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Case Presentation- Amavata
- 1. DR. SHAILESH 2nd YEAR PG SCHOLAR DEPARTMENT OF PANCHAKARMA SDMCA&H CASE PRESENTATION 1
- 2. BIODATA NAME :NAGARATHNAMMA AGE : 46 YRS SEX : FEMALE RELIGION : HINDU MARITAL STA : MARRIED OCCUPATION : HOUSE WIFE ADDRESS : ANANTAPAUR, A.P. D.O.A :19-12-16 D.O.D : 29-12-16 OP NO : IP NO :18228 2
- 3. CHIEF COMPLAINTS •Stiffness •Swelling •Burning in soles Pain in all major and minor joints - since 5yrs Without steroids 3
- 4. ASSOCIATED COMPLAINTS Lethargy Constipation Loss of appetite Heaviness of body Feverishness -during the episode of pain 4
- 5. H/O PRESENT ILLNESS •As per the patient she was normal 5 year’s back. •One day she experienced feverishness followed by multiple joint pain • This pain subsided without medications •After an year she noticed stiffness in the fingers. •Later, there was pain in the low back region. 5
- 6. • Gradually she started complaining of pain in wrist, elbow, shoulder, knee and ankle bilaterally. • Severity of the pain started increasing and sometimes associating with swelling. • During the episodes of pain she experienced stiffness in all major and minor joint along with lethargy. 6
- 7. H/O PAST ILLNESS FAMILY HISTORY Menorrhagia - Hysterectomy done in 2009 No relevant family history contributing to the current condition of the patient. All members are said to be healthy. 7
- 8. PERSONAL HISTORY Appetite : Decreased Bowel : 1time/day, Hard stools Micturition : 4-5 times/day Sleep : disturbed Addiction: - 8
- 9. GENERAL EXAMINATION Built Moderate Pallor Absent Icterus Absent Cyanosis & Clubbing Absent Lymphadenopathy Absent Tongue coating ++ Pulse rate 84/min BP 130/90 mm Hg 9
- 10. HIGHER MENTAL ACTIVITIES Consciousness Well conscious Orientation Good Memory Good Speech Normal 10
- 11. ASHTA STHANA PAREEKSHA JIHWA UPALEPATWAM NAADI KAPHA-VATA MALA AMAYUKTA MOOTRA PRAKRUTA SHABDHA PRAKRUTA SPARSHA RUKSHA DRUK PRAKRUTA AAKRUTI MADYAMA 11
- 12. DASHAVIDHA PAREEKSHA 1) PRAKRUTI - VATA-PITTA 2) VIKRUTI - HETU- AHARA -VATAKAPHA KARA VIHARA - AVYAYAMA DOSHA - TRIDOSAJA DUSHYA - RASA, ASTHI, MAJJA DESHA - JANGALA BALA - MADHAYAMA 12
- 13. CONTD……. 3) SARA - MADYAMA 4) SAMHANANA - MADYAMA 5) PRAMANA - 52 kgs 6) SATVA - MADYAMA 7) SAATMYA - SARVA RASA SATMYA 8) AHARA SHAKTA Jarana shakti- Avara Abhyavarana shakti- Madhyama KOSHTA - KRURA 9) VYAYAMA SHAKTI- AVARA 10) VAYA - MADYAMA 13
- 14. SYSTEMIC EXAMINATION Respiratory system – NVBS Cardiovascular system- NAD Musculo skeletal system – On inspection – • difficulty in extension of fingers • mild swelling in interphalangeal joints On palpation – • rise in temp in joints • mild tenderness in joints 14
- 15. LABORATORY INVESTIGATION HAEMATOLOGY Hb 13.8 gm% T.WBC 10,100 cells/cu mm ESR 32 mm/hr DIFFERENTIAL COUNT Neutrophils 72(40-70%) Lymphocytes 25(20-40%) Monocytes 01(2-6%) Eosinophil 02(1-4%) Platelet 3.25 lakhs RBC 4.86 mil/mm3 BIO CHEMISTRY FBS RA 100.8 mg/dl + ve 15
- 16. DISCUSSION NIDANA - abhishandi aahara (curd rice), nischla (sedentary life style), mandagni POORVARUPA - ajeerna, aruchi, shrama RUPA - sarva sandhishula, shota UPASHAYA - ushna jala snana, visharama SAMPRAPTI -Nidana jataragnimandya kaphavata prakopa sthanasamshraya in sandhi lakshana 16 NIDANA PANCHAKA
- 17. Atura bala – madhyama Roga bala – pravara Upadrava – none Sadhyasadhyata – kruchra sadhya 17
- 18. NIDANA 18
- 19. SAMPRAPTINidana Ama Kapha – Pitta – Vata – Ama Saama dosha dhamani pratipadhyate Vaayuna prerito ama shleshma sthaanam pradhaavati Srotaamsya abhishyandati - picchilatvat Amavata 19
- 20. SAMPRAPTI GHATAKA a) DOSHA - Vata – vyana, samana, apana, udana Pitta – pachaka kapha – shleshaka b) DUSHYA Dhatu - rasa, asthi, majja Mala - badha pureesha c) SROTAS - rasa,asthi, majja d) AMA - jataragni & dhatvagni e) UDBAVASTHANA - amashaya g) SANCHARA STHANA - sarva shareera h) VYAKTA STHANA - sarva sandhi (sleshmasthana) 20
- 21. CONTD……. i) ROGA MARGA – madhyama j) ROGA ADISHTANA – sarva sandhi k) VYADHI PRAKARA – chira kaleena l) SAPEKSHA NIDANA – amavata, sandhigata vata 21
- 22. SANDHIGATAVATA 22 वातपूर्णदृततस्पर्णः र्ोथः सन्धिगतेऽनतलेे| प्रसारर्ाकु ञ्चलयोः प्रवृत्तिश्च सवेदला||३७|| च.चच.२८/३७
- 23. AMAVATA 23 अङ्गमदोऽनरुचचस्तृष्र्ा आेस्यं गौरवं ्वरः | अपाकः र्ूलताऽनङ्गालामामवातस्य ेक्षर्म् ||६|| मा.तल.२५/६
- 25. प्रवृद्ध आमवात लक्षण • उत्साह हानि• संधध रूजा • संधध शोथ • संधध स्तब्धत • वृष्चिक दंस्रवत्वेदिा • ज्वर • गौरव • दाह • शूल • अरुधि • प्रसेक • अष्निमांध्य कोचटाधित सावव दैहहक मािससकस्थानिक 25
- 26. VYADHI VINISHCHAYA Pravruddha Amavata 26 स कष्टः सवणरोगार्ां यदा प्रकु त्तपतो भवेत् | हस्तपादशर्रोगुल्फत्रिकजालूरुसन्धिषु ||७|| करोतत सरुजं र्ोथं यि दोषः प्रपद्यते | स देर्ो रु्यतेऽनत्यथं व्यात्तवद्ि इव वृन्श्चकः ||८|| जलयेत् सोऽनन्नलदौर्णल्यं प्रसेकारुचचगौरवम् | उत्साहहातलं वरस्यं दाहं च र्हुमूिताम् ||९|| कु क्षौ कठिलतां र्ूें तथा तलद्रात्तवपयणयम ् | तृट्छठदणभ्रममूछाणश्च हृद्रहं त्तवड्त्तवर्द्िताम् | जाड्याधिकू जमालाहं कष्टांश्चाधयालुपद्रवाल् ||१०|| मा.तल.२५/१०
- 27. दोषभेदेल ेक्षर् (मा.तल.आमवाताचिकार) • दाह, ज्वर • मन्दाष्नित्तपि • ववबन्ध,अन्ग मदव • बल ब्रम्श, उत्साह हानिवात • ष्स्तसमतं, जाड्य • गौरव, शोथ, गुरुताकफ 27
- 28. सामाधय चचककत्सा शसद्िांत ेंघलं स्वेदलं ततक्त दीपलातल कटुतल त्तवरेचलंस्लेहपालंर्न्स्तकमण 28
- 31. VIRECHANA पक्वार्यगते चात्तप देयं स्लेहत्तवरेचलम्। र्स्तय: र्ोिलीयाश्च प्रार्ाश्च ेवर्ोिरा:॥ (सु.चच.४/५) 31
- 32. AS PER BHAVAPRAKASHA आमवत गजेधद्रस्य र्रीरे वलचाररणर्। एक एव तलहधत्यार्ु एरण्ड गजके सरर॥ 32
- 33. …….बस्तयश्िाममारुते प्रव्रुद्िो मारुतस्य पक्विालं प्रिावतत। र्ीततकरोतत कायन्नल र्ें चास्यापकषणयतत॥ स्िोतस्तु र्ुद्िार्ुद्िेषु यठद र्न्स्त प्रदीयतत। स गंभीरोगत: काये सवंर्ो ल तलवणतणते॥ (भे.शस.५/४-५) 33
- 34. Day Date Procedures Observations 1 19/12/16 •Sar. Udvartana + parisheka with DMQ + Dhanyamla •Valuka sweda at night •Chitrakadi vati 3 tid. b/f •Amavatari rasa 4 tsp. tid. •Guduchi churna + yastimadhu churna (2:1) 1 tsp. with water a/f •Sandishota reduced •Sandi shula present •Gaurava present •Her steroid dose was reduced to half 2 20/12/16 Same as above 3 21/12/16 Same as above 4 22/12/16 In addition to above treatment, •Nimbamrutadi eranda taila 3 tsp. at 6pm (empty stomach) •Mudga yusha from pathyahara •Sandi shula reduced •Rest same 34 TREATMENT
- 35. Day Date Procedures Results 5 23/12/16 •Sar. parisheka with DMQ + Dhanyamla •Valuka sweda at night •Chitrakadi vati 3 tid. •Amavatari rasa 4 tsp. tid. •Panchakola phanta 50ml tid. (b/f) •Guduchi churna + yastimadhu churna (2:1) 1 tsp. with water In addition to above treatment, •Nimbamrutadi eranda taila 3 tsp. at 6pm (empty stomach) •Mudga yusha from pathyahara Sandi shota, shula, gaurava reduced. 6 24/12/16 In addition to the above treatment, Matrabasti with 80 ml pippalyadi taila 7 25/12/16 Vaitarana basti was added to the above treatment schedule Patient stopped taking steroids 8 26/12/16 Same as above 35
- 36. Day Date Procedures Results 9 27/12/16 •Sar. Abhyanga with sarshapa taila followed by parisheka with DMQ + Dhanyamla •Valuka sweda at night •Chitrakadi vati 3 tid. •Amavatari rasa 4 tsp. tid. •Guduchi churna + yastimadhu churna (2:1) 1 tsp. with water •Mudga yusha from pathyahara •Vaitarana basti 10 28/12/16 Same as above 36
- 37. VAITARANA BASTI Anuvasana Basti:- Brihat saindavadi taila- 80 ml Niruha basti:- Guda paka:120 ml Chincha rasa: 5 gms Saindhava : 12 gms B.S.Taila:- 100 ml Gomutra:- 200 ml पे र्ुन्क्त कर्ण कु दव अन्लेक शसधिूजधम गोमुि: तल्युक्तो अयम र्न्स्त र्ुे आलाह आमवत हर: चक्रदि 1st 2nd 3rd 4th 5th 6th A N N N N A A A A A 37
- 38. DISCHARGE MEDICINES (FOR 2 MONTHS) Guduchi churna(200gm) + shunti churna(30gm)+ bala churna(100gm) + arjuna twak churna(100gm) + yashtimadhu churna(10gm) Mixture of above churna -1 tsp. with warm water Amvatari kashaya 4tsf tid. b/f with water Cap. Cervilon 1 bd. b/f Kaishora guggulu 2 bd. a/f Abhaya massage oil for L/a 38
- 39. RESULTS Parameters BT AT Shota:- +++ Nil Shula:- +++ + (Slight pain on motion) Sthamba:- +++ Normal Tenderness ++ Absent Lab Investigation BT AT (on follow up) ESR 32 RA + ve 39
- 40. A/C MODERN DIFFERENTIAL DIAGNOSIS– Osteo Arthritis Rheumatoid Arthritis 40
- 41. OSTEO ARTHRITIS Restricted movement (capsular thickening, blocking by osteophyte) Palpable, sometimes audible, coarse crepitus (rough articular surfaces) Bony swelling (osteophyte) around joint margins Deformity, usually without instability Joint-line or periarticular tenderness Muscle weakness, wasting No or only mild synovitis (effusion, increased warmth) 41
- 42. RHEUMATOID ARTHRITIS Diagnostic Criterias of Rheumatoid Arthritis : • Morning stiffness (>1hr) • Arthritis of 3 or more joints • Symmetrical arthritis • Rheumatoid nodule • Rheumatoid factor • Duration of 6 weeks or more 42
- 47. CONCLUSION Amavata as a separate disease and its detailed description is available in medial period text Madhava Nidana. It can be concluded that Mandagni is largely responsible for the formation of Ama which chief pathogenic factor of the disease. Amavata is the disease having Vata and Kapha predominance. But, in fact it is Tridoshika with origin from both Pakvashaya and Amashaya 47
- 48. THANK YOU…… 48
Editor's Notes
- #20: If a person continuously indulge in the etiological factors as described in the context of the disease such as Viruddha Ahara, Nishchala Cheshta, or mental factors such as Kama, Krodha, Shoka, Chinta, Bhaya etc. it leads to the deviation of the Agni from the normal stage causing Mandagni. This Mandagni causes the formation of Ama. Along with this, there is vitiation of Vata due to indulgence in the Vata Prakopaka Nidana. Now this morbid Ama circulates all over the body by the vitiated Vata Dosha. This condition can be clinically termed as Samavata. Ama propelled by Vata reaches the Sleshma Sthana of the body. Here, Ama blends with all the three Doshas and consequently attains various colors and becomes heavy and viscous. The vitiated Ama facilitates Srotoabhishyandana and Srotorodha, vitiated Vata and Ama reaches the Trika and other joints causing stiffness in the whole body and thus producing disease Amavata.
- #25: Now let us see what are the samanya lakshana’s of Amavata. The disease amavata is characterised by angamar…
- #28: No sloka. Explain the sloka.. The disease amavata is corelated with ra. Now let us have a look on few facts about RA.
- #29: It is very important tat the disease am लंघनं स्वेदनं तिक्त दीपनानि कटुनि च ।विरेचनं स्नेहपानं बस्तयः च आममारुते ॥रुक्षस्वेदो विधातव्यो वालुका पोटलैः तथा ।उपनाहश्च कर्तव्याः तेऽपि स्नेह विवर्जिताः ॥(यो.र) उपनाहश्च कर्तव्याः तेऽपि स्नेह विवर्जिताः ॥(यो.र) लंघनं स्वेदनं तिक्त दिपनानि कटुनि च ।विरेचनं स्नेहपानं बस्तयश्चाममारुते ॥ सैन्धवाध्येनानुवास्य क्षारबस्ति प्रशस्यते । (च.द) avata should be handled very tactfully. The avasthanusari management of amavata is important…
- #32: Sushrutha in vatavyadhi chikitsa adhyaya have clearly stated that (tell sloka here) that is when the prakupita vata is present in pakvashaya then one should so for snehavirechana and then shodhana basti’s. while commenting on same sloka dalhana says that “ पक्वाशय: पुनरिह द्विविध: - पित्तवाताशयभेदेन, तयोर्मध्ये पित्ताशयगते वोयौ स्नेहविरेचनं तिल्वकसिद्धम् एरण्डतैलादिभिर्वा, वातशयगतस्य तु वायो: मलकफैरावृतस्य यथादोषं कषायकल्कस्नेहबस्तय:।
- #33: Very much importance have been given to eranda sneha in the treatment of amavata. Vangasena had said that eranda taila is like a gajakerasi in controling the amavata gajendra..hence many of the yoga’s have been mentioned with eranda taila in the management of amavata. The use of eranda taila in amavata suggests that in this disease snigdha and not ruksha virechana should be employed, since it does not produce generalised snehana effect but by its snigdha, ushna etc. characteristics, it augments the agni in addition to its vata anulomana action.
- #34: Last in treatment of amavata basti is mentioned if the dosha’s are gambeeragata and the disease is pravruddha (chronic), after shodhana karma, physisian should plan for basti karma. This is because if dosha’s are gambheeragata, then there is a chance that the pravruddha vaata will enter pakvashaya and may cause agnimandya and apakarshana of bala. Hence it is important that basti should be planned in gambheeragata doshas or in pravruddha avastha of disease after shodhana because kaayashodhana will not be able to remove entire dosha’s from body.. The same thing had been clearly mentioned by Bhela in siddhi stana with the verse which goes like this (sloka here)