Khanja case presentation

1. Dr. Sahana
2nd Year PG Scholar,
Dept of PG Studies in Kayachikitsa,
SKAMCH&RC,
Bangalore.

2. Patient Data
Name : Chaithra
Age :21yrs
Sex :Female
Religion :Hindu
Socio-Economic status :Upper middle class
Marital status :Unmarried
Education :B.Com
Occupation :Student

3. Date of Admission :16/07/2015
Ward :Semispecial Ward
Source of History :Patient, Patient’s mother,
Patient’s grandmother.
Case taken on :20/07/2015
Consultant Doctor :Dr. Rinjin
IP No :2761/15
OP No :19546
Address :House No 836
4th cross,11th block,
2nd stage
Nagarbhavi,Bangalore
Contact No :9686165037

4. PRADHANA VEDANA
 C/O pain in her back and paraspinal region since 2
years.

5. ANUBANDHA VEDANA
C/O difficulty in walking since 20 years.
C/O urinary incontinence since 16yrs.
C/O swelling in left leg on and off since 1 yr.

6. VEDANA VRITTANTA
 Patient was a K/C/O spina bifida operated for
myelomeningocele on the day of birth. She has been presenting
with deformities in her lower limb, urinary incontinence.
Patient was otherwise normal 2 years back. Since past 2 years
she gradually started developing pain in her back. Pain would
be present in the paraspinal region as well. Pain would
aggravate on continuous standing, walking ,sitting in same
posture for long time and pain would relieve on lying down
supine on the floor. She initially neglected the symptom. Later
on the intensity of pain was increased. She then consulted an
orthopedician and a neurologist, who suggested a spinal

7. Surgery.As the surgery would have the complication of
developing paraplegia, she did not go forward with it. She has
been consuming analgesics since then when pain manifests.
Since past 1 year she has also developed swelling in the left leg
i.e. down the knee joint up to the heel whenever she has got
pain in her back. On developing swelling in her legs, she finds
it difficult to walk. Since past six months the intensity of pain
has become severe and she finds it difficult to do her routine
activities when pain is present.For these complaints she has got
admitted in SKAMCH on 16/07/2015.

8. Poorva vyadhi Vruttanta
 On birth patient was diagnosed with myelomeningocele
and was operated for the lump on her lower back on the
first day of birth. Patient is said to have normal growth
and development. Her milestones were normal. She
started walking at the age of 1 year, When she was 3-
4years, they observed that the child could not walk
independently and she needed support of a person or the
wall. She used to place her legs cross i.e both leg
outwards.She was not able to place her left sole

9. completely touching the ground,but the right sole could not
be placed properly on the ground and there would be more
pressure on the lateral aspect of the foot.She also had
difficulty in passing urine.Either she would not be able to
pass urine or pass in very little quantity.Within few
minutes after passing urine,she would again get a urge for
micturition.Her bowel habits were once in two or three
days.She was taken to a hospital in davanagere for these
complaints and there she was referred to NIMHANS
hospital.At the age of 5years i.e in January 2000,in
NIMHANS,she was diagnosed with operated

10. Lmbar myelomeningocele with tethered cord and ACM Type-2 and was
operated for the same.She was advised to use catheter for urination.
After the surgery her mother’s observation was that the urinary
incontinence was reduced. Her bowels were still constipated and she
would pass stools only on intake of medicine.By 11-12yrs of age the
bowel habits became regular without medicines.She would pass
stools once or twice in a day. Sometimes the frequency of stools
increase in a day and the consistency would vary from medium to
watery.would Later on the difficulty in walking increased gradually.
Patient later consulted many hospitals for the complaint of difficulty
in walking. In St.Joseph hospital she was given shoes for the
correction of difficulty in walking. On using the shoes the complaint

11.  of difficulty in walking was reduced. The extent of
crossing of legs was reduced.On walking barefoot the
symptoms persisted.She used the shoes upto the age of
17years.She was seeking a permanent relief and so she
consulted Sparsha Hospital.In April 2011,she was operated for
calcaneous deformity. Samilson osteotomy was done and
Tibialis anterior to TA transfer was done.Post surgery the
placement of right sole on the floor was improved.After a gap
of 1year she underwent a surgical correction in the left leg as
well,the details of which are not available.After surgery the
extent of crossing of left leg was reduced,still the symptoms
did not relieve fully.

12. Antental history
 Patients mother had consumed abortion pills at the 3rd
month of her pregnancy. She was then working as
Commercial tax Inspector. She had been working till the
9th month of pregnancy. There was a travel H/O 3hrs
everyday from her home to workplace. Iron and folic acid
supplementation were taken as per consulting doctor’s
advise. Patient had hyperemesis gravida and she was on
medication for the same as per doctor’s advise. There is no
H/O maternal smoking or alcoholism during pregnancy.

13. KOUTUMBIKA VRITTANTA
 Patient has a elder brother.
 No H/O consangeunious marriage of parents.
 No one in the family is said to have similar
complaints.

14. VAYAKTIKA VRITTANTA
 Diet -Mixed,Non-veg-chicken monthly once,egg
and fish –once in three months or so
 Appetite - Good, skips breakfast sometimes.
 Sleep - Sound,Disturbed when pain is severe.
 Micturition-4-5times/day,4times/night,self catheterization.
 Bowel -1-2 times/day, controls the urge,if not at home.
 Habits - Milk occasionaly-once in a week or so.

15. GENERAL EXAMINATION
 Built - moderate built
 Nourishment - moderately nourished
 Pallour - Present
 Icterus - Absent
 Cyanosis - Absent
 Clubbing - Absent
 Lymhadenopathy - Absent
 Edema - left foot
 Tongue - Not coated

16.  Pulse - 78/m
 B.P - 110/80 mm of Hg
 Temp - 98° F
 Respiratory - 18/min
 Height - 1.45mts
 Weight - 45kg
 BMI -21.40

17. SYSTEMIC EXAMINATION
 PA
Inspection:
Distended
Umbilical centrally placed
No visible peristalsis,scars
Palpation:
Soft, No tenderness, No organomegaly

18. Percussion:
Tympanic sound heard
Dullness in right hypochondrium
Auscultation:
Bowel sounds heard
 CVS
On auscultation; S1 S2 heard, No murmurs.

19.  RS
Inspection
 Shape of chest - bilaterally symmetrical
 Respiratory rate - 18/min
Palpation
 Trachea - centrally placed
Auscultation
 No added sounds

20. Spine Examination:
Inspection:
Position of head-No twisting to one side
Level of shoulders-symmetrical
Scapula-Symmetric
Spine curvature-Normal, No functional/structural scoliosis
Palpation:
Tenderness-Maximum in lumbar region
Swelling-absent
Wasting and rigidity-Absent

21.  Movements:
Flexion-Possible
Extension-painful
Lateral movement-Possible
Rotation-Possible
Measurements:
Rt-88cms
Lt-86cms
SLR- Negative on both sides

22. CNS EXAMINATION:
1)HMF
 Consciousness – Conscious- GCS-E4M6V5
 Orientation to -time
-place Intact
-person
 Memory-immediate
-recent Intact
-remote
 Intelligence- Intact
 Hallucination & Delusion- Absent

23.  Speech disturbance-Absent
 Handedness-Right
2)Cranial Nerve Examination
 Olfactory- Smell sensation-intact
 Optic-a) Visual acuity
-b)Visual field NAD
-c)Light reflex
-d)Accomodation
-e)Colour Vision-Not elicited

24.  Occulomotor,Troclear & Abducent Nerve
-Eyeball movement-Possible in all directions
-Pupil-position
-shape
-size NAD
-symmetry
-Ptosis-Absent
 Trigeminal
Sensory-Touch, pain and pressure sensation intact
-corneal reflex-present
Motor-clenching of teeth -possible
-lateral movement of jaw- possible

25. Reflex-corneal-present
- jaw jerk-absent
 Facial
A)Forehead frowning -present
b)Eyebrow raising -possible
c)Eye closure -possible
d)Teeth showing -no deviation of angle of mouth
e)Blowing of cheek -no pursing of lips
f)Nasolabial fold -equal on both sides

26.  Vestibulo-cochlear
-Nystagmus-absent
-Rinne’s test-negative
-Weber’s test-equal on both sides
 Glossopharyngesl and Vagus
Position of uvula- central
Taste sensation-intact
 Spinal accessory
Shrugging shoulder-possible against resistance
Neck movement -possible against resistance,painful on right
side

27.  Hypoglossal
Protrusion of tongue -possible
Tongue movements-possible

28. Motor System
1)Attitude of limbs:
Upper limb-Normal
Lower limb- inversion of right foot
2)Nutrition:
Muscle bulk Right (in cms) Left (in cms)
a)UL - arm 24.5 24.5
-forearm 17 17
b)LL -thigh 45 45
-calf 23 23

29. 3)Tone
UL- Normal
LL-Normal
4)Power Rt Lt
a)Shoulder- adduction 5/5 5/5
-abduction 5/5 5/5
-flexion 5/5 5/5
-extension 5 /5 5/5
b)Elbow-flexion 5/5 5/5
-extension 5 /5 5/5

30.  c)Wrist-flexion 5 /5 5 /5
-extension 5 /5 5/5
Lower limb
Hip-adduction 5 /5 5/5
-abduction 5 /5 5/5
-flexion 5/5 5 /5
-extension 5/5 5/5
Knee-flexion 5/5 5/5
-extension 5/5 5/5
Ankle-dorsiflexion 3/5 3/5
-plantarflexion 3/5 3/5

31. 5)Coordination
Rapid alternative movements-possible in UL and LL
Finger nose test-Possible
Knee heel test-Possible
Tandem walking-Not Possible
Walking on heels,toes-Not possible
Shallow knee bending-Possible
Romberg’s sign-Positive
Pronator drift-Positive
6)Involuntary movement- Absent
7)Gait- Limping

32. 8)Reflexes-Superficial
a)Corneal - Present
b)Abdominal - Present
c)Plantar - Negative
Deep Rt Lt
a)Biceps jerk + + + +
b)Triceps jerk + + + +
c)Supinator jerk
d)Knee jerk + + + +
e)Ankle jerk + + +
f)Clonus-patella + +
-ankle + +
g)Jaw jerk - Negative

33. Sensory system
a) Pain - Present
b)Temperature sensation - Present
c) Light Touch - Present
d)Vibration - Present
e)Position sense - Present
f)Stereognosis -Present
g)Graphaesthesia -Present
h)Point localization -Present
i)Extinction -Present
j)Two point discrimination- Present

34. Meningeal Signs
 Neck Mobility-No rigidity
 Brudzinski’s sign- Negative
 Kernig’s sign- Negative
 Lhermitte’s sign-Negative

35. Summary
 Shortening of left limb by 2cms,but no compensatory
functional scoliosis seen
 Talipes varus deformity of right foot
 No sensory deficit
 No signs of meningitis
 Tandem walking-ataxia
 Romberg sign-ataxia from dorsal column
 Pronator drift-corticospinal tract lesion

36. Dashavidha Pareeksha
Prakruti - Vata pitta
Vikruti :-
Hetu - Maturapachara-consumption of abortion pill,atiyana during
pregnancy.
Dosha - Vata(Vyana,Apana),Kapha
Dushya – Rasa, Mamsa, asthi,Majja
Prakruti-
Desha - Sadharana
Kaala - Varsha
Bala - Pravara
Lakshana- Pain in the back,swelling in left leg, urinary
incontinence,difficulty in walking.

37.  Saara-Madhyama
 Samhanana-Avara
 Pramana- Ht-1.45mts
-Wt-45kg
 Saatmya- Ghrita,Taila,shadrasa pradhanyata with
lavana,katu pradhanyata
 Satva- Madhyama
 Aahara shakti-Abhyavaharana-Madhyama
-Jarana shakti-Madhyama
 Vyayama shakti-Avara
 Vaya -Baala
 Vikara-Pravara

38. Nidana Panchaka
Nidana- Maturapachara- pill during pregnancy
Viharaja- Yana during Garbhini avastha
Purvarupa- Avyakta
Rupa- Pain in the back,swelling in left leg, urinary
incontinence,difficulty in walking.

39. Samprapti:-
 Nidana sevana
 Dosha prakopa
 Garbhashaya pravesha
 Na kartsnyena dooshana of garbha
 Leading to garbhavikara and not garbhavinasha
 Beejabhaga avayava dushti in matruja(Basti) and
pitruja(Asthi) bhava
 Janmabala pravrutta vikara with dushti in rasaja bhava at
the time of birth
 Dushti seen in the avayava developed from the particular
effected beeja bhaga avayava in the later stage of life.

40. Samprapti Ghataka:-
 Dosha- Vata(Apana,Vyana), Kapha
 Dushya-Rasa,Mamsa, Asthi, Majja
 Agni-Jatharagni, Dhatwagni
 Srotas-Mamsavaha, Asthivaha, Majjavaha
 Udbhava sthana- Pakwashaya
 Sanchara sthana-Rasayani
 Vyakta sthana- Adhonabhi
 Adhistana-Garbha
 Marga- Madhyama
 Saadhyaasaadhyata -Yapya

41. Vyavachedaka Nidana
vyadhi Inclusion criteria Exclusion criteria
Udanavruta
vyana
Chesta hani present Stabdata,nimilana,asw
eda absent
Apanavruta
vyana
Vinmutra atipravrutti
present
Presence of difficluty
in walking,leg
deformity
Gudagata vata Trika durbalata,
prushta roga present
Shoola,adhmana,
shosha absent
Pakwashayagata
vata
Kruchra mutratwa,
trika vedana present
Antra kujana,
shoola,atopa, anaha
absent
Snayugata vata Khalli present Involvement of bowel
and bladder symptoms

42. Vyadhi Inclusion criteria Exclusion criteria
Khalli Pada mula avamotana
present
Presence of urinary
incontinence, pain in
back
Pureeshavruta
vata
Prushta ruk, history of
presence of vibandha
Shroni,vankshana
peeda, anaha absent
Khanja with
mutrateeta
Difficulty in walking, with
urine
Pangu ----------

43. Vyadhi Vinishchaya
Khanja with mutrateeta

44. DIFFERENTIAL DIAGNOSIS
Disease Inclusion
criteria
Exclusion criteria
Polio Myelitis Leg deformity
since childhood
Bowel and bladder
incontinence present,
pyrexia,headache absent
Multiple
Sclerosis
Urinary
incontinence,
positive tandem
walking
Numbness,tingling sensation,
diplopia,Lhermitte’s sign
negative

45. Disease Inclusion criteria Exclusion criteria
Transverse
Myelitis
Urinary
incontinence
Weakness,numbness of
limbs,senory deficits
absent

46. Disease Inclusion
criteria
Exclusion criteria
Cauda equina
syndrome
Bowel and
bladder
incontinence
present, low back
pain,
Pain limited to back,
numbness,tingling
sensation absent.
Myelomeningo
cele
Bowel bladder
incontinence, leg
deformity.Pain in
back
----------

47. DIAGNOSIS
Myelomeningocele

48. Investigations
 MRI Lumbo-sacral spine with whole spine screening on
27/06/2013
Known case of myelomeningocele with tonsilar herniation
and basilar invagination-Arnold chiari malformation-2
Status post laminnectomy of L4 and L5
Tethered cord at the level of L5 and S1.

49.  USG of Abdomen and Pelvis on 5/07/2013
Prevoid volume-275cc
Post void volume-78cc
Significant postvoid residue
 Bilateral Arterial & Venous Doppler Study on 15/07/2015
No evidence of DVT to femoro-popliteal system
Low velocity flow to bilateral anterior tibial and
dorsalispedis artery.

50. Chikitsa
Date Treatment Observations
16/7/
2015
1)Sarv Abhyanaga with Sahachardi
Taila+Bashpa Sweda
2)Ghrita sadhita yavagu
Pain in back,
urinary
incontinence,
difficulty in
walking
17/7/
2015
1)Sarv Abhyanaga with Sahachardi
Taila+Bashpa Sweda
2)Yavagu sadhita ghrita
3)Siravyadha near right ankle joint
Symptoms
persisting
18/7/
2015
&
19/7/
2015
1)Sarv Abhyanaga with Sahachardi
Taila+Bashpa Sweda
2)Lashuna sadhita takra
Reduction in pain,

51. Date Treatment Observations
20/7/
2015
1)Sarv Abhyanaga with Sahachardi
Taila+Bashpa Sweda
2)Ghrita sadhita yavagu
No Pain,
Frequency of
urination
increased
21/7/
2015
1)Sarv Abhyanaga with Sahachardi
Taila+Bashpa Sweda
2)Yavagu sadhita ghrita
3)Siravyadha near right ankle joint
Urine frequency
reduced, Pain in
the back, Pain
reduced after
Rx.
22/7/
2015
1)Sarv Abhyanaga with Sahachardi
Taila+Bashpa Sweda
2)Yavagu sadhita ghrita
3)T.Diarex-sos
3 episodes of
stools, pain
presenting at
day time

52. Date Treatment Observation
23/7/2015
to
27/7/2015
1)Choorna pinda sweda with
Kottamchukkadi churna
2)Adhoshaka Udwartana with
kolakuthadi churna
3)Adhoshaka dashamoola parisheka
4)Swarna malini vasanta-10
Pravala panchamrita with mukta-30
Abhraka bhasmashatputi-5gms
Kanta loha bhasma-10gms
Godanti bhasma-20gms
Divided into 40 parts,1part twice
daily with honey followed by
Ashwagandha+Shatavari+Brahmim
ksheerapaka
C/O pain
reduced
after two
days of Rx.
Urinary
incontinence
present.

53. Date Treatment Observation
28/7/2015 1)Sarv Abhyanga with
Ksheerabala Taila
2)Shashtika Shali Pinda Sweda
3)Kati Basti with Ksheera bala
taila
4)Eranda moola Niruha Basti- To
be started from tomorrow
Increased
frequency of
stools since last
night,Pain
reduced,urinary
incontinence
present.

54. Proposed line of treatment:-
 Sarv Agnilepa
 Sarv abhyanga with Dhanwantara Taila
 Sarv Shashtika ShaliPinda Sweda with Bala moola
kwatha
 Matra Basti with vastyamayantaka ghrita-start with
30ml

55.  Tab.Panchamruta loha guggulu 2-0-2
 Bhadradarvyadi kashaya 2tsp-0-2tsp
 Punarnavadi Kashaya2tsp-0-2tsp2
 Avapidaka sneha with vastyamayaka ghrita

56. THANK YOU