Jaundice/ kaamla/ jalodara case presentation in @and year MD kayachikitsa 2016 SKAMCH&RC Bangalore

1. Case presentation
Presentator :
Kamal Kishore
PG Scholar 2nd year
Dept. of PG studies in Kayachikitsa
SKAMCH&RC

2. ATURA VIVARANA
Name : Mr. Yogesh
Age : 23 Years
Sex : Male
Religion : Hindu
Marital status : Bachelor
Socio economic status : Middle class
Education status : PUC
Occupation : Shopkeeper
Date of admission :05/05/16
Date of discharge :18/05/16

3. Ward : Male General ward
Source of history : Patient
Consultant doctor : Dr. Supreeth/Dr. Kiran M. Goud
O.P No : D14095
I.P. No : 2090/16
Case taken on : 14th May 2016
Address :Sh. Annapoorneshwari, sira
Tumkur
Karnataka

4.  Ubhaya adhogata shakha shotha (dakshina>vaama)
 Krishna varna, kandu,
fluid filled eruptions with erosions
on extensor surface on Rt leg
 Udara utsedha
 Peeta varna Akshi
 Haridra varna mootrata
Since 20 days
Since 1 month

5.  Difficulty in ambulation
 Tiredness (shrama)
 Reduced appetite
 Discomfort in sitting
Since 1 month

6. The above said patient was diagnosed with
Wilson Disease 8 years back. He was
asymptomatic 40 days back, when he
experienced fever followed by loose stools(2-
3 watery episodes) for which he visited a
clinic nearby and was managed with some
I.V Fluids and Oral medications (details of
which are not known) following which the
symptoms came down. 30 days back he
noticed simultaneous swelling in b/l lower
limbs (Rt>Lt) which was same throughout

7. the day. Gradually he developed blackish
discoloration, itching on b/l lower limbs(Rt>Lt)
and fluid filled eruptions with erosions on
extensor surface Rt leg. This hampered the
ambulation of patient as he started developing
tiredness after walking more than 5 min. 20
days back he noticed yellowish discoloration of
sclera, dark yellow urine and gradual distension
of abdomen with discomfort in sitting and
reduced appetite. Bowel and bladder were said
to be regular.

8. For these complaints he went to General
Hospital where the consulting physician
advised him some tests and referred him
to visit an Specialist consultant nearby, so
the patient went there and took the
consultation.
Along with this the patient also went to
an Ayurvedic clinic and took medication
following which his swelling and itching
reduced. The same Ayurvedic doctor
advised him to approach SKAMCH&RC for
further management.

9. Patient was diagnosed with Wilson
disease 8 years back.
He is on following medication from Indira
Gandhi Institute of Child Health Hospital
B’lore .
1.Tab. Pencillamine 250mg 2-0-2
2.Tab. Zincovit 0-0-1

10.  Rx From General Physician since past twenty days
1. Urosolol 150mg 1-0-1
2. Lasilactone 50mg 1-1-0
3. Aldactone 25mg 2-2-0
 Rx From Ayurvedic Clinic (from 22nd april to 2nd
May)
1. Udaramrith juice 15ml b.d. (B/F)
2. Syp. Cardorium plus 10ml b.d. (A/F)
3. Tab. Immunocin 1tab b.d. (A/F)
4. Tab. Shiva Gutika 1tab b.d. (A/F)

11. HTN & T2DM
Since 8 years
(on med)
HTN Since
5 years (on
med)
Wilson
disease
since 8 years

12. Diet : Vegetarian diet
Appetite : Good
Bowel : once/day (regular)
complete evacuation.
Micturition : 5-7 times/day
once/night
Sleep : Good
Addictions : None

13. Patient was conscious, alert, oriented to
time, place and Person.
Built : Medium
Nourishment : Moderate
Pallor : Absent.
Cyanosis : Absent.
Nail : Normal
Icterus : Present
Oedema : Absent
Lymphadenopathy : Absent.

14. Temperature: Afebrile
Pulse :78 bpm.
BP :120/80 mmHg.
R/R :20/minute.
Tongue : UnCoated.
Height : 160cm
Weight : 60Kg
BMI : 23.4

15.  Naadi-78 bpm
 Mootra- 5-7times a day, once at night occasionally.
 Mala- Once a day,
 Jihwa- Alpalipta
 Shabada- Prakruta
 Sparsha–Prakruta
 Drikka- Prakruta
 Aakriti - Madhyama

16.  Prakriti :- Pitta pradhana Vaata
 Vikriti :- Pravara
Hetu:- beeja Dushti, Aaharaj Nidaana
Dosha:- Pitt Vriddhi, Vaat vriddhi, Kapha
Vriddhi
Dooshaya:- Rasa , Rakta, Maansa
Desha:- Saadharana
Bala:- Madhyama
Kaala:- Greeshma
Prakriti:- Prakriti SamSamveta
 Saara :- Avara

17. Samhanan: Madhayama
Pramana: Madhayama Ht: 160cm
Wt: 60 kg
Saatmaya : Sarvrasa satmaya
Satva : Avara
Aahara Shakti : Madhyama
Abhyavaran Shakti : Madhyama
Jarana Shakti : Madhyama
Vyayama Shakti : Madhyama
Vaya :Madhyama

19.  Jatata: Sadharana
 Samvardhita: Sadharana
 Vyadhita: Sadharana

20. P/A EXAMINATION
Inspection –
*Distended
*Umbilicus – Inverted
 Auscultation -Peristaltic sounds heard,
2-3 /min
 Palpation –
* Soft, No tenderness.
* organomegaly not elicited.
 Percussion – Shifting dullness noticed.
 Abdominal Girth - 65cm

21. CVS
S1 S2 heard, no added sounds/murmurs.
RS
Shape of chest -bilaterally symmetrical.
Trachea -centrally placed
Normal vesicular breath sounds heard.
No added sounds.

22. EYE EXAMINATION
 VA 6/6 in both eyes
 sclera slight yellowish
 K.F rings present in b/l cornea
SKIN EXAMINATION
 Color : blackish discoloration of extensor surface
of b/l Leg, yellowish discolration of sclera.
 Moisture: Dryness
 Texture: Rough
 Turgor: normal
 Temperature: equal to body temp (98.6 f)
 Lesions :Vesicular eruptions on rt extensor surface
of leg with erosions

24. INVESTIGATIONS

33.  Nidana – Beeja dushti
Aharaja – Katu amla lavana rasa pradhana
bhojana,vidaahi ahara( excessive
masala food,curds), Guru aahara
 Purvaroopa -
 Roopa – Ubhaya adhogata shakha shotha
(dakshina>vaama)
Krishna varna, kandu, pidika ( dakshina
adhogata shakha )
Udara utsedha
Peeta varna Akshi
Haridra varna mootrata

34. Aaharaj
NidaanaBeeja Dushti
Pitta prakopa
Ras Dushti, Rakta Dushti,
Maamsa Dushti
Yakrit, Pleeha Dushti
Koshtagata KaamalaYakritdalyodar, pleehodara
JALODARA
Shyava kandu
sarava yukta Pidika

35.  Upashya – Vishraama.
 Anupashaya – Guru, Vidahi, Ati ambu sevana.

36. Dosha – pitt pradhana tridosha
Dushya - Rasa,Rakta,maansa
 Srothas –Rasa,Rakta,maansa
 Sroto dusti - Sanga, vimarga gamana
Agni - Jatharagni and Dhatvagni mandya

37.  Udbhavasthana - Aamashya
Sancharasthana – Rasayani, Ambuvaha
Strotas
Vyaktasthana – Udara, Adhosakha,
Adhishtana – Aamashaya
Rogamarga – Abhyantara
Sadhya-Asadhyata - kruchra sadhya

39. Disease Inclusion Exclusion
Plihodara Udara abhinivartyati ,
arochaka , daurbalya
Spleenomegally
Yakritodhara Udara abhinivartyati
Arochaka,daurbalya

40. 
 DISEASE
 INCLUSION

 EXCLUSION
 Asruja yonivyapat/ Rakta yonivyapat
 Ati pravartana of rakta from yoni marga.
 No daha,
 No osha, choshadi pitta lakshana`s
 Lohitakshara yoni vyapat
 Rakta ksharana
 No Osha, chosha, jwara, daha
Disease Inclusion Exclusion
Jalodhara Annanaakansha
Dourbalya
Gudsrava
Shifting dullness
Panaki Santapa,
Bhinnavarchasa,
peeta
Panduta
netraraga
Haleemaka/
laghava/ alasa
Mridu jwara
Balo utsaha kshaya
Mandagani
aruchi
Angamardha,varna ,
breathlessness
Bhrama , harita
shyava peeta varna,
Tandra, shwasha,
trishna

41. 
 DISEASE
 INCLUSION

 EXCLUSION
 Asruja yonivyapat/ Rakta yonivyapat
 Ati pravartana of rakta from yoni marga.
 No daha,
 No osha, choshadi pitta lakshana`s
 Lohitakshara yoni vyapat
 Rakta ksharana
 No Osha, chosha, jwara, daha
Disease Inclusion Exclusion
Pandu Daurbalya
Jwara
shrama
Akshikoota shotha
Shishir dweshi
Atinidra, bhrama
Shativan
Pidikodweshtana
Shakha Ashrita
kamala
Daurbalya
Jwara, Hikka
Parshava shoola
shwasha
shweta varchasa
Aatopa, vishtambha,
Kostha Ashrita
kamala
Aruchi
Daurbalya
Netra peetata
Shakrit peetata
Kumbha kamala Kaalantrat
kharibhoota, aruchi
,Jwara.
Shoona/Shootha
krishna
Peeta shakrut mutra
parvbheda

42. DIFFERENTIAL DIAGNOSIS
 Haemochromatosis
 Hepatitis A/E
 Hepatitis B/C/D
 Liver cirrohosis

43. 
 DISEASE
 INCLUSION

 EXCLUSION
 Asruja yonivyapat/ Rakta yonivyapat
 Ati pravartana of rakta from yoni marga.
 No daha,
 No osha, choshadi pitta lakshana`s
 Lohitakshara yoni vyapat
 Rakta ksharana
 No Osha, chosha, jwara, daha
Disease Inclusion Exclusion
Hamachromatosis Metallic hue/
pigmentation over legs
Liver disorders
Fatigue, weakness,
Serum Iron levels were
found to be normal
Hepatitis A/E Spreads by faeco oral
route,
Fever, anorexia,
splenomegally,
jaundice after 1-2
week of fever
Recovery occur in 3-6
weeks
Severe elevations of
AST,ALT (>300U/L)
Hepatitis B/C/D Fever, anorexia,
splenomegally,
jaundice
Spread of route is
percutaneous or sexual
contact
Severe elevations of
AST,ALT (>300U/L)
Transmitted by
intravenous route, sexual
Cirrohosis of liver Shrunken liver
Jaundice
Ascites

44.  Liver cirrohosis with mild Ascites
 Jalodara
 Wilson disease

45.  Krichha Saadhya

46. DATE TREATMENT GIVEN OBSERVATIONS
5/5/16 –
12/5/16
1.Gomutra
haritaki
6gm haritaki
+30ml of
Gomutra
On empty
stomach
before
breakfast.
2.Tab. liv52DS
2tid
3.Nirocil Syrup
3tsp tid
4.Vasa
Guduchyadi
kwatha
6tsp tid
p.t.o
Pada shotha
Vaivarnya in pada
Udara Utsedha

47. DATE TREATMENT GIVEN OBSERVATIONS
5. Mukta Bhasma
2gm
Godanti bhasma
40gm
Guduchi Satva
50gm
Mixed and given
1tsp tid
During the entire
course of
treatment patient
was advised to
take Rice and milk
diet only.

48. DATE TREATMENT GIVEN OBSERVATIONS
13/5/16 –
19/5/16
1.Gomutra
haritaki
6gm haritaki
+30ml of
Gomutra
On empty
stomach
before
breakfast
On alternate
days.
2.Rest medicine
continued same.

49. BEFORE TREATMENT AFTER TREATMENT
Pada shotha Pada shotha absent
Krishna Vivarana in pada with
kandu
Krishna Vivarana in pada with
kandu reduced
Udara Utsedha Udara utsedha reduced
Peeta vivarana of akshi Peeta vivarana of akshi reduced to
a greater extent
Vesicular eruptions with erosions Vesicular eruptions have changed
into crusts, erosions absent

50. BEFORE TREATMENT
Investigations
21 April 2016
AFTER TREATMENT
Investigations
Total Bilirubin 4.65 3.31 ▼
Direct 2.86 1.03 ▼
Indirect 1.79 2.28
Total protein 5.9 7.9 ▲
Albumin 2.84 2.6
Globulin 3.06 5.3
Ag Ratio 0.93 0.5
SGOT/ALT 46.8 18.9 ▼
SGPT/AST 116.8 31.8 ▼▼
Alkaline Phosphatase 89.5 93.8
Gamma Glutyl
Transferase
40.8 33.3 ▼

51. Kayser–Fleischer ring

52. Kayser–Fleischer rings

53. RIGHT LEFT
During Treatment

54. RIGHT LEFT
After Treatment

55. 1.Gomutra haritaki
6gm haritaki +30ml of Gomutra
On empty stomach before breakfast on alternate
days.
2.Tab. liv52DS
2tid
3.Nirocil Syrup
3tsp tid

56. 4.Vasa Guduchyadi kwatha
6tsp tid
5. Mukta Bhasma
2gm
Godanti bhasma
40gm
Guduchi Satva
50gm
Mixed and given 1tsp tid
Breakfast with milk diet only.
Regular meals for Lunch and Dinner.
Avoid fatty and spicy food items.
Follow up after 30 days.

57. Shamana
1. Gomutra haritaki 6gm haritaki with 30ml gomutra
b.d B/f
2. Darvyadi choorna 1tsf tid with Water B/f
3. Vasa guluchyadi kashayam 3tsf tid with water A/f
4. Kalyanaka gudam 5gm b.d with milk A/f
Shodhana
Virechana with Trivrit avleha &
Triphala kwatha

58. Rasayana
1. Shilajatu rasayana 1 tab tid with Gomutra a/f
2. Pipali vardhmana Rasayana for 13 days (max dose
5gm for 5 days)
3. Swarna makshika bhasma 1 ratti with Madhu A/f

60. Pathya Apathya
Cereals Old rice, wheat, barley Fried and difficult to
digest articles of food
Pulses Pigeon pea (arahara),
green gram (mudga),
masura
Peas, black gram
Fruits and vegetables Papaya, banana,
potato, amalaki,
pomegranate, grapes,
anjira, apple,
paravala, mango,
Others Cow milk, buttermilk Excessive use of oil
and clarified butter,
mustard oil, betel,
spices, rye, hingu,
sesame, heavy food

61. Pathya Apathya
Lifestyle vegdharana, maithuna,
diwaswapna,atapa
sewana, Vyayama,
krodha,
atichankramana, ati
ambu paana

62. Thank you !