unmada case

1. 1

2. Case presentation
Dr. Amritha Edayilliam
2nd Year
Dept of PG studies in Kayachikitsa
2

3. Patient Data
Name : Mrs. Netravathi
Age : 27 years
Sex :Female
Religion :Hindu
Socio-Economic status : Middle class
Marital status : Married
Education : BA
Occupation : Accountant in DTP shop
for 7 years.
Own nandhini parlour
for 4 months
3

4. Date of Admission :7/06/2016
Ward :FGW
Source of History :Patient’s husband & Patient’sMother
Case taken on :15/06/2016
Consultant Doctor :Dr. Amarnath
OP No : D17518
IP No :2597/16
Address : No.27, Allapa garden
Banagiri nagara
Banshankari, Bangalore- 27
4

5. Pradhana Vedana
• C/o Impairment of memory (smruthi vibramsha)
• C/o Absence of menstrual cycle (anaarthava) 1 year 4 months.
• C/o Poor self care, Social interaction.( aachara vibhrama)
• C/o No emotional feelings.
• C/o Lack of initiation for day today activities.
5

6. Anubandha Vedana
•C/o Increased frequency of micturition. Since 9 months.
•C/o Disturbed sleep since 4 months.
6

7. Vedana Vrittanta
Patient was apparently normal 1 year 4 months back. In the
month of February 2015 patient noticed heavy bleeding per
vagina for >5 days during her menstrual cycle for which she
consulted nearby clinic and was prescribed oral medication, but
patient didn’t get relief in bleeding even after taking medicine
for 7 days. Hence they consulted another practitioner who
prescribed medicine for 1 month(?OCP) and advised to check
thyroid profile after the completion of treatment.
7

8. • Bleeding stopped after 3 days of medication but she developed
severe headache on 12/3/15 in the morning which was
persistent, continuous through out the day not disturbing her
daily activities. On the same day she herself stopped the
medications prescribed to control menstrual bleeding. On
13/3/15 consulted nearby clinic for headache and was prescribed
medications (details not known) but patient did not notice any
relief from headache.
8

9. On 15/3/15 along with headache she developed giddiness, had
an episode of vomiting in the afternoon (vomitus contained food
particles), tiredness & irrelevant speech. Her husband sent her to her
mothers place (RT nagar).
The severity of headache, irrelevant speech, tiredness got
increased and her mother took her to Kaveri hospital on 16/3/15.
She was administered IV fluids and medications. Condition of
patient worsened on 17/3/15, she lost her consciousness. On further
investigations it was diagnosed as Deep CVT (Cerebo venous
Thrombosis) with bilateral Thalamic medial temporal
capsuloganglionic and cingulate haemorrhagic infarcts and
obstructive hydrocephalous. 9

10. She was refered to NIMHANS on 17/3/15. By that time she
was not responding to any verbal commands, not vocalising, or
recognising family members. On 18/3/15 done Ventricular
Peritoneal (VP) shunting and was put on ventilator due to poor
sensorium. Patient was in ICU almost a month and weaned off
the ventilator after gaining her conscious and discharged on
20/4/15.
10

11. Condition at the time of discharge (20/04/2015)-
• She was not able to recognise any of the family members.
• Weakness over right upper limb and lower limb.
• Not talking to family members.
• She was not able to do her ADL.
• Not able to recognise urge of defaecation and micturition.
• Absence of menstrual cycle.
By physiotherapy and exercises, the right upper & lower limb
weakness improved within 10 days but other complaints persisted.
11

12. • Gradually by the training given by mother she was able to repeat the
names of family members and recognise and perform minimal activities
of daily living such as dressing by herself, eating, started habits of
going toilet by herself (but was on diapers) with in a span of 3 months.
She required regular instructions for doing activities and there was no
variation in emotional status with anyone and any situation.
• In Aug – Sep 2015, she was weaned of her diapers & her mother
noticed increased frequency of micturition (once in every half an hour),
4-6 times at night. For the past four months (Feb- Mar) mother noticed
that the patient used to be awake at night & did not sleep regularly.
• For further management they approached SKAMC&HRC on 7/6/16.
12

13. Poorva Vyadhi Vrittanta
• H/o Anemia 16 years back(details not known)
• H/o excessive bleeding per vagina 1 ½ year back
• H/o increased intermenstrual period since menarche.
• H/o puberty menorrhagia at the age of 11.
• No h/o trauma, seizures, fever, thyroid abnormalities.
13

14. Chikitsa Vrittanta
• Treatment given at NIMHANS
• VP shunting done on 18/3/15
• Inj Heparin 5000 units
• Tab Acitrom 2mg OD
• Inj Eptoin 100mg IV TID followed by oral.
• Inj mannitol 150 ml
• Syp. Glycerol 30ml
14

15. • Tab. Syndopa 110mg 1 BD
• Tab Pacitane 1mg 1 TID
• Tab Baclofen 10mg 1 BD
Advice on discharge 20/4/15
• Tab Acitrom 2mg OD
• Tab Eptoin 100mg 1 TID
• Syp. Glycerol 30mlTab.
• Tab Syndopa 110mg 1 BD
• Tab Pacitane 1mg 1 TID
• Tab Baclofen 10mg 1 BD
• Tab pantodac 40mg 1 OD
• Tab Nexito 5 mg 1 OD (at night)
• Tab ferrous sulphate 1 BD
• Tab optineuron 1 OD
15

16. Presently on medication
• Tab Optineuron 1OD
• Tab Glowfol-Z 1BD
• Tab Donep-10 1BD
• Tab Epin 1BD
• Tab Zolfresh10 1OD( at night)
• Tab Becoplex 1 OD.
16

17. Koutumbika Vrittanta
27
yr
7 yr
46
yr
34 yr
26 yr
55yr
• No h/o similar complaints in the family. 17

18. Vayaktika Vrittanta
• Diet - Mixed, Nonveg – once in a week
Chicken/mutton.
• Appetite - moderate
• Sleep - Initiation of sleep- good
Awakening at night 3-4 times
• Micturition - increased frequency >20 times/ day
3 times at night.
• Bowel - once/ day, regular
• Habits - none
18

19. • Menstrual history-
• Menarche- age of 11.
• Menstrual cycle - 4-5 days bleeding till feb 2015
35- 60 day cycle
• Secondary amenorrhea since 1 year and 4 months.
19

20. • H/o 3 episodes of increased menstrual bleeding
• 1st episode on her menarche at the age of 11- bleeding for 1
month- done blood transfusion of 5 pints of blood(as per
mother).
• 2nd episode at age of 21, after marriage- 12 days of heavy
bleeding- took conservative treatment.
• 3rd episode on Dec 2014 - 20 days of bleeding- took
conservative treatment.
20

21. Obstetric history
• Married at the age of 18.
• Normal delivery at age of 20
• P1G0A0L1D0
21

22. General Examination
• Built -Moderate
• Nourishment - moderate
• Pallor - Absent
• Icterus - Absent
• Cyanosis - Absent
• Clubbing - Absent
• Lymphadenopathy - Absent
• Edema - Absent
• Tongue - uncoated
22

23. • Pulse - 70 BPM
• B.P - 110/70 mm of Hg
• Temp - 98.6° F
• Respiratory rate - 16 /min
• Height -150cm
• Weight - 53kg
• BMI - 23.5
23

24. SYSTEMIC EXAMINATION
24

25. RESPIRATORY SYSTEM
Inspection
•Shape of chest - bilaterally symmetrical
•Chest movements- symmetrical
•Respiratory rate – 16/min
Palpation
Trachea - centrally placed.
TVF- equal on both sides
Auscultation
Normal vesicular breath sounds heard over all
zones. 25

26. •CARDIOVASCULAR SYSTEM
Inspection
•No distended blood vessels.
Palpation
•Subcutaneous shunt is palpable over right lateral
aspect of neck.
•Apex beat Felt.
Auscultation
S1,S2 heard, no murmurs. 26

27. • PER ABDOMEN
Inspection:
• Shape of abdomen- scaphoid.
• Umbilicus- inverted , centrally placed
• No visible peristalsis, surgical scar present at right lateral
aspect of umbilical quadrant (scar of VP shunting).
• No visible striae.
Auscultation:
• Bowel sounds heard
27

28. Palpation:
• Soft
• No tenderness
• No organomegaly
Percussion:
• Tympanic sound heard all quadrants of the abdomen
except liver dullness.
28

29. Mental status examination
29

30. General appearance- on 16/6/16
Looks comfortable
Grooming- done by mother
Dressing – herself- appropriate
Self care- poor (such as daily ablutions)
Facial expression- None
Appearance and behaviour
30

31. Attitude towards examiner
Cooperative
Obeys commands
Level of consciousness- Alert and awake, responds fully
• Gait and posture
Normal
• Motor activity
• No involuntary movements.
31

32. • Rate And quantity of speech
• Speech present, spontaneous, rapid.
• Productivity- less
• Volume
• Decreased (soft)
• Flow and rhythum of speech
• Sudden.
Speech And Language
32

33. • Language
• Quality of spontaneous speech- Fluent, rapid, effortless,
articulation good.
• Word comprehension- obeys 3 stage commands( moderate)
• Repetition- impaired
• Naming – impaired
• Reading comprehension- impaired
• Writing- moderate.
33

34. • Mood
• No variation in mood to any stimuli
• Thoughts and perceptions
• Thought content- no phobias, anxiety
• No illusions, hallucinations
Insight and judgement
• Absent
34

35. • Orientation to
• Time- poor
• Place- moderate
• Person- moderate
• Attention
• Digit span- poor performance
• Serial 7s- poor performance
• Spelling backward- poor performance
Cognitive Functions
35

36. •Memory
•Remote memory- impaired
•Recent memory- impaired
•New learning ability- poor
•Registration- impaired
36

37. •Higher cognitive function
•Information and vocabulary- poor
•Calculating ability- poor (dyscalculia)
•Abstract thinking- absent
•Constructional ability-poor (dysgraphia)
Clock drawing is poor
Simple circles, rectangles can draw
MMSE-14/30- impaired. 37

38. CNS EXAMINATION
•Handedness-Right
Cranial Nerve Examination
•Olfactory- Smell sensation-impaired.
•Optic-a) Visual acuity
-b)Colour vision
-c)Visual field NAD
-d)Light reflex
-e)Accomodation
38

39. • Visual field test on 20/6/16
• BE- 6/6
• RE- 6/9 ?
• LE- 6/12p ?
• Pupillary dilatation
Right Left
Media clear clear
Fundus Normal normal
Optic disc normal normal
Blood vessels Normal Normal
Macular reflex-+
39

40. •Occulomotor, Troclear & Abducent Nerve
•Eyeball movement-Possible
•Convergence - possible
•Pupillary reflex- present
•Pupil -position
• -shape
• -size NAD
• -symmetry
•Ptosis-Absent
•No diplopia
40

41. Trigeminal
•Sensory-Touch, pain and pressure sensation- Intact
•Motor-Clenching of teeth –possible
Lateral movement of jaw- possible
Mastication possible
•Reflex-corneal-present
Jaw jerk-present
41

42. Facial
A)Forehead frowning - possible
b)Eyebrow raising - possible, equal in both sides
c)Eye closure - possible equal in both sides
d)Teeth showing -No deviation of angle of mouth
e)Blowing of cheek - possible
• f)Nasolabial fold - No deviation
• watering of eyes
• No dribbling saliva
• Facial reflex- Glabellar reflex +
• Bells phenomena –ve 42

43. Vestibulo-cochlear Rt Lt
-Rinne’s test- bone conduction present present
Air conduction present present
-Weber’s test- No lateralisation
AC>BC
• Glossopharyngeal and Vagus
Position of uvula- centrally placed
Taste sensation -Intact
Gag reflex - normal
Speech- no dysarthria.
Swallowing- good 43

44. Spinal accessory
• Shrugging shoulder- No weakness
• Neck movement - No weakness
Hypoglossal
• Protrusion of tongue – possible
• Tongue movements - possible
• No wasting
44

45. Motor System
1)Involuntary movements – Absent
2)Muscle bulk – Rt Lt
Midarm - 29cm 28.5 cm
Forearm - 19cm 18cm
Mid thigh - 46cm 45cm
Calf muscles - 29cm 28.5cm
45

46. 3)Muscle tone
Right hand - Good
Left hand - good
Right leg - good
Left leg - good
4)Muscle strength Rt Lt
• a)Elbow - flexion 5/5 5/5
extension 5/5 5/5
• b)Wrist - flexion 5/5 5/5
-extension 5/5 5/5
• c) Finger- abduction 5/5 5/5
• d) Test of grip -Good
46

47. Rt Lt
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 5/5 5/5
-plantarflexion 5/5 5/5
47

48. 5)Coordination
•UL-Finger nose test Co-ordination present
•LL-Knee heel test
•Tandem walking- possible
•Rapid alternative movements-
dysdydacokinesia-+
6)Gait- Normal
Romberg sign -ve
7)Reflexes
Superficial
a)Corneal -present
48

49. 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 - plantar flexion
49

50. 8)Sensory system
1)Superficial:
a)Touch -Intact
b)Temperature -Intact
c)Pain - present
2)Deep:
a)Crude touch -present
b)Vibration - present
LOCOMOTOR EXAMINATION
•ROM – possible
•No other abnormalities
50

51. •Conclusion based on clinical examination
• Based on Mental status examination point towards-
• Cognitive impairment,
• Wernickes aphasia,
• Dementia,
• Amnesia.
51

52. Atura bhumi desha pareeksha
•Jatataha- Sadharana
•Samvrudhaha- sadharana
•Vyadhitaha- sadharana
52

53. Atura Deha pareeksha
53

54. Ashta sthana pareeksha
• Nadi- 70bpm
• Mootra- 15-20 times day, thrice at night
• Mala- once /day/regular
• Jihwa- alipta
• Shabda- Avishesha
• Sparsha- anushnasheetha
• Akruthi- madhyama
54

55. Dashavidha pariksha
• Prakruti - Pitta Vata
• Vikruti :-
Hetu - Shareerika, manasika,
abheshaja/Visha
Shareerika Dosha - Kapha
Pitha
Vata
Manasika dosha- Tamas -+++
Rajas- ++
55

56. • Prakruti - Vata pitha
• Desha -Saadharana
• Kaala - shishira /Varsha ritu
• Bala - Madhyama
• Sara -Madhyama
• Samhanana -Madhyama
• Pramana - Ht-150cm
-Wt- 53kg
56

57. • Satmya - vyamisra ( katu, amla, lavana rasa satmya)
• Satva -Avara
• Ahara sakthi-
Abyavaharana shakthi- madhyama
Jarana shakthi –madhyama
• Vyayama shakthi - Avara
• Vaya - youvana
57

58. Investigations
Report of MRI on 16/3/15
•Deep CVT with bilateral Thalamic medial temporal
capsuloganglionic and cingulate haemorrhagic infarcts
and obstructive hydrocephalous.
58

59. Investigations on 20/6/15
Urine routine
• Sp.gravity-1.010
• Colour-pale yellow
• Transparency-clear
• Protein-nil
• Sugar-nil
• Ketone bodies-nil
• Urobilinogen-nil
• WBC pus cells- 4-6/hpf
• Epithelial cells-2-4/hpf
• Glucose-nil
• Pus cells-2-3/hpf
• Epithelial cells-2-3 hpf
• Casts RBC-nil
• Hb%-14.2
• USG Abdomen and Pelvis 24/6/16
• Impression- Thin endometrium 59

60. ROGA PAREEKSHA
60

61. NIDANA
• Shareerika- amla lavana kshara, ushana teekshna ahara
snigdani, pishithani
sheetha jala, sheetha padartha
• Abheshaja- OCP ?and other medications(details not known)
61

62. SAMPRAPTHI
62

63. AbheshajaRajodushti
Ahara/vihara
/manasika
NIDANA
Apana vata
dushti
Udavartha
Doshaja
shiromarma
abhighata
Prana vata
dushti
Udana vata
dushti 63
Avarana
Vyana vata
dushti
Samana
vata dushti

64. Chethanadhishta
nadooshanam
Vikrutha in
Budhi chitha
dhruk.
Vakpravruthi
prayatna
smruthikriya
Dheevibhrama, moodachetha, na
sukham na dukham,na aachara
dharma, smruthi vibhrama,
samnjavibrama, manovibhrama.
Anarthava
Avarana
?
Abheshaja?
Apana
dushti
?
64

65. Samprapthi ghataka
• Dosha -tridosha
• Dooshya - rajas, tamas, rasa, rakta, arthava
• Agni -Jataragni, dhatvagni
• Ama - Amashayodbhava
• Srothas - rasavaha,
• raktavaha,
• arthavavaha
• manovaha
• Srotho dushti prakara – sanga, vimargagamana
• Udbava sthana -Shiras
• Vyaktha sthana - Manovaha srothas, arthavavaha srothas
• Adhishtana - manas
• Marga - Madhyama
• Sadhyasadhyatha - kruchrasadhya
65

66. VATA, PITTA,
KAPHA
Lakshanas.
Vikrutha in
Prana Budhi hrudaya chitha dhruk
Udana Vakpravruthi prayatna smruthikriya
Apana Mootra, arthava nishkramana
Sadaka pitta Budhi medha abhimanaadhi abhiprethartha
sadhanam.
Tarpaka Indriyanam athmaveeryena anugraham karothi.
66

67. DOSHA VRUDHI KSHAYA
Vata • Alpam bhashite hitham
• Samnja moha
• Moodasamnja
Pitta • Sheethakamitwa
• Alpanidrada
• Indriyadourbalya
Avarana lakshanas at present
• Apanavrutha prana- moha
• Apanavrutha vyana- sangrahana of rajas, mootra athipravruthi
• Pranaavrutha vyana- smruthi kshayam, Indriya shoonyathwa
• Vyanavrutha apana- udavartha
67

68. • Manavaha lakshana- Manovibhrama +
Budhivibhrama +
Dhruthi vibhramsha +
Samnja vibhrama +
Smruthi vibhrama +
Bhakthi vibhrama +
Aachara vibhrama +
68

69. DUSHYA LAKSHANA
Arthava Yadhochithakaala adarshanam.
Rajas Adhruthi
Tamas Budhi nirodham,
Ajnanam
Ojas Durmana
69

70. VYAVACHEDAKA NIDANA
70

71. Disease Inclusion Exclusion
Unmada(vibhramavast
ha)
Dheevibhrama,
moodachetha, na sukham
na dukham,na aachara
dharma, smruthi
vibhrama,
samnjavibrama,
manovibhrama
Bhaktiricha vibhrama
Doshaja
shiromarmabhighata.
Past history of
shirashoola, pakshaghata,
manyasthambha, moha,
chakshuvibhrama,
swarahaani.
At present not
presenting with
these
complaints.
71

72. Disease Inclusion Exclusion
Apasmara Apagatha smruthi
smruthi budhi satwa
samplavat.
vegakaala, avasthika
thamapravesha,
bheebhatsacheshta
Udavartha Apana vata dushti
Anarthava.
Shoola pradhanyatha.
72

73. Vyadhi vinishchaya
Unmada – vibhramavastha?
73

74. Differential diagnosis
• Vascular dementia
• Delirium
• Amnestic disorder
• Parkinsonism
• Pick’s disease
• Cerebellum cognitive disorder
• Alzheimer's disease
74

75. Disease Inclusion Exclusion
Organic mental
disorder-
Vascular
Dementia
Cause- organic cause
Multiple impairement of Cognitive
functions without the impairement in
consciousness.
Impairment in intellectual functions
Impairment in memory
Deteoration of personality with lack of
personal care,
Delirium Cognitive impairment
Sleep wake cycle impairment.
Acute confusional stage,
Impaired consciousness,
Orientation grossly
disturbed,
Onset rapid, anxiety
irritability.
Worsening of symptom at
evg and night
Visual illusions
Hallucination. 75

76. Disease inclusion exclusion
Amnestic disorder Impairement in memory
(recent and remote)
Cognitive impairement.
Most of the cases No
impairment in
attention,intellectual
functioning.
Unprovoked agitation.
Cerebellum cognitive
disorder
Cognitive impairment
Impairement in memory
Inattention
Dulling of emotional
response
Motor symptoms
Gait disturbance,
Intentional tremors
Jerky, explosive speech.
76

77. Disease Inclusion Exclusion
Alzhiemers disease Dementia Degenerative condition
Deposits of intraneuronal
amyloid plaques
Occur after 6th decade.
Parkinsonism
Pick’s disease
Dementia
Sleep disturbance
Dementia
Degenerative condition
Resting tremor, stiffness
Gait disturbance,
Pill rolling movement
Atropy in frontotemporal
region
Degenerative disease
Neuronal loss over this
region, gliosis. 77

78. DIAGNOSIS
Organic mental disorder- Vascular Dementia
78

79. TREATMENT GIVEN
date treatment observation
07/6/2016 • ShiroDhara
withTakra,musta,amal
aki -1st day
• Padaabhyanga with
himasagara thaila- 1st
• Brahmi vati 1-0-1 A/f
• Brahmi ghrita 1tsp-0-
1tsp b/f
• Saraswatharishta 1tsp-
0-1tsp a/f
Pt was not trying to
remember her daily
activities.
Sleep- disturbed at
night( awakening at
3.00am)
Bowel-
once/day/regular
Bladder-increased
frequency
>15times/day
3times at night.
79

80. date treatment observation
08/6/2016
9/6/2016
1) Same treatment
2) Trataka chikitsa-
• ShiroDhara with
Takra,musta,amalaki.
• Padaabhyanga with
himasagara thaila
• Brahmi vati 1-0-1 A/f
• Brahmi ghrita 1tsp-0-1tsp
b/f
• Saraswatharishta 1tsp-0-
1tsp a/f
Pt was not trying to
remember her daily
activities.
Sleep- disturbed at night(
awakening at 3.00am)
Bowel-once/day/regular
Bladder-increased
frequency >15times/day
3times at night.
80

81. Date Treatment Observation
10/6/2016
11/6/16
• Shiropichu with
himasagara thaila
• Shirodhara with
takradhara
• Padabhyanga
• Brahmi vati 1-0-1 A/f
• Brahmi ghrita 1tsp-0-
1tsp b/f
• Saraswatharishta 1tsp-0-
1tsp a/f
Added Cap sagarlic2-0-2
a/f
c.s.t
Pt was not trying to
remember her daily
activities.
Sleep- disturbed at night(
awakening at 3.00am)
Bowel-once/day/regular
Bladder-increased
frequency >15times/day
3times at night.
81

82. date treatment observation
12/6/16
13/6/16
• Added Sarvanga Gomutra
seka- for 3 days
• Shiropichu with himasagara
thaila-3/3
• Shirodhara with takradhara
• Padabhyanga-
• Brahmi vati 1-0-1 A/f
• Brahmi ghrita 1tsp-0-1tsp b/f
• Saraswatharishta 1tsp-0-1tsp
a/f
• Planed for vamana karma.
• Started chitrakadi vati 1-0-1
• Shiropichu with himasagara
thaila
• Shirodhara with takradhara
• Padabhyanga
Pt was not trying to
remember her daily
activities.
Sleep- disturbed at night(
awakening at 3.00am)
Bowel-once/day/regular
Bladder-increased
frequency >15times/day
3times at night.
82

83. date treatment observation
14/6/16
15/6/16
• chitrakadi vati 1-0-1
• Shiropichu with himasagara
thaila
• Shirodhara with takradhara
• Padabhyanga
• Snehapana with
panchagavya gritha- 30ml
Stopped all other medications
including allopathic
jeerna lakshana couldn’t
observe
Given ganji at 2 pm.
Sleep at night-disturbed
Bladder- >15 times/day,
twice at night.
Bowel- not paseed
83

84. Date Treatment Observation
16/6/16
17/6/16
Snehapana with 70ml
Snehapana with 110ml
Jeerna lakshana couldn’t observe
Ganji given at 4.00pm
No episodes of vomiting
Sleep- disturbed
Bladder- increased frequency.
Bowel- once/day/regular
Jeerna lakshana couldn’t observe
Koshta snigdada attained.
Bowel-once /day/loose consistency
Ganji given at 6.30pm
And 8.oo clk.
One episode of vomiting
Sleep- disturbed
84

85. Date Treatment Observation
18/6/16
19/6/16
Vishramakaala
Sarvanga abhyanga with
sarshapa thaila
Followed by bhaspa
sweda.
Kapha utkleshakara aharas
Conducted vamana
No episodes of vomiting
Sleep- disturbed
bladder- >15 times morning
>6times at night
Bowel-once/day/regular
Vegas- 6
Samsarjana karma for 3
days- 1/3rd
85

86. 20/6/16 Samsarjana karma
2nd day
Good sleep- 9 hours sleep
micturition-5 times/day
Once at night
Good response to all questions.
21/6/16 Samsarjana karma
3rd day
Reading comprehension-improved
Good sleep
Bladder-5 times/dy, once at night.
22/6/16 Planed for
virechana
Started chitrakadi
vati 2-0-2
1/3rd
Respondes to questions like-the
school she studied, her daughter is
studying.
Good sleep- 9 hours sleep
bladder-5 times/day
Smruthi vibrama still persisting
86

87. 23/6/16 Chitrakadi vati 2-0-2
Cap Sagarlic 2-0-2
Gomutra seka 1/3
Good sleep- 9 hours sleep
bladder-5 times/day
Smruthi vibrama still persisting.
24/6/16 Chitrakadi vati 2-0-2
Gomutra seka 2/3
Cap Sagarlic 2-0-2
25/6/16 Chitrakadi 2-0-2
Gomutra seka 3/3
Cap Sagarlic 2-0-2
26/6/16 Chitrakadi 2-0-2
Cap Sagarlic 2-0-2
87

88. 27/6/16 Snehapaana with panchagavyam
30ml
Jeerna lakshana couldn’t elicit.
Not asked for food till 7.00pm.
Given ganji at 7.00am
Bowel-once/day passed
Bladder- 5 times/day
Sleep-good
28/6/16 Snehapana with panchagavya
grutha-70 ml
Bowel- 6 times after snehapana
Loose stools with more snigdada
Ganji given at 4.00pm
Bladder- 5 times/day
No vomiting
Good sleep
29/6/16 Snehapana with panchagavya
grutha-90ml + shunti churna
Bowel- Not passed
Ganji given at 7.00pm
No vomiting
Bladder- 5 times/day
Good sleep
30/6/16 Snehapana with panchagavya
grutha-120ml + shunti churna
88

89. Observation on patient-20/6/16 - 30/6/16
• Speech- Not spontaneous.
• Memory- trying to recollect the things.(recent and remote)
• Immediate retention and immediate recall improved.
• Impairement of memory persisting
• Reading comprehension- improved
• Attention- poor
• Constructability- improved
• Frequency of micturition- normal 5 times/day,once at night
• Sleep awake cycle- got normal
• Orientation to time-improved
89

90. Thank you90