While returning from our intern rounds we met this lean and thin man who was out in the garden for some fresh air. He didn’t look like a patient but he was quite uncomfortable because of weather out there. We inquired if he was admitted to the hospital. He nodded and told us that he is uncomfortable because of the cold breeze and was admitted for multiple joint pain. When we inquired why he was sitting alone to which he responded with a smile and said that he has switched to many renowned physicians in which he lost a lot of time and money, so his family members are working hard to pay his hospital bills. His brother too complains of the same problem but he can’t start treatment because of all the responsibilities. We promised to visit him again in the IPD KC ward while suggesting him to go inside. 

What could be the possibilities? How many of his joints are involved?? Is he responding to the treatment? We left with a whole lot of questions in our mind.

    On our next visit, what questions shall we ask to complete our clinical history?

    To assess pain we have this easy mnemonic for all our answers – SOCRATES

    Patients response – I was asymptomatic before 6 years then gradually I developed pain in my shoulder joint which slowly shifted to my bilateral wrist joints. Then to metacarpo phallengeal joints and to interphallengeal joints of bilateral hands.

    He has the history of morning stiffness which takes nearly an hour to subside. Along with all the pain, his joints are swelled up. His reflexes are proper and there’s no complain about any sort of numbness or tingling sensation.

    No H/O HTN / DM/ Typhoid/ Malaria/ or any known drug allergy.

    Diet – Vegetarian, includes all rasa’s in diet, regular dietary habits

    No H/O addiction

    Joint family with total 11 members, with 3 children.
    His maternal grandmother also suffered from the same disease.

    Examinations

    Pulse – 84/min, regular, full volume
    Urine – Normal amount (4-5 times a day), pale yellow, not significant, tail bindu pariksha not done
    Stool – Bina atidrava sanghaat, thuthbhavet jale, Durgandha rahit
    Tongue – Clear
    Voice – Gambhir (Kaphaj)
    Touch – Afebrile, Rough
    Eyes – Normal
    Appearence – Symmetrical

    • Dashvidha pariksha
      • Prakruti – VK
      • Vikruti – Asthivaha sroto dushti
      • Sara – Madhyam
      • Pramaan – Madhyam
      • Satmya – Sarva rasa satmya
      • Satva – Madhya
      • Aahar shakti – Madhyam (medium). Abhyavarana shakti – Madhyam. Jaran shakti – Madhyam
      • Vyayaam shakti – Awar
      • Vaya – Madhyamavastha
    • General physical examinations
      • Aakruti (appearance) – Symmetrical
      • Temperature – Afebrile
      • P/R – 84/min
      • R/R – 110/min
      • Pallor – absent
      • Cyanosis – absent
      • Jaundice – absent
      • Skull – Normal
      • Oral cavity/throat –
      • Neck – Normal
      • Lymph nodes ( Cervical/ Axillary/ inguinal ) –
      • Weight – 50 kg
      • Height – 5’4″
      • Nose – Normal
      • Eyes – Normal
      • Ears – Normal
      • Hairs – Normal
      • Bones – Swelled at joints. Asthi Shool ( bone pain )
      • Joints –  Pain in multiple joints e.g. MCP, MTP, Wrist joint etc
      • Nails – Normal, no clubbing
      • Oedema – Absent
      • Skin –  dry
    • Srotas involvement
      • Praanavaha srotas – Atisrama swasa ( Increased respiratory rate )
      • Rasavaha srotas – Anga marda ( body ache)
      • Karshya ( Emaciation )
      • Medovaha srotas – Aalasya ( Lethargy )
      • Asthi vaha srotas – asthi shool ( bone pain )
      • Majjavaha srotas / Prana vaha srotas – Pain in interphallangeal joints
      • Swedovaha srotas – Parushta ( Roughness of skin )
    • Motor examination
      • Nutrition – Normal
      • Tone – Normal
      • Power – Normal
      • Co-ordination – Proper
      • Involuntary involvement – Not found
    • Sensory examination
      Sensation to touch, temperature, Vibration – Normal
    • Reflexes
      • Right – BJ- ++, TJ- ++, SJ-++, KJ-++, AJ-++, Planter flexion
      • Left –  BJ- ++, TJ- ++, SJ-++, KJ-++, AJ-++, Planter flexion
    Investigations
    • CRP – Negative
    • RA factor – Negative
    • LFT – SGOT – 17  IU/L
    • SGPT – 20.0 IU/L
    • RFT – Serum creatinine – 0.7 mg/dl
    • Blood urea – 31.0 mg/dl
    Diffrential diagnosis
    • Aama vata
    • Sandhivata
    Diagnosis

    Jirna aamavata

    Treatment

    1. Amrat bhallataka – 5gm B.D. with water
    2. Nagradhya churna – 2gm
    Ashwagandha churna – 3gm / 1X2 with leukwarm water
    3.Yogaraja guggulu – 1 B.D. with water
    4. Panchakarma treatment – Vaitarana basti and Saindhavadi anuvaasana

    Results

    Patient is responding really fast to the treatment and within a month he said that he has got approximately 70 % relief

    Follow up suggestions (if any )

    Patyaapathya palana ( do’es and don’ts )

    • Apathya aahara – Dadhi ( Curd ), Guda, Matashya, Kshira ( milk ), viruddha anna, Vishamaashana, guru, Abhishyaandi anna
    • Apathya vihaar – Vegaavrodha, Purva vata, jaagran
    • Pathya aahara – Yava, shaali chawal, vaastuk, shigru, punarnava, karvellaka, patol shaak, Lashuna sanskrita takra, aadraka sanskrita takra, usshnodaka paan, Jaangal maas
    • Pathya vihara – Heated Saindhava/ Sand tied in a cloth – local hot application