- present
Flexion- both painful
Extension-both painful
Adduction-painful
Abduction- painful
Hand grip – Decreased strength in both hands.
Elbow jt Rt- ++
Lt- ++
Rt- ++
Lt- ++
Rt- present
Lt- present
Rt- present
Lt- present
Flexion- both painful
Extension- both normal
Supination- both normal
Pronation- both normal
Cont 1

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LOCOMOTOR SYSTEM EXAMINATION
15
B/L Joints Pain Tenderness Warmth Swelling ROM
Shoulder jt Rt- ++
Lt- ++
Rt- ++
Lt- ++
present Absent 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 + + present Absent Flexion- normal
Extension- painful
Rotation- Painful
Lateral Bending- painful
Cont 2

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अष्ट स्थान परीक्षा
 नाडि – 78 / min
 मूत्र – 4-5 times / day, 2-3 times/ night
 म्िह्वा – shushka, rakta varnata
 मल – once/ day
 शब्द – prakruta
 स्पशश – ushna sparsha
 दृक् – Has Haziness of vision
 आकृ म्त - madhyama
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17. Clinical Case Presentation 19th March 2015 Page No.
DASHAVIDHA PARIKSHA
1) प्रकृ तिि: – Vata pittaja
2) सारतः – Avara
3) संहननि – Avara
4) प्रमाणतः – Height - 5’ 6’’
Weight - 68 kgs.
5) सात्म्यि – sarvarasa satmya
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18. 6) सत्मवि – Avara
7) आहर शक्ति - अभ्यवहरण शक्ति – Avara
जरण शक्ति – Avara
8) व्यायाम शक्ति – Avara
9) वयः – Madhyama
10) ववकृ ति – Pravara
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19. Clinical Case Presentation 19th March 2015 Page No.
NIDANAPANCHAKA
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Nidana: Agnimandya, intake of hot, spicy and
oily food, untimely intake of food, working soon
after intake of food , chinta, shoka.
Rupa: Angamarda, aruchi, trushna, jwara,
Apaka, shunata anganam.
Upashaya: was taking NSAID’s/ DMARD’s(?)
Upadrava: Jadya, antrakujana, anaha, trushna,
chardi, bahumutrata, shoola, nidraviparyaya.

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SAMPRAPTI
Nidana sevana
Agnimandya
Ama dosha utpatti due to amajanya karana like guru, snigdha bhojana, mamsa sevana, adhyasana.
+ tridosha vitiation mainly vata due to working continuosly, ratri jagarana, shoka , chinta
Pravruddha ama dosha propelled by vitiated vayu lodges in shleshma sthana like sandhi, amashaya
Ahara rasa circulating in rasayani attains dravata, guruta, snigdhata, pichilata, tantumata,
asamyuktata, avipakwa, abhisyandi gunas along with vitiation of tridoshas leading to atipichilta and
hence causing srotoavarodha
Dosha dushya sammurchana leading to dhatukshaya(rasa dhatu)
Produces symptoms like Angamarda, gourava, dourbalya, jwara, shotha, shoola, stabdhata.

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SAMPRAPTI GHATAKA
21
Dosha: Tridosha (mainly vata)
Dushya: Rasa
Srotas: Rasavaha, Annavaha
Srotodushti: sanga, vimarga gamana
Agni: Jatharagnimandya, Rasadhatwagnimandya
Vyadhi swabhava: Ashukari, chirakari
Udbhava sthana: Amashaya
Adhistana: Sarva sandhi
Sanchara sthana: Rasavaha srotas
Rogamarga: Madhyama rogamarga
Sadhyasadhyata: Krichra sadhya

22. Clinical Case Presentation 19th March 2015 Page No.
SAMBHAVITAROGA
 Sandhigata vata
 Vatarakta
 Amavata
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 Septic(pyogenic) arthritis
 Osteoarthritis
 Rheumatoid arthritis
 SLE
 Rheumatic fever with arthralgia

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VYAVACHEDAKA NIDANA
23
Lakshana/ Parameters Sandhivata vatarakta Amavata
Dosha Vata predominant Vata,rakta pradhana tridoshaja Vata kapha pradhana tridoshaja
Dushya Rasa 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 and shotha present Initially both, in later stages
only pain. (vrischika
damshavat vedana)
Jwara Absent Absent Present (in most cases)
Effect of sthanika
snehana
useful useful In initial stages causes
aggravation, in later stages
useful

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LAB INVESTIGATIONDone on 12/2/15 Reference range
 Hb% - 11.3 gms% Male: 13.5- 18 mg/dl
Female: 12- 16 mg/dl
 WBC - 14500 cells/cumm Adult: 4000- 11000cells/cumm
 Differential count - Neutrophils - 75% Adult: 40-65%
Lymphocytes - 17% 20-45%
Monocytes - 8% 2-10%
 ESR- 73 mm/hr Male: 1-10 mm/hr
Female: 1-20 mm/hr
 RF assay- 388.5 IU/L < 14 IU/ml
 C-Reactive protein- 13.7 mg/l < 5 mg/ l
Done on 14/3/15
 BUN - 12.5 mg/dl 17- 43 mg/dl
 Sr. creatinine - 0.48 mg/dl 0. 66- 1 mg/dl
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25. Clinical Case Presentation 19th March 2015 Page No.
DIFFERENTIALDIAGNOSIS
1. Septic(pyogenic) arthritis: Bigger joints are involved especially the
knee and it is monoarticular. Hence ruled out.
2.Osteoartritis: Primarily affects elderly people. Slowly progressive non
inflammatory joint disease. Usually affects weight bearing joints.
Clinically, mild aching pain is localized to either to one side of the
joint or generalized over the joint. Aching pain on movement and
stiffness with rest, tenderness, crepitus on movement of affected joint
prresent. Stiffness at rest or in morning may be present in some case
but for a brief period of less than 30 mins. Absence of systemic
features. Hence possibility ruled out.
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26. Clinical Case Presentation 19th March 2015 Page No.
3.Rheumatoid arthritis: Onset mostly in 4th and 5 th decades. Chronic inflammatory
systemic disease characterized by symmetrical arthritis of small and big joints
usually or MCP, MTP joints, Knees, Elbows, Wrists. Morning stiffness or
tenderness and swelling of the joints noted. There is painful limitations of
movements.
Diagnosis is confirmed by clinical criteria like symmetrical swelling in one or
more joints continuously for not less than 6 weeks. Raised ESR, CRP, RA factor
positive.
4.Systemic lupus Erythematous(SLE): Usually occurs 90% in women of child bearing
age. Clinical features like Fever, fatigue are present. But other features like
rashes(butterfly rash), photosensitivity, alopecia, peritonitis, seizures are absent.
RA factor is positive in 40% cases. But confirmatory tests like ANA Antibody test
and biopsy of the skin not done to rule out the disease.
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27. Clinical Case Presentation 19th March 2015 Page No.
5. Rheumatic fever with arthralgia: It is an inflammatory disease that involves
heart, joints, skin and brain. It typically develops 2-4 weeks after throat
infection by Streptococcus bacteria. Symptoms include fever, multiple
painful joints, sometimes non itchy rash. Diagnosis made by the signs and
symptoms along with recent H/O streptococcal infection. In this pt there is
no such history noted.
VYADHIVINISCHAYA
Amavata / Rheumatoid arthritis
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28. Clinical Case Presentation 19th March 2015 Page No.
DiagnosticCriteriaconfirmingRA(Asper2010Americancollegeof
Rheumatology)
28
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
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 - 10/10.

29. Date lakshana Chikitsa Outcome
23/2/15 Pain in multiple joints,
fever,( temp- 102 F), burning
sensation in epigastric
region, vomitting- non
projectile, containing food
particles.
1. Sarvanga valuka sweda for 7 days
2. T.simhanada guggulu 2 tab tid A/F
3. Shadanga paneeya churna 2 tsp
boiled with hot water- for drinking
4. T. A-flu-o-cil 1 tab TID
24/2/15 Pain in multiple joints,
nausea , burning sensation in
epigastric region present.
Inflammation and redness of
tongue present.
Added 5. Rasnadi churna- to mix with
warm water and apply to body.
6. Yashti ksheerapaka 200 ml TID
Pain in the joints slightly reduced.
Vomitting stopped. Fever reduced
completely.
25, 26 th Feb Pain in multiple joints
slightly reduced.
Same treatment contd. Nausea reduced, inflammation of
tongue reduced, burning sensation
in epigastric region reduced. Was
able to eat food.
29
TreatmentAdvised
Pathya:Ganji–Rice/RavaGanji, Greengramkhichadi,Riceidliwithsambar.

30. 30
Date Lakshana Chikitsa Outcome
27/2/15 Pain in multiple joints present Added 7.Amrutottara kashaya
2tsp +6tsp water TID
8. T.Rhumayog with gold 1 tab
OD A/F
Increase in joint pain after
valuka sweda noted.
28/2/15 Pain in multiple joints
increased.
Valuka sweda stopped, started
Agnilepa. All other
medications continued.
Multiple joint Pain
decreased
after agnilepa.
4/3/15 Pain in multiple joints and body
ache increased
Added 9. Ashwagandharishtam
and Balarishtam 2tsp each + 4
tsp waterTID A/F
5/3/15 Pain in multiple joints .B/L
pitting edema in lower limbs
noted, also non pitting edema
noted in dorsal aspect of both
hands.
Agnilepa stopped.
Added Yoga basti. Anuvasana
with Brihat saindhavadi taila,
Niruha with Eranda moola
niruha basti.
Pain in multiple joints
reduced by 20%.

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Date Lakshana Chikitsa Outcome
10/3/15 Pain in multiple joints aggravating at night, b/l
lower limb pitting edema, non pitting edema in
dorsal aspect of both hands present.c/o Dry
cough, pain in the throat.
Added yashtimadhu
churna for gargling, along
with other medications.
Pain in multple
joints- status quo
11/3/15 Pain in multiple joints- status quo, b/l lower limb
pitting edema, non pitting edema in dorsal aspect
of both hands present. Dry cough present.
Yoga basti changed to
kala basti.
Pain in the throat
reduced.
13/3/15 Pain in multiple joints, b/l lower limb pitting
edema, non pitting edema in dorsal aspect of
both hands present.
Added Jadamayadi
churna – mix with warm
water and apply to joints.
Cough reduced.
14/3/15 Pain in multiple joints, b/l lower limb pitting
edema, non pitting edema in dorsal aspect of
both hands present. c/o pain in the hypogastric
region- intermittent in nature
Added Tab.chandraprabha
vati and punarnavasava
16/3/15 Pain in multiple joints, b/l lower limb pitting
edema, non pitting in dorsal aspect of both hands
present.
Same treatment contd. Pain in hypogastric
region completely
reduced.

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