Patient is a 13-year-old male who presented with swelling and pain in his left knee joint for 3 years that was aggravated for the last 10 days. On examination, there was swelling, warmth, and tenderness in the left knee with reduced range of motion. Differential diagnoses considered included juvenile idiopathic arthritis, rheumatic fever, and viral arthritis but were excluded based on lack of relevant symptoms and examination findings. The patient's condition was assessed as a madhyama prakriti with involvement of vata and kapha doshas in the left knee joint.

1. Case presentation
DR. GURMEL SINGH
I YEAR PG SCHOLAR
DEPT., OF PG STUDIES IN
KAYACHIKITSA
SKAMCH&RC, BANGALORE
1

2. PREMILINARY DATA OF PATIENT
2
Name : Jeevan Raj
Age : 13Years
Sex : Male
Religion : Hindu
Socio economic status : Middle class
Marital status : Un-married
Education status : 7 Standard
Occupation : Student
Date of admission :24/06/15
Date of discharge : 06/06/15

3. Ward : Semi Special Ward
Source of history : Patient, Mother
Case taken on : 27/06/15
Consultant doctor : Dr. Amarnath B.V. B
O.P No : 16822
I.P. No : 2444/15
Address :House no. 33,
3rd Cross, 2nd stage
Doddanna industrial estate
Peenya ,
Bengaluru -58
3

4. प्रधान वेदना/CHIEF COMPLAINTS
4
सन्धिशोथ (Swelling in Left Knee joint )since 3
years aggravated since 10 days
सन्धिशूल (Pain (On & off) in Left Knee joint)
since 3 years, aggravated since 10 days.

5. अनुबन्ध वेदना/ASSOCIATED COMPLAINTS
5
Morning stiffness (<30 min) since 10 days
Following symptoms present Since 2 ½ years
aggravated since 10 days
Pain(On & Off) in Left thigh region
Difficulty in walking, climbing up & getting
down stairs, squatting

6. HISTORY OF PRESENTING COMPLAINTS
6
Patient was apparently healthy 3 years back,
suddenly he noticed swelling on lateral aspect of left
ankle joint followed with pricking type of pain which
was causing difficulty in walking.
After one week he developed severe swelling and
pricking type of pain on his left knee joint along with
morning stiffness. He also complained of having, on
and off fever, reduced appetite and difficulty in
activities like climbing & getting down stairs and also
sitting in squatting position.

7. 7
For these complaints they consulted at SRM
Medical College and Hospital, Chennai and he was
prescribed oral medication. By this treatment patient
got relief in pain.
During the course of medication, after 6 months,
these symptoms re-occurred along with symptoms
like pain in right knee joint, pain in left thigh region
which aggravated during walking, playing and
symptoms got subsided by rest and hot fomentation.
He continued with the same medication for 2 years
and found relief in pain and mild decrease in swelling
on left knee joint .

8. He stopped all the medications since 1 year following
the physician advice.
2 months back he fell down from bicycle and got bruise
on his left knee joint which got healed within one week.
10 days back, after morning walk, he noticed severe
pricking type of pain along with swelling in left knee joint
for which he approached SKAMCH & RC
8

9. HISTORY OF PAST ILLNESS
9
Patient is not a k/c/o
Diabetes Mellitus, Hypertension, Tuberculosis
No history of chikungunya, viral fever, dengue
fever

10. TREATMENT HISTORY
10
S.R.M.HOSPITAL&RESEARCH CENTRE
05/11/2013
Tab. Pan 20mg 0-0-1
Tab. Hifanac-P ½-0-1/2
Tab. Medrol 4mg 0-1/2-0 (daily)
Tab. Folitrax 5mg 11/2 weekly once
Tab. Folic acid 5mg 0-0-1 (daily)
Except Wednesday
He stopped all the medications since 1 year

11. कौटुम्बिक वॄत्तान्त/Family History
11
FATHER
PATIENTBROTHER
MOTHER
Not a consanguineous marriage of the parents
No significant contributing information from the family
history.

12. वैयक्तिक वृत्तान्त/PERSONAL HISTORY
12
All developmental milestones achieved normally.
All vaccinations done as per the immunization schedule.
Diet : Mixed
(Non veg. 1 time in a week)
Appetite : Good
Bowel : 2times / day (regular)
complete evacuation.
Micturition : 3-4 times / day
1-2 times/ night
Sleep : Good

13. GENERAL PHYSICAL
EXAMINATION
13
General Condition : Fair
Built :well-Built
Nourishment :well-Nourished
Pallor : Absent.
Swelling : Lt. knee joint
Cyanosis : Absent.
Nail : Normal
Icterus : Absent.
Lymphadenopathy : Absent.

14. Temperature: Afebrile
Pulse :94 bpm.
BP :110/80 mmHg.
R/R :25/minute.
Tongue :Un-coated.
Height : 136cm
Weight : 40Kg
BMI : 21.73
14

15. Systemic Examination
15
CNS
Patient was conscious, alert, oriented to time, place and
Person.
CVS
S1 S2 heard, no added sounds/murmurs.
RS
Shape of chest -bilaterally symmetrical.
Trachea -centrally placed
Normal vesicular respiratory sounds heard.
No added sounds
PER ABDOMEN EXAMINATION
Soft,No Tenderness,No Organomegaly

16. LOCOMOTOR SYSTEM EXAMINATION
16
Joints Pain Tenderness Warmth Swelling Measurments
Range of
movements.
Ankle joints Rt-Absent
Lt-Absent
Rt- Absent
Lt- Absent
Rt-Absent
Lt- Absent
Rt-Absent
Lt- Absent
Rt – 23.5cm
Lt – 23.5cm
Flexion
Both Normal
Extension-
both Normal
Inversion –
both Normal
Eversion
- Both
Normal
Gait – Antalgic

17. 17
Joints Pain Tenderness Warmth Swelling
Range of
movements.
Hip joints Rt- Absent
Lt- Absent
Rt-Absent
Lt- Absent
Rt-Absent
Lt- Absent
Rt- Absent
Lt- Absent
Flexion-both
Normal
Extension-both
Normal
Abduction-both
Normal
Adduction-
Normal
Int.Rotation-
both Normal
Ext Rotation-
both Normal

18. Joints Pain Tenderness Warmth Swelling
Measurment
s
Range of
movements
Wrist joints Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt – 13cm
Lt – 13cm
Flexion- both
Normal
Extension-
both Normal
Adduction-
both Normal
Abduction-
both Normal
Hand grip –
both Normal
Elbow joints Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt –21.5 cm
Lt – 21.5cm
Flexion- both
Normal
Extension-
both Normal
Supination-
both Normal
Pronation-
both Normal
18

19. B/L Joints Pain Tenderness Warmth Swelling
Measureme
nts
(circumfere
nce)
Range of
movements
Shoulder
joints
Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt- Absent
Lt- Absent
Rt – 33.5cm
Lt – 33.5cm
Flexion
Both Normal
Extension-
both Normal
Int Rotation-
both Normal
Ext
Rotation-
both Normal
Neck Absent Absent Absent Absent 34.5cm Flexion-
Normal
Extension-
Normal
Rotation-
Normal
Lateral
Bending-
Normal
19

20. KNEE JOINTS (EXAMINATION)
20
INSPECTION Left knee Right knee
Redness/rashes Absent Absent
Muscle wasting Absent Absent
Scars Medial side Absent
Genu valgum Absent Absent
Genu varum Absent Absent
Swelling ++ Absent
Bakers cyst Absent Absent

21. 21
PALPATION Left knee Right knee
Warmth ++ Absent
Tenderness +++ Absent
Effusion(patellar tap) Positive Negative
Crepitus Absent Absent
Fluctuation test Negative Negative

22. 22
Range of movement Left knee Right knee
Flexion Painful Normal
Extension Normal Normal
Int. Rotation Normal Normal
Ext. Rotation Normal Normal
Measurement
Circumference of knee
joint
Left knee joint Right knee joint
On knee 37 cm 34.5cm
Above knee 38 cm 35.5cm
Below knee 30 cm 29.5cm

23. 23
Special tests Right knee joint Lt knee joint
McMurray Test No click felt or heard
No tenderness
No Abnormality detected
Valgus stress test No pain No pain
Varus stress test No pain No pain
Anterior drawer sign No pain or abnormality No pain or abnormality
Posterior drawer sign No pain or abnormality No pain or abnormality

24. अष्ट स्थान परीक्षा
24
नाडि : 94 bpm / min
मूत्र : 3-4 times / day
1-2 times/ night
म्िह्वा : Alipta
मल : 2times / day (regular)
complete evacuation
शब्द : Prakruta
स्पशश : Prakruta
दृक् : Prakruta
आकृ म्त : Madhyama

25. दश ववध पररक्षा
25
1) प्रकृ ति: : Vata Kapha.
2) सारतः : Madhyama.
3) संहनि : Madhyama.
4) प्रमाणतः : Height - 136 cm
Weight - 40kgs.
5) सात्म्यि : Vyamishra.

26. 6) सत्मवि : Pravara
7) आहर शन्ति : अभ्यवहरण शन्ति – Pravara
जरण शन्ति – Pravara
8) व्यायाम शन्ति : Madhyama
9) वयः : Bala
10) ववकृ ति : Madhyama
26

27. ननदान पञ्चक
27
तनदान- Katu, Tikta Ahara ,Ati vyayama
पुवशरूप - Could not be elicited
रूप- Sandhi shoola ,Sandhi shotha
उपशय-Rest and hot fomentation
अनुपशय- Jumping, playing, Green pea , Tomato,
Unripen Banana recipe

28. सबप्राम्ि घटक
28
दोष –
दूष्य –
स्रोतस ् –
स्रोतोदुक्ति –
अक्तनि –
उद्भव स्थाि –
संचार स्थाि –
व्यि स्थाि –
 रोग मागग –
 साध्यासाध्यता –

29. व्यवच्छेदक म्नदानाम्न /DIFFERENTIAL DIAGNOSIS
29

30. 30
व्याधध Reason for inclusion Reason for exclusion
अन्थथमज्जागि वाि सन्धिशूल
भेदोअन्थथपववणां
मांस बलक्षय
अथवप्न
सधििारुक
सन्धिगि वाि सन्धिशूल शोफ
प्रसरण आकु धचनयो प्रवृति
सवेदना
वािपूण्र ्द्रुतिथपशव
कॊष्टुक् शीर्वक शोथजानुमध्ये थथूल कॊष्टुक् शीर्वथिु
जानु महारूज

31. 31
व्याधध Reason for inclusion Reason for exclusion
वािरति (ग्भीर ) श्वयथु
थिब्ि
अधिभ्रॄशातिवमान
श्याव थिाविाम्र अथवा
दाहिोदथफु रण पाकवान
चिुथवक ज्वर ( श्लेन्ष्मक )
जधघाभ्यां शूल
आमवाि जानु सन्धि रूजं शोथं अंगमदो
अरुचच
िॄष्णा
आलथय
गौरवं
ज्वर
अपाक शूनिा अंगानाम

32. 32
Disease Reason for inclusion Reason for exclusion
Seronegtive
spondyloarthritis/
Juvenile Idiopathic Arthritis
(JIA)
 Found in children.
 Asymmetric pain,
 persistent swelling of
affected joint(i.e knee
ankle or wrist joint )
 Morning stiffness
 ESR ,CRP increased
 RF,ANA negtive
 Enthesitis
Acute Rheumatic fever  Arthalgia
 CRP,ESR increased
 Leucocytosis
 Persistent fever
 Erythema marginatum
and erythema nodusom
 Chest Skiagram showed
no cardiac enlargement
 ASLO negative
 No abnormality
detected in CVS
examination

33. 33
Disease Reason for Inclusion Reason for Exclusion
Pseudo gout  Knee is common site
 Fever
 Stiffness
 swelling
 Generally the cause for acute mono
arthritis in elderly
 Self limiting synovitis
 Generally it is due to meta bolic
disorder s
Haemoarthrosis
associated with
clotting
abnormality
 Skiagram of lt. knee
joint shows
haemoarthrosis
 CT and BT are found normal
Multiple
epiphyseal
dysplasia
 Found in children
 Major joints are
involved ( hips/knee)
 Joint effusion
 Congenital disease
 O.A / Arthrosis is not seen

34. 34
Disease Reason for inclusion Reason for exclusion
Viral arthritis Arthralgia
Enthesitis
 Acute onset with fever
 Self limiting
 Rash present generally
in the form of slapped
cheek
Leukaemia Arthritis
Haemoarthrosis
 Thrombocytopenia
 Lymph node
enlargement
 Weight loss
 Coagulation disorders

35. व्याक्ति क्तिर्गय/Diagnosis
35
 Seronegative spondyloarthritis
Juvenile Idiopathic Arthritis (JIA)  AAMVAAT ???

36. LAB INVESTIGATIONS
36

37. 37

38. 38

39. 39

40. 40

41. 41

42. 42

43. 43

44. 44

45. 45

46. 46

47. 47

48. 48

49. 49

50. 50

51. 51

52. 52
DATE LAKSHANA CHIKITSA
25 June 2015 c/o Pain and swelling
in left knee joint.
Morning stiffness.
Pain in left thigh region
(Anterior ).
1) Agani lepa (1st day)
2) Sathanika parisheka with
dashmool kwatha (2nd
day)
3) Sathanika jambeer pind
sweda (2nd day)
4) Kottamchukkadi lepa (e/a
on left knee) at night (n0t
done)
26 june 2015 c/o pain in right ankle
joint
1) Agni lepa (2nd day)
2) Sathanika parisheka with
dashmool kwatha (3rd day)
3) Sathanika jambeer pind
sweda (3rd day)
4) Kottamchukkadi lepa (e/a
on left knee) at night (n0t
done)

53. 53
DATE LAKSHANA CHIKITSA
27 June 2015 c/o Pain and
swelling in left knee
joint.
Morning stiffness.
Pain in left thigh
region (Anterior ).
pain in right ankle
joint.
1) Agni lepa (3rd day)
2) Sathanika parisheka with
dashmool kwatha (4th day)
3) Sathanika jambeer pind sweda
(4th day)
4) Kottamchukkadi lepa (E/A on
left knee) at night (not done)
28june 2015 No examinations
done as the pt had
went home with
permission.
1) Agni lepa (3rd day)
2) Sathanika parisheka with
dashmool kwatha (4th day)
3) Sathanika jambeer pind sweda
(4th day)
4) Kottamchukkadi lepa (E/A on
left knee) at night (n0t done)
All above treatment not done

54. 54
DATE LAKSHANA CHIKITSA
29 June 2015 c/o Pain and
swelling in left knee
joint.
Morning stiffness
decrease
Pain in left thigh
region (Anterior )
Decrease by 5%
Pain in right ankle
joint.
1) Agani lepa (4th day)
2) Sathanika parisheka with
dashmool kwatha (5th day)
3) Sathanika jambeer pind sweda
(5th day)
4) Kottamchukkadi lepa (E/A on left
knee) 1st day
30 June 2015 c/o Pain and
swelling in left knee
joint.
Morning stiffness
decrease
Pain in left thigh
region (Anterior )
Decrease by 5%
Pain in right ankle
joint.
1) Agani lepa (4th day) stop
2) Sathanika parisheka with
dashmool kwatha (6th day)
3) Sathanika jambeer pind sweda
(6th day)
4) Kottamchukkadi lepa (E/A on left
knee) 2nd day
5) Pancha tikta gharita 2tsp TID
6) Asthi poshak vati 2-0-2
7) Manjisthadi lepa (E/A on left
knee,right ankle) 1st day

55. 55
DATE LAKSHANA CHIKITSA
1 July 2015 c/o Pain and swelling
in left knee joint.
Morning stiffness
decrease
Pain in left thigh
region (Anterior )
Decrease by 5%
Pain in right ankle
joint.
1) Sthanika parisheka with dashmool kwatha
(7th day)
2) Sthanika jambeer pind sweda (7th day)
3) Kottamchukkadi lepa (E/A on left
knee,right ankle) stop
4) Pancha tikta gharita 2tsp TID
5) Asthi poshak vati 2-0-2
6) Manjisthadi lepa (E/A on left knee,right
ankle)2nd day
7) Nimbamruthadi erand tail30 ml with hot
water @night time (today only)
2 July 2015 c/o Pain and swelling
in left knee joint.
Morning stiffness
decrease
Pain in left thigh
region (Anterior )
Decrease by 5%
Pain in right ankle joint
decrease
1) Sthanika parisheka with dashmool kwatha
(7th day) stop
2) Sthanika jambeer pind sweda (7th
day)stop
3) Pancha tikta gharita 2tsp TID
4) Asthi poshak vati 2-0-2
5) Manjisthadi lepa (E/A on left knee,right
ankle)3rdday
6) Tikta ksheer basthi 1st day

56. 56
DATE LAKSHANA CHIKITSA
3 July 2015 c/o Pain and swelling
in left knee joint increase
Morning stiffness
increase
 pain in left thigh
region (Anterior side)
Increased
1) Pancha tikta gharita 2tsp TID
2) Asthi poshak vati 2-0-2
3) Manjishthadi lepa (E/A on left knee,right
ankle)4th day
4) Tikta ksheer basthi 1st day
Stop all treatment
4 July 2015 c/o Pain and swelling
in left knee joint .
increase
Morning stiffness
increase
 pain in left thigh
region (Anterior side)
Increased
Revised treatment
1) Guduchi churna 50mg
2) Amalaki churna 50mg
3) Mustha churna 50 mg
4) All mixed ,2tsp +60 ml water reduce to
30 ml Bd (B/F)
5) Sanjeevani vati 2-0-2
6) Tribhuvan keerthi rasa 1-0-1 BD
7) Manjishtha churna lepa for E/A (on left
knee)

57. 57
DATE LAKSHANA CHIKITSA
5 July 2015 c/o Pain and swelling
in left knee joint
decrease by 10%
Morning stiffness
decrease
 pain in left thigh
region decrease by 10%
1) Gaduchi churna 50mg
2) Amalaki churna 50mg
3) Mustha churna 50 mg
4) All mixed ,2tsp +60 ml water reduse to
30 ml Bd (B/F)
5) Sanjivani vati 2-0-2
6) Tribhuban kirthi rasa 1-0-1 BD
7) Majistha churna lepa for E/A (on left
knee)
6 July 2015 c/o Pain and swelling
in left knee joint
decrease by 20%
Morning stiffness
decrease
 pain in left thigh
region decrease by 20%
1) Gaduchi churna 50mg
2) Amalaki churna 50mg
3) Mustha churna 50 mg
4) All mixed ,2tsp +60 ml water reduse to
30 ml Bd (B/F)
5) Sanjivani vati 2-0-2
6) Tribhuban kirthi rasa 1-0-1 BD
7) Majistha churna lepa for E/A (on left
knee)

58. वािरति
58
ग्भीरे श्वयथु थिब्ि कठिनो अधिभ्रॄशातिवमान
श्याव थिाविाम्र अथवा दाहिोदथफु रण पाकवान ्॥
थवेदो अत्मयथं वा काष्यव थपशवञ्त्मव ्ं क्षिेअतिरुक्
सन्धिशैचथल्यमालथयं सदनंवपदकोद्गम
जानुजधघोरुकट्यं सहथिपादाधगसन्धिर्ु
तनथिोद थफु रणं भेदो गुरु वं सुन्प्िरेव च॥
कण्िू संचिर्ु रुग्भुत्मवा भूत्मवा नश्यति चासकृ ि ्
वैवण््व मण्िालोत्मपविवाविासृकपूवव लक्षणम्॥

59. आमवाि
59
अंगमदो
अरुचच
िॄष्णा
आलथय
गौरवं
ज्वर अपाक शूनिा अंगानाम
हथिपाद शशरोगुल्फ त्रिकजानु उरु सन्धि
करोति स रूजं शोथं यि दोर्ं प्रपद्यिे

60. चिुथवक ज्वर
60
जधघाभ्यां श्लेन्ष्मक पूव ्ंव शशरथिो अतनल स्भव

61. अन्थथमज्जागि वाि
61
भेदोअन्थथपववणां सन्धिशूल
मांस बल क्षय
अथवप्न सधििारुक

62. संग्रहणी
62
आधिकू जन
आलथय
दौबवल्यं
सदनं
द्र्वं
शीि
घन
न्थनग्ि
सकठट वेदना
शकृ िाआम्ं बहुपैचचल्यं सशब्दं मधदवेदना
पक्षांमासाव्दतनत्मयं
ठदवाप्रकोपो भवन्धि
रािौ शान्धि दुवववग्नेय दुचचककत्मसा चचरकाल अनुबन्धि

63. कॊष्टुक् शीर्वक
63
वािशोणणि
शोथजानुमध्ये महारूज
कॊष्टुक् शीर्वथिु थथूल

64. सन्धिगि वाि्
64
हन्धि सन्धिगि सन्धिशूल शोफ
वािपूण्र ्द्रुतिथपशव
शोथ सन्धिगिे अतनल
प्रसरण आकु धचनयो प्रवृति सवेदना

65. वािबलासकी
65
तनत्मयमंधदज्वरो रुक्ष शूनकथिेन सीदति
थिब्िांग श्लेष्मभूतयष्िो नरो वािबलासकी॥(अ.स.तन
२)