CSBT 3

Dr. Shrilatha Kamath T.

Professor & HOD
PG & PhD Studies in Kayachikitsa & Manasaroga
SDMCA Udupi
 z PRELIMINARY DATA

 NAME : USHA
 AGE : 40 YEARS
 SEX: FEMALE
 RELIGION : HINDHU
 MARITAL STATUS : MARRIED
 ADDRESS : MANGALORE
 OCUPATION : HOUSEWIFE
 EDUCATIONAL STATUS : SSLC
 I.P.D NO : 139868
 O.P.D NO: 295135
 WARD NO : FGW 65
 D. O. A : 20/03/2019
 z
CHIEF COMPLAINTS

C/O REDDISH ROUND TO OVAL , RAISED SKIN LESIONS IN

THE BODY

A/O ITCHING AND SWELLING SINCE 4 YEARS

 HISTORY OF PRESENT ILLNESS
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 A moderately built 40 year old female, who was apparently normal
before 4 years, on a fine day in the month of May 2015 patient
presented with complaints of reddish round to oval lesions in the
abdomen, bilateral forearms ,arms and flanks associated with
severe itching and swelling. For these complaints patient consulted
an Ayurvedic physician in Mangalore and treatment was taken. The
symptoms reduced in a week after the medication. Patient
discontinued the medicines after the symptoms cured. There was
no similar episode of lesions throughout the year. In the year
September 2016, patient got similar lesions in the body, with more
severity initially started over abdomen then developed in the face,
forearms, arms, legs and thighs which are round to oval in shape,
varied in size and elevated with minimum scales on borders.
 z

She went to the same Ayurvedic physician, but this time, the lesions
didn’t subside on medication. So she went KMC Mangalore and was
got admitted there for a week, skin biopsy and other necessary tests
were done and started with steroid treatment, the lesions didn’t
reduce even then, so consulted in our hospital in the month of
October 2016. Patient got admitted in our hospital underwent a
course of virechana karma , there was slight reduction in the
symptoms, patient was under regular medications after that. The
severity of lesions reduced after a continuous treatment of 6 months,
later in the whole year of 2018 patient didn’t get any lesions.
 z In the month of March 2019 ,patient had a episode of fever and cold later
after 3 days patient got a single lesion in the right side of the neck, which
the patient ignored, after few days, patient observed similar reddish round
to oval elevated lesions in the abdomen, flanks and later within 1 day
progressed to bilateral forearms, arms, neck, chest, thighs, face, back, ears
and upper eye lids. The lesions were associated with severe itching, and
swelling. The itching used to aggravate at night times, and there was more
itching in the palms and foot regions . The lesions were more in the
extensor aspect of the forearms and legs. They were smooth in texture, and
used to get minimum scales from borders and not associated with oozing,
or bleeding on itching. The healed lesions used to leave a light blackish
discoloration in the skin. It was associated with itchy scalp with hairfall with
no visible lesions. The symptoms used to aggravate when consumption of
non veg food, curd, certain vegetables, and relieve on medication and
topical application. For these complaints patient got admitted in our hospital
 z ELABORATION OF SYMPTOMS
 Chief symptom : Reddish oval to circular plaque lesions a/o
itching
 Duration : 4 years ( on & off)
 Onset : Acute
 Site :Extensor surface of B/L forearm
Extensor surface of B/L thighs
Neck and chest region
Abdomen and bilateral flanks
Back region
Face ( sparring lips and nose)

 Progress : Recurent
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BEFORE TREATMENT
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z
HISTORY OF PAST ILLNESS

 No h/o DM/HTN
 No h/o any other systemic disorders
 No h/o any drug allergies
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TREATMENT HISTORY

 No h/o any surgical intervention( other than skin biopsy)

 Ayurvedic treatment : Details not known
 KMC Mangalore: Tab Wysolone 10 mg 2-0-0 for 5 days
1-0-0 for 5 days
Tab Pan 40 mg 1-0-0
Tab CPM 1-0-1
Calak lotion for L/A
z
GYNAECOLOGICAL HISTORY

 Menarche : age of 14 years

 Menstrual cycle : once in 30 days, regular
 Not a/o dysmenorrhea, menorrhagia, foul smell
 H/o scanty menstrual flow 4 years back, treated
z
OBSTETRIC HISTORY

 P1A0L1
 Single live male child
 Normal vaginal delivery with no complications
z
SOCIO ECONOMIC HISTORY

 Patient is a house wife belong to a middle class family

 Patient initially worked as a salesgirl in a bakery shop, left since
1 year
 z
PERSONAL HISTORY
 Appetite – moderate

 Bowel -- once /day, usually constipated

 Urine -- 4-5 times/day
 Sleep -- disturbed due to itching , otherwise normal
 Diet

Break fast –Tea,Dosa/Idli with veg/nonveg sidedish

Lunch -Rice, sambar,palya,eggs/fish fried
Evening – Tea, Morning snacks, or bakery items
Dinner – Rice, sambar, non veg fry, curry
 Habits : Nothing specific
 z
GENERAL EXAMINATION
 Consciousness : Conscious , Alert
 Appearance : Normal
 Built : Normosthenic
 Pallor : Present
 Icterus : Absent
 Cyanosis :Absent
 Clubbing : Absent
 Lymphadenopathy : Absent
 Gait : Normal
 Edema :Superficial edema in the areas where lesions are present
 Hair : Normal, straightened, rough in touch
 Nails : NAD
z

 Eye : Normal
 Tongue : Uncoated
 Height : 5’5”
 Weight : 52kg
 BMI : 18.5

Vital Signs
 Temperature : 98.6°F
 Pulse : 72/min, regular
 Blood Pressure : 110/80mmHg in Supine Position
 Respiratory Rate : 20 cycles/min
z
SYSTEMIC EXAMINATION

 RS - NAD
 CVS - NAD
 GIT - NAD
 MSS - NAD
 CNS - NAD
 SKIN EXAMINATION
z
 Color of the skin : Normal, Erythematous rashes
 Distribution : Symmetrical
 Extent : B/L forearm, B/L thighs, Neck and chest region, Abdomen and
bilateral flanks, Back , Face ( sparring lips and nose)
 Condition of the skin : Dry , Not wrinkled
 Elasticity : Normal
 Thickness : Normal
 Tenderness ; absent
 Temperature : Normal
 Texture : Smooth
 Sensation : Intact
 Photosensitivity : Absent
 Lesion-:
z
1. Primary: plaques, Few annular, erythematous, odematous plaques
with central spared over the forearms and arms, and neck, back
2. Secondary : scales ( collarette scale)
 Color-: Erythematous

 Number : Multiple

 Size : varied (1-6 cm in diameter)

 Shape : oval to round/Irregular

 Site & Distribution: Symmetrical

Behaviour of lesion: Initially there was a erythematous single

lesion, later similar lesions appeared in the body , as the days
progressed there was central clearance from lesions
 Discharge: absent
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 No Scaring, crust, lichenification, Ulceration,

 Associated symptoms : itching

 No burning sensation, pain, numbness

 Auspitz sign : Negative

 Candle grease sign : negative
 Koebners phenomenon : Absent
 Mucous membrane involvement : Absent
 z
अष्टस्थान परीक्षा

• lÉÉÌQû- 72/min
• qÉsÉ- mÉëÉM×üiÉ
• qÉÔ§É- प्राकृ त
• ÎeÉÀûÉ-प्राकृ त
• zÉoS-mÉëÉM×üiÉ
• xmÉzÉï- प्राकृ त
• SØMçü- प्राकृ त
• AÉM×üÌiÉ- qÉkrÉqÉ
 z
दशविध परीक्षा
• mÉëM×üÌiÉ : वातपित्त
• ÌuÉM×üÌiÉ: qÉkrÉqÉ
• xÉÉU- qÉkrÉqÉ
• xÉÇWûlÉlÉ-qÉkrÉqÉ
• mÉëqÉÉhÉ- qÉkrÉqÉ
• xÉÉiqrÉ- qÉkrÉqÉ
• xÉiuÉ-qÉkrÉqÉ
• AÉWûÉUzÉÌ£ü- mÉÔuÉïMüÉsÉÏlÉ- qÉkrÉqÉ
A±iÉlÉMüÉsÉÏlÉ- AuÉU
• urÉÉrÉÉqÉzÉÌ£ü- mÉÔuÉïMüÉsÉÏlÉ- mÉëuÉU
A±iÉlÉMüÉsÉÏlÉ- AuÉU
• uÉrÉ- qÉkrÉqÉ
 z निदान पञ्चक

 ÌlÉSÉlÉ : आहारज : विरुद्धाशन, आनूप मांस, मत्स्य ,दधि

विहारज : दिवास्वप्न

 mÉÔuÉï ÃmÉ : अरुचि , देह साद

 ÃmÉ : कण्डु , त्वक् राग, मण्डल ,उत्सन्न ,शोथ

 EmÉzÉrÉ : अविशेष

 AlÉÑmÉzÉrÉ : निदान सेवन

 z
xÉÇmÉëÉÎmiÉ bÉOûMü
 SÉåwÉ- कफ uÉÉiÉ प्रधान त्रिदोष
 SÕwrÉ- त्वक् ,रस रक्त
 xÉëÉåiÉxÉç- रसवह, रक्तवह
 UÉåaÉ qÉÉaÉï- बाह्य
 E°uÉ xjÉÉlÉ- आमmÉYuÉÉzÉrÉ
 xÉgcÉÉU xjÉÉlÉ- xÉuÉï zÉUÏU
 urÉ£ü xjÉÉlÉ- त्वक्
 अग्नि : जाठराग्नि
 आम : अविशेष
 INVESTIGATIONS
TEST z RESULT REF.RANGE
Hb 11.75 13-16gm%
TC 6200 4000-
10000cells/cum
N 78 40-70%
L 17 20-40%
E 04 2-6%
M 01 2-6%
B 00 0-1%
ESR 64 <15mm 1st hr
Platelet count 2.4 1.5-4.0lakhs/cum
RBC 3.9 3.8-5.8mill/cumm
PCV 33.2 40-52%
MCV 85.1 82-92fl
MCH 30.1 27-32Pg
RDW 12.4 11-16%
TEST RESULT REF.RANGE
RBS z 97 60-140mg/dl
Blood Urea 12 10-50mg/dl
S.Creatinine 0.8 0.6-1.4mg/dl
S.Uric acid 2.0 3-7mg/dl
T.Bil 0.9 0.2-1.2mg/dl

D.Bil 0.1 0-0.3mg/dl

In.Bil 0.8 0-0.9mg/dl

SGOT 21 Upto 40U/L

SGPT 10 Upto 40U/L
ALP 54 100-290U/L
T.Protein 5.7 6.6-8.7g/dl
Albumin 3.4 3.5-5.1g/dl
Globulin 2.3 1.8-3.4g/dl
 z
TEST RESULT REF.RANGE
A/G ratio 1.4 0.9-2.0 ratio
Urine Test
U.Albumin Nil
U.Sugar Nil
Epithelial cells 1-2 3-5/HPF
Pus cells 2-3 2-3/HPF
RBC’s 0-1 0-1/HPF
Casts Nil /HPF
Crystals Nil /HPF
Others Nil /HPF
 z
FBS 89 60-110mg/dl

T.Chol 124 130-220mg/dl

S.TG 104 40-160mg/dl

HDL Chol 30 30-70mg/dl

LDL Chol 76 65-150mg/dl

VLDL Chol 21 8-32mg/dl

TC/HDL Ratio 4.1 Ratio <3- LR,3-5-AR,>5- HR

z
z
DIFFERENTIAL DIAGNOSIS
 CLINICAL FEATURES: ERYTHEMATOUS PLAQUE SKIN LESIONS
WITH ITCHING AND MINIMUM SCALING
ERUPTIONS IN WHICH SCALES ARE OFTEN
 PSORIASIS
 SEBORRHOIC DERMATITIS
 PITYRIASIS ALBA
 TINEA CORPORIS
 ICTHYOSIS
 EXFOLIATIVE DERMATITIS
 SECONDARY SYPHILIS
 DRUG ERUPTIONS
 PITYRIASIS ROSEA
z
VYAVACHEDAKA NIDANA

 LAKSHANA: KANDU, RAGA, UTSANNA MANDALAKARA

 DOSHA BAHULYATA: KAPHA AND VATA
 VYVACHEDA NIDANA : MAHAKUSTA VS KSHUDRA KUSTA
 KSHUDRA KUSTA: KAPHA DOSHA PRADHANA:
DADRU,KITIBHA, SIDHMA,ALASA, VIPADIKA,
 ANYA: SHITAPITTA, UDARDA, KOTA, UTKOTA , VISARPA
z
DIAGNOSIS

 RECURRENT PITYRIASIS ROSEA

 UDARDA
 z
Pityriasis rosea

 Pityriasis rosea is a common, acute exanthem of uncertain etiology. Viral and

bacterial causes have been sought, but convincing answers have not yet been
found. Pityriasis rosea typically affects children and young adults. It is
characterized by an initial herald patch, followed by the development of a
diffuse papulosquamous rash. The herald patch often is misdiagnosed as
eczema. Pityriasis rosea is difficult to identify until the appearance of
characteristic smaller secondary lesions that follow Langer's lines (cleavage
lines). Several medications can cause a rash similar to pityriasis rosea, and
several diseases, including secondary syphilis, are included in the differential
diagnosis.
 z
CHIKITSA SUTRA

 अभ्यङ्गः कटुतैलेन सेकश्चोष्णाम्बुभिस्तथा ।

उदर्दे वमनं कार्यं पठोलारिष्टवारिणा ।।
त्रिफला पुरकृ ष्णाभिर्विरेकश्चात्र शस्यते।
त्रिफलां क्षौद्रसंयुक्ताम् खादेश्च नवकार्षिकम् ।।
भै र उदर्दशीतपित्तकोठ अधिकार
z
Treatment Given

 Tab Chitrakadi vati 4-4-4

 Snehapana with Anabhishyandi ghrita
 Virechana with trivrut leha 40 gm with anupana of ksheera
 No of vegas : 12
z
Before….
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AFTER TREATMENT
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Treatment ON DISCHARGE

 Cap Yastimadhu 2-2-2

 Yastimadhu taila L/A
 PATHYA & APATHYA
z
mÉjrÉ AmÉjrÉ

AHARAJA: AHARAJA:
• Jeerna shali • Ksheera vikara
• Jangala mamsa • Ikshu vikara
• Mudga yusha • Matsya
• Kulatha yusha • Audaka mamsa
• Karkotakam • Anupa mamsa
• Karavelakam • Naveena Madhya
• Shigru • Guru anna pana
• Vetragram • Virudha ashanam
• Dadimam • Snigdha, amla, madhura rasa
• Triphala pradhana dravya
• Madhu VIHARAJA:
• Katu, tikta, Kashaya rasa • Ati vyavaya
pradhana dravya • Divaswapna
KARMAJA: • Atapa sevana
Vamana , virechana, lepa, • Vamana vega dharana
raktamokshana
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THANK YOU