parkinsons disease case presentation

1. CASE
PRESENTATION
DR. VINAY TIWARI
2ND YEAR P.G. SCHOLAR
DEPARTMENT OF KAYACHIKITSA
SKAMCH & RC
VIJAYANAGAR
BANGALORE 1

2. ATURA PARICHAYA
 Name : Md. Zaheeruddin
 Age : 67 Years
 Sex : Male
 Religion : Muslim
 Socio economic status : Middle class
 Marital status : Married
 Education status : 10th standard
 Occupation : Provisional shop owner
 Date of admission : 14/07/16
 Date of discharge : 23/07/16
2

3.  Ward : Semi Special Ward
 Source of history : Patient & her wife
 Case taken on : 18/07/16
 Consultant doctor : Dr. Abdul Khader
 O.P No : D – 21303
 I.P. No : 3075/16
 Address : # 13th cross Gowripalya
Bangalore.
3

4. PRADHANA VEDANA
 C/O Tremors in right upper limb since 3 years
aggravated since 1 year.
 Pain in both knee joints since 15 years and aggravated
since 1 year.
 Low back ache since 1 year.
 Swelling in both lower limbs since 1 year.
4

5. ANUBANDHA VEDANA
 C/O Tendency to fall forward with difficulty in walking
since 1 year with slowness of movements.
Difficulty in writing, holding objects, and activity of
daily living since 1 year
Difficulty in passing motion (constipated) since 1 year.
5

6. VEDANA VRUTTANTA
•Patient was apparently healthy before 3 years, one day he
met with an accident and got injured on dorsal aspect of
foot with profuse bleeding for which he got operated in
St. Marthas Hospital Bangalore. After one week he
developed fever with chills for which he got admitted to
the same hospital and was managed conservatively. Next
day morning patient noticed tremor in his left hand which
got subsided by itself.
Continue….6

7. After 1 year patient gradually developed tremors in his
right hand and experienced difficulty in writing and
holding objects for which he consulted a Neurologist in
Rajarajeswari Medical College & Hospital, Bangalore
and diagnosed with Parkinson’s disease and was put on
medication( details of which are not known). After
continuing the same medicine for one year the patient
stopped the medication without any consultation.
Continue….
7

8. Following which there was an increase in the symptoms
along with tendency to fall, slowness in movements,
bilateral lower limb swelling for which he consulted St.
Marthas Hospital, Bangalore and was advised CT scan
and was given some medications. Since 1 year he
developed constipated bowel movements along with
increased bilateral knee joint pain and low back ache .
So for the above mentioned complaints he approached
SKAMCH&RC for further management.
8

9. POORVA VYADHI VRUTTANTA
 Known C/O Hypertension since 20 years
Ischemic Heart Disease since 5 years(on medication).
 He is a not a known case of Diabetes mellitus, Asthma,
Tuberculosis .
9

10. CHIKITSA VRUTTANTA
Presently on
•Tab – Ecosprin 150 mg 0 – 1 - 0
• Tab – Clopilet 75 mg 0 – 1 – 0
• Tab – Pantop 40 mg 1 – 0 – 0 (B/F)
• Tab – Atorva 40 mg 0 – 0 – 1 After food
• Tab – Syndopa plus 1 - 0 – 1
• Tab – Parkin 2 mg ½ - ½ - ½
• Tab – Streepress XL 25 mg 1 – 0 – 0
10

11. KAUTAMBIKA VRUTTANTA
 No history of similar complaints in the family.
11
PATIENT
67 Yr
WIFE
59 Yr
SON SON DAUGHTER
SON DAUGHTER DAUGHTER
PATIENT
FATHER
PATIENT
MOTHER

12. VYAKTIKA VRUTTANTA
 Diet : Mixed (non veg 2 to 3 times in a week) .
 Appetite : Reduced since 3 years(after surgery)
 Sleep : Disturbed since 1 year
 Bowel : 1-2 times/day, regular
constipated (incomplete evacuation)
 Micturation : 4 to 6 times/day.
1 to 2 times/night.
 Habits : Tea – 5 to 6 cups per/day.
12

13. GENERAL PHYSICAL EXAMINATION
 General Condition : Fair.
 Built : Moderately built.
 Nourishment : Moderately Nourished.
 Pallor : Absent.
 Oedema : Bilateral pedal oedema (pitting).
 Nails : No clubbing
 Cyanosis : Absent.
 Icterus : Absent.
 Lymphadenopathy : Absent.
 Pulse :78 bpm.
13

14.  BP :130/90 mmHg.
 R/R :18/minute.
 Tongue : Coated.
 Height : 1.88 m
 Weight : 94 Kgs
 BMI : 26.62
14

15. SYSTEMIC
EXAMINATION
15

16. PER ABDOMEN EXAMINATION
Inspection -: Umbilicus centrally placed
-: No distension
-: No scar marks
Auscultation -: Bowel sounds heard
Palpation -: Soft, no tenderness
-: No organomegaly
Percussion -: Tymphanic sounds heard
16

17. RESPIRATORY SYSTEM
Inspection -: Shape of chest - bilaterally symmetrical
-: Respiratory rate -18/min
Palpation -:Trachea -Centrally placed
-: No tenderness
 Percussion - : Resonant sounds heard except the
cardiac dullness.
 Auscultation -: Normal Vesicular Breath
Sounds heard.
17

18. CARDIO VASCULAR SYSTEM
Inspection -: No distended blood vessels over
chest and neck
 Palpation -: Apex Beat felt at 5th intercostal space
9 cm from the mid sternal line.
 Percussion -: Defined Area of cardiac dullness.
 Auscultation -: S1S2 Heard
-: No murmurs
-: No added sounds heard
18

19. CENTRAL NERVOUS SYSTEM
Handedness- right
1.HMF
 Conscious
 Orientation to -Time
-Place Intact
-Person
 Memory - Recent Intact
- Remote
 Intelligence Intact
 Hallucination & Delusion Absent
 Speech disturbance
19

20. 2. Cranial Nerve Examination
 Olfactory -: Smell sensation - Intact
 Optic -: a) Visual acuity - difficulty in
distant reading
b) Visual field -Not affected
c) Light reflex Not affected
d) Drooping of eye lids (Ptosis) -Absent
 Occulomotor
 Trochlear Eye ball movement – possible in
 Abduvent Nerve all directions.
20

21. Pupil - Position
- Shape No abnormality detected
- Size
- Symmetry
 Trigeminal Nerve
Sensory – Touch
Pain Present
Pressure sensation
Motor - Clenching of teeth Possible
- Lateral movements of jaw Possible
21

22.  Facial Nerve
a) Forehead frowning - Present
b) Eyebrow raising - Possible
c) Eye closure against- Possible resistance
d) Teeth showing - No deviation of angle of mouth
e) Blowing of cheek - Not Possible
f) Nasolabial fold - Equal on both sides
 Vestibulo cochlear
 Rinne’s test - Negative
 Weber’s test - Equal on both sides
22

23.  Glossopharyngeal & Vagus nerve
Position of uvula - No deviation
Taste sensation - Intact
 Accessory Nerve
Shrugging the shoulder - Possible against resistance
Neck movement - Possible against resistance
 Hypoglossal Nerve
Protrusion of tongue - Possible
Tongue movements - Possible
23

24. 3) Sensory system
 Superficial
a) Touch - Intact
b) Temperature - Intact
c) Pain - Intact
 Deep
a) Crude touch - Present
b) Position Sense & Pressure sense - Present
 Cortical
a)Tactile localization - Present
b) Tactile discrimination - Present
c) Stereognosis - Present
d) Graphesthesia - Present 24

25. 4) Motor system
 Attitude of limbs
Upper limb : Normal
Lower limb : Normal
 Muscle Bulk Right (in inches ) Left (in inches)
a) Upper limb
Arm 12.5 11.5
Forearm 9.5 9.5
b) Lower limb
Thigh 18 18
Calf 13 12.5
25

26.  Tone - Upper limb & Lower limb - Normal
 Power - Not affected
 Coordination
Romberg sign- +ve
Upper limb- Finger nose test- Able to perform (slowly)
Lower limb-Knee heel test - not able to perform due to
pain
 Involuntary movements - Present
Right hand - Tremor
 Gait-
–Parkinsonian/festinating gait
26

27.  Reflex
a) Biceps jerk -++
b) Triceps jerk-++
c) Supinator jerk-++
d) Knee jerk-++
e) Ankle jerk-++
f) Clonus -Patella – absent
-Ankle- absent
g) Jaw jerk- ++
h) Babinski reflex - plantar flexion
27

28. LOCOMOTOR SYSTEM EXAMINATION
Joints Tenderness Warmth Swelling Measurments Range of movements.
Ankle
joints &
foot
Rt & Lt
Absent
Rt-
Present
Lt-
Present
Rt- Present
Lt- Present
Rt – 10.8 inch
Lt – 10.8 inch
Flexion-Rt & Lt – Normal
Extension-Rt & Lt – Normal
Inversion – Rt & Lt Painful
Eversion- both normal
Knee
joints
Rt- ++
Lt- ++
Crepitus
present on
both joints.
Rt-
Present
Lt-
Present
Rt- Present
Lt- Present
Rt – 14.8 inch
Lt – 14.8 inch
Flexion- Painful
Extension- Painful
Internal rotation- Both Painful
External rotation-Both Painful
28

29. Joints Tenderness Warmth Swelling Range of movements
Hip joints Rt & Lt
Absent
Rt & Lt
Absent
Rt & Lt
Absent
Flexion - Painful
Extension - Painful
Abduction - Painful
Adduction - Normal
Int.Rotation - Painful
Ext Rotation – Normal
Thumbs Rt & Lt
Absent
Rt & Lt
Present
Rt & Lt
Present
Flexion- Both Normal
Extension-Both Normal
Abduction- Both Normal
Adduction- Both Normal
Opposition- Rt & Lt – Normal
29

30. 30
Joints Tenderness Warmth Swelling Measurments Range of movements
Wrist joints Rt & Lt
Absent
Rt & Lt
Absent
Rt & Lt
Absent
Rt – 8.1 inch
Lt – 7.9 inch
Flexion -Normal
Extension -Normal
Adduction -Normal
Abduction - Normal
Hand grip – Normal
Elbow
joints
Rt & Lt
Absent
Rt & Lt
Absent
Rt & Lt
Absent
Rt – 11.2 inch
Lt – 10.8 inch
Flexion - Normal
Extension - Normal
Supination - Normal
Pronation - Normal
30

31. B/L
Joints
Tenderness Warmth Swelling Measurements Range of movements
Shoulder
joints
Rt & Lt
Absent
Absent Rt & Lt
Absent
Rt – 14.2 inch
Lt – 13.8 inch
Flexion- Rt- upto 90 degree,
Lt- upto 90 degree Normal
Extension- Both Normal
Int Rotation- Both Normal
Ext Rotation- Normal
Neck /
cervical
joint
Absent Absent Absent 16.5 inch Flexion - Normal
Extension - Normal
Rotation - Normal
Lateral Bending- Normal
31

32. आतुर भूमि देश परीक्षा
 जाततः - आनूप
 संवृद्धतः - आनूप
 व्याधधतः - साधारण
32

33. DASHAVIDHA PARIKSHA
1) प्रकृ तत -वात - कफ
2) ववकृ तत
दोष : वात , कफ​
दूष्य : रस , रक्ता, मांस , मेदा , अस्थि मज्ज​, थनाय
देश : साधारण
बल : अवर
काल : वषाा
33

34. 3) सार : मध्यम
4) संहनन : मध्यम
5) प्रमाण : मध्यम
6) सात्म्य : मध्यम
7) सत्मव : मध्यम
8)आहार शस्क्त
अभ्यवहरण शस्क्त : अवर
जरणशस्क्त : अवर
9) व्यायाम शस्क्त : अवर
10) वयः : मध्यम
34

35. NIDANA
 Rookshaanna
 Alpa anna
 Abhojana
 Vegadharana
 Krodha
 Bhaya
Divaswapna
Avyaayaama
Achinta
35

36. SAMPRAPTI
Nidana & Jara Kapha vruddhi by swanidana
Dhatukshaya Avarana of vata by kapha
Vata prakopa Vyana
(Gatisanga)
Affecting Affecting affecting udana
mastulunga snayu sandhi (gurugatratwa, aruchi)
Majja in
shira marma Kampa janu shula, Further anyonya avarana
katishula
Shakruth graha
Indriya hani(pani, Udanavruta vyana
pada) & Snayu dushti (chestani)
36

37. SAMPRAPTI GHATAKA
 दोष : वात, कफ​
 दूष्य : रस, रक्ता,मांस, मेदा, अस्थि,मज्ज​,
थनाय
अस्नन : जठरास्नन,धात्मवास्नन
 आम : तद्जन्य
 स्रोतस् : रस, रक्त, मेदो, अस्थि, मांस,
मज्जावह
 स्रोतोदस्ष्ि प्रकार : सङ्ग , ववमागागमन
 उद्भव थिान : आम​-पक्वाशय
 व्यक्त थिान : दक्षिण पाणण
 मागा : मध्यम
 साध्यासाध्यता : कृ च्छ्र साध्य
37

38. VYAVACHEDAKA NIDANA
38
Provisional
diagnosis
Inclusion criteria Exclusion criteria
Kostha gata vata Mala nigraha
Hridya roga
Mutra nighara
Gulma roga
Arsha
Parswashoola
Pakvasaya gata
vata
Pureesha sangha Aanaha
Mutra kruchra
Udara shola
Trik pradesha
vedana 38

39. VYAVACHEDAKA NIDANA
39
Provisional
diagnosis
Inclusion criteria Exclusion criteria
Kati shula Shula in kati
pradesha
sarvanga vata Sphutanthi va
sandhayaha
Gatra sphurana,
bhanjana
Mamsagata vata Guruanga Toda,
dandamushtihata
vedana 39

40. 40
Provisional
diagnosis
Inclusion criteria Exclusion
criteria
Tandava roga Vida bibandha
Vepathu
Bala kshaya
Harshadikhata
Krimi sanchaya
Janu sandhi
gata vata
Vata purna dhriti sparsha
Sotha prasarna
aakunchana sa vedana
kampavata Vepathu
Peshikriya hani
Kara pada kampa nidra
bhanga
40

41. DIFFERENTIAL DIAGNOSIS
Provisional
diagnosis
Inclusion
criteria
Exclusion criteria
Dementia with
lewy bodies
•Slow movements
•Tremors
•Recurrent visual
hallucinations
•Mental decline
•Dementia
Multiple system
atrophy
•Incomplete
evacuation stools
•Tremor
•Hypotension
•Blurred vision
•Loss of muscle
coordination
•Lose of balance 41

42. Provisional
diagnosis
Inclusion criteria Exclusion criteria
Ataxia •Gait impairment
•Tremor
•Visual blurring
•Uncontrolled or
repetitive eye
movements
•Head ache
•Behavioral changes
•Unclear speech
42

43. Provisional
diagnosis
Inclusion criteria Exclusion
criteria
Osteoarthritis Pain in weight bearing joint.
Functional restriction of
joints.
Crepitus present
43

44. Provisional
diagnosis
Inclusion criteria Exclusion criteria
Parkinson’s
disease
•Tremor
•Slow movements
•Speech difficulty
•Incomplete
evacuation of
stools
•Fear of falling
•Sleep disturbance
44

45. VYADHI VINISCHAYA
 Kampa vata with Sandhigata vata
 Parkinson’s disease with Osteoarthritis
45

46. 46
CHIKITSA
VRUTTANTA

47. 47
DATE TREATMENT
14/07/16
To
21/07/16
1) Sarvanga abhyanga with dhanwantaram taila + Kottumchukkadi taila
followed by patra pinda sweda.
2) Sarvanga churna pinda sweda with Kottumchukkadi churna + Rasna
churna + Triphala churna
3) Tab – Bruhat vata chintamani 1-0-1
4) Cap – Neuro-XT 1-0-1
5) Syp – Dashmolarishta 3 tsp bd
6) Syp – Balarishta 3tsp bd
7) Syp – Aswgandharista 3tsp bd
8) Kapikachu churna 1 tsp OD with milk
9) Gandharva hastayadi taila 15 ml with 100 ml lukewarm milk @ bed time
in night.
10) Matra basti with Maha masha taila 80 ml. (20 & 21 july). 47
Later patient refused to basti treatment.

48. Date Adviced Observation
14/07/16
&
15/07/16
1) Sarvanga abhyanga with dhanwantaram taila +
Kottumchukkadi taila followed by patra pinda
sweda.
2) Sarvanga churna pinda sweda with
Kottumchukkadi churna + Rasna churna + Triphala
churna
3) Tab – Bruhat vata chintamani 1-0-1
4) Cap – Neuro-XT 1-0-1
5) Dashmolarishta 3 tsp bd
6) Balarishta 3tsp bd
7) Aswgandharista 3tsp bd
8) Kapikachu churna 1 tsp OD with milk
9) Gandharva hastayadi taila 15 ml with 100 ml
lukewarm milk @ bed time in night.
Patient feels better
Gatragurutha reduce
20%
Appetite- reduced
Bowel- constipated
Pain and tremors
persisitiing
48

49. Date Adviced Observation
16/07/16
&
17/07/16
Continue same
treatment (1 to 9)
C/O Tremor reduced by
20 %
Sleep improved
18/07/16
&
19/07/16
Continue same
treatment (1 to 9)
Patient feels better
C/O Tremor reduced by
40 %
Able to hold objects
without any involuntary
movements for 5 minutes
Bowel – irregular,
complete evacuation
Appetite improved.
Sleep – sound 49
Pain in joints reduced 30%

50. Date Adviced Observation
20/07/16
&
21/07/16
Continue same treatment
1 to 9
Along with Matra basti with
Maha masha taila 80 ml.
Patient feeling 60%
improvement in
tremors.
Improvement in
slowness in
movements.
Constipation relieved.
Able to do his daily
routine activities.
Pain in joints 30%
reduced.
50

51. DISCHARGE MEDICINES
 Tab – Bruhat vata chintamani gold 1 – 0 – 1 (A/F)
 Cap – Neuro – XT 1 – 0 – 1 (A/F)
 Dashmoolaristha 3ts bd.
 Bhadradarvyadi Kashaya 3 tsp bd.
 Balaristha 3 tsp bd.
 Kapikachu churna 1 tsp with milk OD
 Nimbamruthadi eranda thaila 2 tsp +1/2 cup hot water at
bed time. 51

52. PATIENT CONDITION ON DISCHARGE
 Patient got considerable relief in symptoms by the time of
discharge.
 Tendency to fall forward & Tremor relieved by 60 to 70
% as per patient words.
 Pain in joints 30% relieved.
 Appetite improved.
 Bowel regularized.
 Review after 20 days. 52

53. THANK YOU
53