cva case in Ayurveda

1. -Dr. Divya K S
1st Year PG Scholar,
Dept of PG Studies in Kayachikitsa,
SKAMCH&RC,
Bangalore.

2. Name : Mrs. Dhanalakshmi
Age : 62yrs
Sex :Female
Religion :Hindu
Socio-Economic status :Middle class
Marital status :Married life of 44yrs
Education : 3rd standard
Occupation : Housewife

3. Date of Admission :22/04/2014
Ward :FGW
Source of History :Patient, Relative of patient
Case taken on :21/05/2014
Consultant Doctor :Dr. Mahesh
OP No :30199
IP No :1628/14
Address : No. 14, 3rd Main,
Shamanna Garden,
New Guddadahalli,
Bangalore.

4.  C/o Karma kshaya in dakshina ardha shareera
and vakaspashtatha since 9 months.

5.  Gamana ashakatata since 9 months.
 Difficulty in grasping things with hand since 9
months.

6. The patient was diagnosed with hypertension 6 years back.
She was apparently said to be normal till before 9 months as
she was on anti hypertensive medication (details are not
available) ,but she had stopped taking her anti hypertensive
medicines 3 months before the attack. On 26/8/13 around 6pm
patient suddenly noticed difficulty in speaking and was feeling
very tired for around 10 minutes. Her son took her to a nearby
clinic and was given anti - hypertensive tablet

7. as her blood pressure was found to be high. She
had food and tablets and was said to be
completely alright for the remaining part of the
night. On the next day morning( 27/8/13) patient
woke up at around 6am and finished her regular
washroom activities.

8. At around 6.30am the patient fell down suddenly
on her bed where she was sitting. She had
generalized weakness, giddiness, loss of strength
on the right half of the body and slurring of speech
along with slight deviation of face towards left
side. She was immediately taken to ESI hospital
and BP was recorded, which showed 180/120mm
of Hg.

9. The patient had 10 episodes of vomiting
starting from 7.30am till 3 pm. After
administering a few medicines, the patient was
referred to NIMHANS hospital from ESI
hospital. From NIMHANS after taking MRI
and CT scan of brain the patient was referred to
Jayadeva hospital.

10. In Jayadeva hospital the patient underwent ECG and
2-D echo. After advising the patient to continue with
the same medications she was sent back to
NIMHANS and from there to ESI. On the same day,
patients relatives took her to St.Martha’s Hospital.
After staying in Martha’s hospital for a period of 3
days from 27th to 29th August 2013 she was taken to
folklore practitioner in Chittoor.

11. She was given oral medications and oil for
application(details not known) for a period of 3
months. After 2 months of taking medicine, the
patient gradually noticed slight improvement in
strength and movement of her limbs of right side.
Since then she stopped oil and oral medication, but
continued to take modern medication. .

12.  She did not take any treatment for the next 4
months. The patient came to SKAMCH for
further treatment.

13.  Patient has reduced hearing in the left ear since
childhood, but has not taken any treatment for the
same.
 Patient had fracture of left lower limb 8 years back
and underwent surgery and IM rod insertion.
 K/c/o HTN since 6 yrs No H/O DM or dyslipidaemia.

14.  From NIMHANS:
CT Brain
• B/l subcortical hypodensitity
• No bleed

15.  From Jayadeva hospital:
2D Echocardiography:
• Sclerotic aortic valve with trivial AR
• Normal chambers,
• Normal LV function
• No regional wall motion abnormalities at rest
ECG Report:
Normal

16.  Blood Report:
Lipid profile
LDL : 162 mg/dL
All other results were found to be within normal
range

17. From ESI hospital:
1 Inj. Lasix 40mg IV stat
2 Tab Amlong 10mg stat
From NIMHANS
1 Tab Ecosprin 150mg 0-1-0
2 Tab Atorvastatin 10mg 0-0-1

18. From Jayadeva hospital :
1 Tab Tonact 10mg 0-0-1
2 Tab Ecosprin 150 mg 0-1-0
3 Tab Stamlo 5mg 1-0-0
4 Tab Emeset 4mg sos
From St. Martha’s Hospital :
1 Tab Deplatt A 75/150 0-1-0
2 Tab Atorva 40mg 0-0-1
3 Tab Strocit 500mg 1-0-1
4 Tab Amlong 1-0-0
5 Tab Shelcal HD 0-1-0

19.  Patient has 5 siblings
 Patient is married and has 4 children.
 No one in the family is said to have
similar complaints.

20.  Diet - Mixed, Nonveg – 1/ week
 Appetite - Normal
 Sleep - Normal
 Micturation - Regular , 5-6 times per day
 Bowel - Regular, once/day
 Habits - 2 cups of milk daily

21.  Menarche at the age of 15 years
 Menopause at the age of 40 years

22.  Patient has 4 children
 First 3 are female and last one is a male.
 The first 3 are normal vaginal delivery and last
is through cesarean section.
 The patient has underwent tubectomy at the
time of cesarean.

23.  Built - Moderate
 Nourishment - Moderate
 Pallor - Absent
 Icterus - Absent
 Cyanosis - Absent
 Clubbing - Absent
 Lymphadenopathy - Absent
 Edema - Absent
 Tongue - slightly coated

24.  Pulse - 80 BPM
 B.P - 120/80 mm of Hg
 Temp - 98.6° F
 Respiratory - 20 Times/min
 Height - 143cms
 Weight - 63 kg
 BMI - 30. 8 Meter/kg2

25.  CVS
On auscultation; S1 S2 heard, No murmurs
 RS
Inspection
 Shape of chest - bilaterally symmetrical
 Respiratory rate – 20 times/min

26. Palpation
Trachea - centrally placed
Auscultation
Normal bronchovesicular sounds heard

27.  PA
Inspection:
 Vertical scar of cesarean below umbilicus
 No distension
 Umbilicus- normal
 No visible peristalsis
Palpation:
 Soft, No tenderness, No organomegaly

28. Percussion:
• Dullness heard over right hypochondrium.
• Tympanic sound heard in the remaining quadrants of
the abdomen
Auscultation:
• Bowel sounds heard

29. CNS
1)HMF
 Consciousness – Fully conscious
 Orientation to -time
-place Intact
-person
 Memory -immediate
-recent Intact
-remote
 Intelligence- Intact
 Hallucination & Delusion- Absent

30.  Speech disturbance- present, slurring of speech
 Handedness-Right
2)Cranial Nerve Examination
 Olfactory- Smell sensation-intact
 Optic-a) Visual acuity
-b)Colour vision
-c)Visual field NAD
-d)Light reflex
-e)Accomodation

31.  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

32. Reflex-corneal-present
- jaw jerk-present
 Facial
A)Forehead frowning - weakness in the
right side
b)Eyebrow raising - weakness in the
right side
c)Eye closure -possible
d)Teeth showing -no deviation of angle of
mouth
e)Blowing of cheek -no pursing of lips
f)Naso labial fold -equal on both sides

33.  Vestibulo-cochlear Rt Lt
-Rinne’s test- bone conduction absent absent
Air conduction present present
-Weber’s test- No lateralisation
 Glossopharyngeal and Vagus
Position of uvula- centrally placed
Taste sensation-intact
Gag reflex - normal
 Spinal accessory
Shrugging shoulder- weakness in the right side
Neck movement -possible against resistance

34.  Hypoglossal
Protrusion of tongue -no deviation
Tongue movements -possible

35. Motor System
1)Involuntary movements – Absent
2)Muscle bulk – Rt Lt
Biceps 30 cm 30cm
forearm 22cm 22cm
mid thigh 50cm 50cm
calf muscles 31 cm 31cm
3)Muscle tone
Right hand – Spastic
Left hand –Normal
Right leg –Spastic
Left leg –Normal

36. 4)Muscle strength Rt Lt
 a)Elbow -flexion 4/5 5/5
-extension 3/5 5/5
 b)Wrist -flexion 0/5 5/5
-extension 3/5 5/5
 c) Finger abduction 0/5 5/5
 d)Opposition of thumb 0/5 5/5
 e) Test of grip 0/5 5/5

37. Rt Lt
Lower limb
Hip -adduction 4/5 5/5
-abduction 4/5 5/5
-flexion 3/5 5/5
-extension 3/5 3/5
Knee -flexion 3/5 5/5
-extension 4/5 5/5
Ankle -dorsiflexion 0/5 5/5
-plantarflexion 1/5 5/5

38. 5)Coordination
UL-Finger nose test Co-ordination present
LL-Knee heel test
6)Gait- Circumscribed gait ( hemiplegic gait)
7)Reflexes
Superficial
a)Corneal -Intact
b)Abdominal - Intact

39. Rt Lt
Deep (2 + indicates normal)
a)Biceps jerk +++ ++
b)Triceps jerk +++ ++
c)Knee jerk +++ ++
d)Ankle jerk +++ ++
(2 + indicates normal)
e)Clonus-patella absent absent
-ankle absent absent
Babinski reflex - positive
Abdominal reflex- absent

40. 8)Sensory system
1)Superficial:
a)Touch -Intact
b)Temperature -Intact
c)Pain - reduced in rt hand
2)Deep:
a)Crude touch -present
b)Vibration - Absent in legs
c)Joint sense -present
d)Position sense -present
e)Pressure sense -present

41.  Prakruti - kapha-pitta
 Vikruti :-
Hetu - Avarana
Dosha -Vata, kapha pradhana tridosha
Dushya -Rakta, meda,
snayu, sira
Prakruti - Vikriti vishama samavaya
Desha -Saadharana
Kaala - Vyaktavastha, Upadravavastha
Bala -Madhyama

42.  Sara -Madhyama
 Samhanana -Madhyama
 Pramana - Ht-143cms,
-Wt-63kg
 Satmya - Madhyama (mamsa rasa, katu,
amla, lavana rasa satmya)
 Satva -Avara
 Ahara sakthi-
Abvyaharana sakthi -madhyama
Jarana sakthi -madhyama
 Vyayama sakthi - Avara
 Vaya -vardhakya

43. Nidana sevana- katu,
amla, lavana rasa,
mamsa sevana
kapha/pitta/raktadusti
occurs
Formation of ama
43
SAMPRAPTHI

44. Reaches masthiska
/uttamanga
Sthanasamsraya in
dhamanis and siras
Causes
margavarodha
44

45. Leads to obstruction
of movement of vata
Karmakshaya
pakshaghata
45

46. Samprapthi ghataka
 Dosha -Vata, Kapha pradhana tridosha
 Dooshya -Rasa, rakta,
sira, snayu
 Agni -Jataragni, dhatvagni
 Srothas -Rakthavaha,
medovaha,
 Srotho dushti prakara -Sanga
 Udbava sthana -Pakvashaya
 Vyaktha sthana - Ardhakaya
 Adhishtana - Masthishkaghata siras
 Marga - Madhyama
 Sadhyasadhyatha - Kricchra sadhya

47.  Pakshaghata
 Kalli(pada janga uru kara moola avamoatani)
 Sarvanga roga(padam sankochayati hastam va)
 Mamsamedogata vata
 Asthimajjagata vata
 Ardhita vata

48. Dakshinabhaga pakshaghata

49.  CVA- Cerebro Vascular Accident.
 TIA- Transient Ischemic Attack.
 Encephalitis / Encephalopathy.
 Brain Tumor.

50.  CEREBROVASCULAR ACCIDENT
 HAEMORRAGE ISCHEMIA
 1.SAH. 1. EMBOLI.
 2.ICH. 2. THROMBOSIS.

51.  CVA(Cerebero Vascular Accident) manifested
as with Right Hemiplegia.

52. 30/4/14
1. Tab. Amlong 1-0-0
2. Tab. Ecosprin 150mg 0-1-0
3. Tab. Chandraprabha vati 1-1-1
4. Tab. Ekanga veera rasa 1-1-1
5. Tab. Smritisagara rasa 1-0-1

53. 6. Avipathikara choorna- 25gm
Godanthi bhasma - 25gm 1 tsp tid
Abraka bhasma - 5gm
Tapyadhi loha - 10gm
7. Alepa chikitsa –for 7 days

54. 5/5/14
 Stopped Alepa chikitsa
 Started sarvanga abhyanga with dhanwantharam taila
and patra pinda sweda
 Started matra vasti with 30ml dhanwantharam taila
14/5/14
 Stopped EVR and Smritisagara Rasa
 started Tab. Palsinuron

55. 20/5/14
 Stopped Patra pinda sweda
 Started shashtika shali pinda sweda

56.  Improvement in strength of both upper and lower
limbs in the right side.
 Able to stand without support.
 Able to walk with support.

57. Thank you

58. Upper motor neuron lower motor neuron
1 Affection Muscle groups Individual muscles
2 Tone Spastic Flaccid
3 Nutrition No wasting Marked wasting
4 Reflexes Exaggerated Diminished
5 Clonus absent present
6 Babinski response present absent

59.  PATHYA
 Sarpi, Taila, Dadhi,
 Godhuma, Maasha, (1yrs old),
 Shashti Shali, Kulatha, Kukuta
 Mamsa, Shigru,
 Lashuna, Dadima, Pakvatala,
 Jambira, Badara, Draksha,
 Naranga, Dugdha, Narikela,
 Eranda Taila, Tambula,
 Matsyandika, Etc.

60.  Chinta, Jagrana, Vegadharana,
 Atishrama, Atichankramana
 Navadhanya, Yava, Rajamasha,
 Mudga, Jambu, Kramuka,
 Karvelaka, Shitajala, Madhu,