welcome

By Dr. Bhavin Kathiriya 2nd yr p G Dept. of Kayachikitsa.

 Name :

Vitthal Poojary Age : 58 yrs Sex : male Address: Sanna Mane Nilaya,Kedoor. Marital status: Married Occupation: Canteen owner I.P.No: 72353 Date of admission : 03/12/11 Date of discharge : 12/12/11

Pt c/o Gradual loss of strength in Right UL & LL since 4 months; stands with support but cant walk. Repeated episodes of seizers Once /10 Days since 4 months.

Associated complaint:
Headache ( on and off pricking type of pain) & slurred speech since 4 months.

 A 58 yr old male patient was apparently normal 4 month back Pt was running a canteen ;on 8th Aug11 at 9 am while working

in hotel Pt suddenly developed involuntary jourkey movements of right hand along with severe headache which was continued for 5 min followed by unconsciousness for 10 min. Pt had been suffering from headache before that also (was on and off pricking type of pain) Pt was shifted to local practitioner and found slight raised BP; he was referred to nursing Home and got admitted in ICU for 1 day. During ICU stay Pt was conscious ;BP was normal. Pt gradually started feeling slight weakness of right UL and Slurred speech. A CT brain was performed which came out with Multiple small calcified lesions in B/L Frontal, left Temporal & right Occipital lobes with evidence of oedema noted in left frontal lobe lesion.

 He was immediately again shifted to KMC,Manipal and got

admitted for 13 days and was given prophylactic treatment. During this period Pt c/o epileptic seizure once per 2-3 days which was of mostly right hand and leg. gradually during hospitalization pt felt numbness in right lower limb followed by reduced strength in both right UL & LL(more in lower limb). There was no history of fever, breathlessness ;no h/0 urinary or fecal incontinence during this period. After 13 days pt was discharged. he was not able to walk and used to stand with support. There was on & off pricking type of pain which was leading to restlessness to the patient , epileptic seizure attack was reduced to 1 per 10 days .So for the above said chief complaints the patient got admitted to SDM HOSPITAL for better relief. Patient is K/C/O HTN since 4 months and under medication & Not a k/c/o DM.

 K/C/O alcoholism & chronic smoking.

Operated for RTA injury at right fore-arm.

All family members are said to be healthy (wife and 2 daughter). Belongs to lower middle class.

 Appetite : Decreased Diet: mixed ( non veg Pork)

Sleep : Disturbed
Bowels : constipated (Once/2-3 day) Micturition : 4-5 times /day; 2 times / night. Habits : alcohol : 1 quarter / day since 15 years ( local brand).

Beedi : 5 beedies / day

Appearance - Normal Built - Normosthenic Nutrition - Moderatly nourished Cyanosis - ab Pallor - ab Icterus - Ab Oedema - ab Height - 159cms Weight - 73 kg Tongue - Uncoated Lymphadenopathy- ab Gait - Altered. Hemiplegic gate Speech - Dysarthria

Temp Pulse Resp rate B.P J.V.P.

- 98.6*F - rate 78/min - 22/min - 130/90 mm of Hg - not raised.

CVS EXAMINATIONS1 & S2 heard , no added sounds..

RESPIRATORY SYSTEM EXAMINATIONNormal vesicular breath sounds, no creps , No added sound.

HIGHER MENTAL FUNCTIONS: Conscious level fully conscious Orientation Time, Place and person- present Intelligence Normal Memory Immediate, Recent and Remote are normal Hallucination, Delusion and Illusion Absent. Speech- Dysarthria present.

1. 2.

Olfactory & Smell sensation Intact & symmetrical both sides. Optic Normal (Color Vision, visual Field, and Accommodation reflex.) Acuity- Myopic, light reflex intact forward bulging of eye- absent 3,4 & 6 Occulomotor ,Trochlear , Abducent Eye ball movement- intact Pupil : Size ,position and Shape-intact; convulsion & Ptosis--absent . 5. Trigeminalsensory- sensation over face - intact Motor- Clenching of teeth-symmetrical Lateral movt of jaw- symmetrical Reflex- Corneal - intact. jaw reflex- intact. 7. FacialFore head furrowing-- sym Eyebrow raising symm Eye closure Symm Teeth showing Symm

Blowing the cheek Symm Nasolabial fold-- normal symm B/L Taste sensation of anterior 2/3 of tongue- intact. 8. Vestibulo Cochlear Tuning Fork test- not elicited. 9& 10. Glossopharyngeal & Vagus. Taste Sensation in Posterior 1/3- intact Position of uvula central. Movement of Palate- intact(air blow- normal) 11. Accessory Dissymmetry of shoulders . shrugging the shoulder possible on left side only. Turning of neck left side-intact right side- affected 12. Hypoglossal position of tongue normal. protrusion of tongue - absent. Wasting & deviation- Absent Dysarthria- present.

Attitude of limb: Rt Lt L.L: Knee & ankle extended. Knee extended,externally rotated U.L: adducted n flexed. intact Nutrition: moderately nourished
Tone: UL & LL

Rt Hypertonic Spasticity - absent Rigidity present

Rt Lt

Lt Isotonic absent absent

Power : UL 3/5

5/5 LL 2/5 5/5 Wasting : Rt-forearm ; lt- intact

Co- ordination: Rt Finger nose test: affected Knee heal test: affected Involuntary movements : absent GAIT: Hemiplegic gate. Reflexes:

Lt intact intact

Plantar-Babinskis sign- Rt: +ve , Lt: -ve Dysdiadochokinesis Present.

 Deep tendon reflexes

Rt Lt Upper limb Biceps - Exaggerated(++) Normal Triceps - Exaggerated(++) Normal Wrist jerksExaggerated (++) Normal Lower limb Knee jerk - Exaggerated (+++) Normal Ankle jerk Exaggerated (+++) Normal Superficial reflexes Corneal reflex Normal Normal Pupillay reflex Normal Normal Abdominal reflex Diminished(-) Normal Clonus Absent Absent

Sensory system examination superficial Touch - intact B/L Temp intact B/L Pain intact B/L Deep

Crude touch, Vibration, Joint sensation, Position Sense Pressure sence ---Intact B/L.
Cortical

Tactile localisation- Rt (L.L.-affected) ; Lt( intact ) Graphaesthesia intact Dysgraphia- absent stereognosis- intect.

CEREBELLAR SIGN: Nystagmus- Absent Dyspraxia-present Intension tremor- absent Dysdiadokokinesis- Present Knee heal incordination-present. Tandom walking- absent. Meningeal signNeck stiffness- absent Kernigs sign absent Brudzunskis sign negative

COMPLETE BLOOD COUNT Hb WBC ESR 12.75 gms% 8000 cells/cumm Platelet count 14 mm/hr PCV (Hct) MCV MCH MCHC Monocytes Basophil 1% 0% 34.2 % 86.7 fl 32.4 pg 37.4 gms % Total RBC 3.9 millions / cumm 3.1 lakhs / cumm

DIFF. COUNT OF WBC

N L Eosinophils 68% 24% 7%

RDW-CV

14.1 %

 Random Glucose : 103 mg/dl ( 60 -140 ) Blood Urea : 18 mg/dl (10-50)

Serum creatinine : 0.8 mg/dl (0.6-1.4)

Serum Uric Acid : 3.8 mg/dl (1.5-7)

 Total cholesterol : 172 mg/dl

Triglycerides: 143 mg/dl

HDL-Cholesterol : 36 mg/dl LDL-Cholesterol : 107 mg/dl

VLDL-cholesterol : 29 mg/dl
TC/HDL Ratio : 4.8 Ratio( 3-5 Avg. Risk) LDL/HDL Ratio : 3 Ratio

 Negative ( 5/12/11 )

 Chemical examination:

albumin- nil sugar- nil Microscopical examination: epithelial cells: 1-2/hpf (3-5/hpf normal value) Pus cells: 1-2/hpf (1-2/hpf normal value) RBCs: 0-1/hpf (0-1/hpf normal ) Crystals: nil Casts: nil Any other: nil

10 aug11 Multiple (about 5 ) small calcified lesions in bilateral frontal , left temporal & right occipital lobes with evidence of oedema noted in left frontal lobe lesion. Possibility : 1) cerebral cysticercosis. 2) calcified tuberculomas. 05 dec11 Multiple peripherally enhancing thin walled cystic lesions with eccentric calcified nodules noted in bilateral cerebral and cerebellar hemispheres, largest measuring 40 mm in diameter in the left frontal lobe, consistent with cysticercosis. Few small calcified nodules are also noted.

 Brain abscess
Subdural Empyema Bacterial meningitis

Todds paralysis.
Primary brain tumors. Neurocysticercosis

 Neurocysticercosis .

Cysticercosis present in brain

Cysticercosis present in smooth muscles.

 Etiology : NCC is the most common parasitic disease of the

CNS worldwide. Humans acquire cysticercosis by the ingestion of food contaminated with the eggs of the parasite T. solium. Eggs are contained in undercooked pork or in drinking water or other foods contaminated with human feces Clinical presentation : Onset of partial seizures with or without secondary generalization. Cysticerci may develop in the brain parenchyma and cause seizures or focal neurological deficits. If present in subarachnoid or ventricular spaces, cysticerci can produce increased ICP by interference with CSF flow.

A) Visiculat syst: MRI ,well defined scolex, minimal contrast enhancement C) Nodular cyst : Nodules with diffused enhancement and no cystic component

B) Colloidal cyst : MRI , ring enhancement, loss of scolex, perilesional oedema D) Calcified granuloma: non-contrast CT showing multiple punctuate calcification

 Tab Eptoin 100 mg 0-0-3 Tab Eptoin 50 mg 0-0-1 Tab gardinal 60 mg 0-0-1 Tab Acamprol 333 mg OD Tab TIM 100 mg OD Tab Ativan 1 mg OD Tab Nicochew 4 mg OD Tab Amlokind H 5mg OD

TREATMENT GIVEN AFTER ADDMISSION IN SDMH : Tab Albendazole 400 mg 1 OD ( for 15 days ) Contined Eptoin 100mg 3 OD & Eptoin 50 mg 1 OD

 Nadi

78/min Mutra prakrita (6 times/day) Mala vikruta (once/2-3day) Jivha Alipta Shabda vikruta Sparsha Prakrut Drik Prakruta Akriti Madhyama.

Dasa vidha pareeksha Prakriti: pitaja-vataj (chapala gati, chesta, bahupralapa, ushna asahishnuta, sheta preeyata, guru gatra, kshuda, sweda adhikata) Vikriti: Dosha- Tridosha(karmahani,sparsh agnatatva, stabdhata, shiro ruja, nidranasha, bala-alpata, gadha varchas, murchcha, dorgandhya,kandu) Dhatu- Rakta, mamsa, Updhatu Sira, Snayu. Saara: avara sara(twak saara- snigdha,) (rakta saara- snigdhata of nakha, mukha) (mamsa saara- upachaya of hanu, udara) (meda saara- snigdhata of kesha,loma) (asthi saara- nothing specific) (majja saara- mrudu anga) (shukra saara- nothing specific) (satva saara- nothing specific).

 Samhanana:

madhyama Saatmya: madhyama Satva: avara Pramaana: madhyama Vaya: Madhyama Vyayama shakti: poorvakaalina: madhyama adhyatana: avara Ahara shakti: abhyavarana shakti: madhyama jarana shakti: avara

Nidana: - aaharaja: ajirna bhojan, sankirna bhojana, virudhdha Ahara ( parihar virudhdha) Poorvaroopa: shirshool. Roopa: karma kashaya(right UL & LL) . Vak sanga, shiroshula, akshepaka,dorgandhyata,karna nad, mano vibhramsha. Upashaya anupashaya: nothing specific

Ajirna bhojan, sankirna bhojana-viruddha ahara (varaha mansa sevetoshna-parihar virdhdha) Klinnata Utpatti in rakta & mamsa & Kopana of Tridosha

Leads to Dhatu Kshaya janya Pakshaghat

Leads to Dakshina Parshva Karma Hani Sthana samshraya in shira snayu

Uttpati of Raktaja krimi Lodges into Raktavaha dhamani

Vata vrudhdhi

Reaches to murdhini

Bala Kshaya and Shosha

KRIMI SHIRO ROGA(Raktaja)

Raktaja Krimi does Shira Snayu Bhakshana

 Dosha:

Tridosha Dushya: rakta, mamsa Agni: jatharagni Srotas: mansavaha,raktavaha. Srotodusthi: sanga. Udbhava sthana: pakvashya Vyakta sthana: shiras n dakshina hast-pada. Rogamarga: madhayama .

 Shiro Krimi janya Pakshaghat.

Marga-avaranjanya pakshghata (kaph-pita

anubandh). Ekanga vata.

Shiro Krimi janya Pakshaghat.

Shat dharana yoga (in Arohana krama 16-19-22-25-28-31-34). Abhyanga with M.N. taila. Shiva Gutika 1-0-0 Tab cruel 1-1-1 Nitya virechana with Shunthi kashaya 20 ml & Eranda taila 20 ml ( at 6 AM) Physiotherapy .

 Abhyanga Snigdha sweda

Mrudu Virechana
Shirovirechana

Some yogas Ekangavera rasa, brihat vata cintamani rasa, dhanadanayanadi kashaya, sameerpannag rasa,maha vidhvansak rasa, shiva gutika, dasamularista, balarista.