2011, ജൂലൈ 31, ഞായറാഴ്‌ച

Change of Srothas in any disease - a case illustration


t{kmX-Êp-I-fpsS ZpjvSn-{]-Imcw A\p-k-cn¨v F{]-Im-c-amWv ]e B´-cm-h-b-h-§fpw XnI¨pw hyXy-kvX-amb {]hr-¯n-I-tfm-Sp-Iq-Snb hyql-§fpw Hscmä tcmtKmÂ]-¯n-bpsS `mK-am-bn-¯o-cp-¶-sX¶v A]-{K-Yn-¨m B[p-\nI {Inbm-im-co-c-§Ä hgn a\-Ên-em-¡m-\m-Im¯ Hcp-]mSv tNmZy-§Ä¡p-¯cw \ap¡v ImWm-\m-Ip¶-Xm-Wv. sshZy-cXv\w BbpÀth-Z-tIm-tfPv Bkv]-{Xn-bn {]th-in-¸n-¨n-cp¶ Hcp tcmKn-bpsS tIkv joäv hgn \ap-¡Xv DZm-l-cn¡mw. F{]-Im-c-amWv Hscmä k{¼m-]vXn-sIm­v H¶n-e-[nIw t{kmX-Êp-Ifn-eq-sS-bpÅ tcmK-{]-hr¯n Imem-´-c-¯n hyXy-kvX-tcm-K-§-fmbn \ap¡v A\p-`-h-s¸-Sp-¶-sX¶v Cu tcmKn-bpsS Ncn{Xw  a\-Ên-em-¡n¯cp-¶p.

a{Zm-knse {]kn-²-amb Hcp Bip-]-{Xn-bnÂ\n-¶pÅ Ah-cpsS UnkvNmÀÖv k½dn ChnsS hkvXp-Xm-hn-h-c-W-¯n-\mbn Xmsg-t¨À¡p-¶p.

sNdnb A\o-anbbneqsS F¶ e£-W¯neqsS {]I-S-amb ]mWvUp-tcm-K-¯nsâ e£-W-am-bn kÔn-th-Z-\-Ifpw t]io-th-Z-\-Ifpw  IW-¡m-¡m-hp-¶-Xm-Wv. ]mWvUp-Xz-sa-¶Xv ck-hm-ln-t{km-X-Ên-sâbpw cà-hm-ln-t{km-X-Ên-sâbpw ZpjvSn-bmbn ]d-bp-¶p-­v. ck-hm-ln-t{km-X-Êp-ambn _Ô-s¸« tcmK-§Ä, GtXXv hym[n-{]-Xy-\o-I-\n-Zm-\-§-fp-am-bmWv tcmKn _Ô-s¸-Sp-¶sX¶-Xn-\-\p-k-cn¨pÅhbmWv {]Xy-£-s¸-Sp-I.
A\p-am-\w þ
·         ]mWvUp-sIm-­p-Xs¶ kqNn-¸n-¡-s¸-«, ck-hm-ln-t{km-tXm-Zp-jvSn-bn ImWp¶ Aán-am-µyw Ch-cn D­m-bn-cp-¶-Xnsâ sXfnhmWv Ct¸mÄ ImWn-¡p¶ DZtIm-Z-cw. Aán-amµyw ZoÀL-Im-e-am-bn-«p-ÅXmsW-¶-Xn\v Zl-\-t¡-Sn\p ]e-h«w NnIn-Õn-¨-Xmbn tcJ-s¸-Sp-¯n-bn-«n-Ãm¯-Xp-sIm­v sXfnhv Csöp-Xs¶ ]d-bmw. AXn-\m Blm-c-]-N-\-hp-ambn _Ô-s¸«Xmbn-cp-¶nà Cu Aán-am-µyw Ft¶m e£-W-§-fn-sÃ-¦nepw {]hÀ¯-\-\n-c-X-am-bn-cp¶ Aán-amµyw Ft¶m ]d-bmw. Cubn-sS-bpÅ DZ-c-iq-e, AXn-km-cw, DZvKm-cw, B[vam-\w, XpS-§n-bh Aán-am-µy-¯nsâ sXfn-hm-Wv. F¦nepw A¯-c-¯n-semcp aµm-ánXzamWv DZ-c-¯n-te-s¡-¯n-¨-sX¶Xn\v sXfn-hm-bn-«n-Ã. Hcp ]t£ aäp tcmKm-h-Ø-I-fp-tStbm D]-tbm-Kn¨ Huj-[-§tfm sIm­v F¯n-t¨À¶ Aán-am-µym-h-Ø-bp-am-Imw.
·         ck-hm-ln-t{km-tXm-aq-e§fmb lrZ-bhpw ck-hm-ln-[-a-\n-Ifpw Zpjn-¨-Xnsâ sXfnhmbn ChÀ¡v  lrt{ZmKhpw cà-k-½À±hpw h¶p-I-gn-ªp. e£-W-ambn {]mW-hm-ln-IÄ ZpjvSnbmWv D­m-Ip-I-sb-¶-Xp-sIm-­p-Xs¶ heXv izmk-tIm-i-¯n-ep-­mb t_k I¬tkm-fn-tU-j³ \ymbo-I-cn-s¸-«p.
·         ]mWvUpsIm­p kqNn-¸n-¡-s¸« cà-hm-ln-t{km-tXm-ZpjvSn NnInÕ ]qÀ®-am-Im-¯Xn-\mÂ, hym[n-{]-Xy-\o-I-amb \nZm-\-§-fp­m-bn-cp-¶-Xp-sIm-­m-Imw, sshIm-sX-¯s¶ cà-hm-ln-t{km-tXm-aq-e-§-fmb bIr-¯ns\ Jco-`q-X-am-¡nb kntdm-kn-tkm, sImgp-¸-Sn-ªp-Iq-Sp-¶-tXm, bIr-Zp-Z-ctam, AXnÂ\n¶pw apt¶-dnb Ah-Ø-bn-epÅ Ptem-Z-ctam Bbn ChnsS {]Xy-£-s¸-«n-cn-¡p-¶-Xv.
·         {]ta-l-]qÀÆ-cq-]-amb a[p-c-aq-{X-X-sIm-­p-Xs¶ sXfn-bn-¡-s¸-«psh¦nepw tatZm-hm-ln-t{km-tXm-Zp-jvSn-bpsS aäp-e-£-W-§-fmb Øqe-tim-^-X  sk³{SÂ H_o-kn-än, \oÀs¡-«nb apJw F¶n-h-sIm­v a\-Ên-em-¡m-hp-¶-Xm-Wv. ck,-c-à,-amw-k,-ta-tZm-hm-ln-t{km-tXm-Zp-jvSn-bp­m-Ip-¶-Xnsâ \mgn-I-¡-sÃ-¶p-Xs¶ ]d-bm-hp¶ e£-W-hn-ti-j-ambn sslt¸m-ssX-tdm-bvUn-ks¯ ImtW-­-Xm-Wv. Kf-KWvUw
·         AØnhm-ln-t{km-tXm-Zp-jvSn- kqNn-¸n-¡p-¶-Xn\vv HmÌn-tbm-ss^ävkns\ A²yØn¡pÅ sXfn-hmbpw HmÌntbm BÀss{X-än-kns\bpw UnkvIv UnP-\-td-jt\bpw kÔn-ssi-Yney¯nsâ sXfn-hmbpw IW-¡m-¡m-hp-¶-Xm-Wv.
·         aÖm-hm-ln-I-fpsS ZpjvSn FÃnÂ\n-s¶¶ t]mes¯ XpSÀ¨-bmb thZ-\bpw HmÌntbmt]mtdm-knkv h¶v AØn-I-fn kpjncw hoWn-cn-¡p-¶-XnÂ\n¶pw a\-Ên-em-¡m-hp-¶-Xm-Wv. ZoÀL-Imew \o­p-\n¡p¶ Ba-hm-Xtam hmX-c-àtam sIm­v hmXn-Im-h-Ø-bn-em-bn-¯oÀ¶ kÔn-IÄ, kÔn-K-X-hmX¯n\v kam-\-amb Ah-Ø-bn-em-Ip-¶p. AXv kÔn-I-fpsS apgp-h-\m-bpÅ \miap­mbn ap«p-amän-h-t¡­ kml-N-cy-¯n-te-s¡-¯n-b-XnÂ\n¶pw a\-Ên-em-¡m-hp-¶-Xm-Wv.
·         DZ-I,-A-¶,ae-hm-ln-t{km-X-Êp-I-fp-sS ZpjvSn-e-£-W-§fpw C¡q-«-¯nÂ\n¶p Xs¶ \ap¡v thÀXn-cn¨v ImWm-hp-¶-Xm-Wv.
Cu [mXp-hn-Ir-Xn-Ifpw e£-W-§-fp-saÃmw tNÀ¶pÅ C¶s¯ Ah-Ø-bn-te-¡pÅ {Iam-\p-K-X-amb ]ptcm-K-a\w k¦Â¸n-s¨-Sp-¯m B tcmKn-bpsS tcmK-§-fpsS kw{]m-]vXn-bm-bn.  Cu ]ptcm-K-a-\w aq¶p coXn-bn BIm-hp-¶-Xm-Wv.
1.      FÃm tcmK-§-tfbpw Hscmä kw{]m-]vXn-bn-te¡v  e£-W-§-sf  tImÀ¯nW¡ns¡m­v _Ô-s¸-Sp-¯p-I.
2.     bmZr-Ýn-I-am-bn am{Xw, AYhm ]c-kv]cw _Ô-s¸-Sp-¯m-¯ coXn-bn FÃm tcmK-§-sfbpw Ah-bpsS e£-W-§-tfbpw Hcp-an¨v Hcp ico-c-¯n {]Xy-£-s¸-Sp¶p F¶ kam-\-X-am{Xw I­p-sIm­v hni-I-e\w sN¿p-I.
3.     CXn Nne tcmK-§fpw e£-W-§fpw aäpÅ tcmK§Ä¡pw e£-W§Ä¡pw Imc-W-am-bn-¯o-À¶tijw kz]p-tcm-KXn Ah-km-\n-¸n-¡p-Itbm ho­pw ]ptcm-K-an-¡p-Itbm sN¿p-¶p-s­¶v  I­p-sIm­v _Ô-s¸-Sp-¯p-I.
B[p-\n-I-k-{¼-Zm-b-{]-Imcw tlXp-enw-Ku-j-[-§Ä hni-I-e\w sNbvXv ioen-¡p¶ \ap¡v c­m-aXp ]dª km²y-X-bmWv IqSp-X Ffp-¸w. hnim-e-ambn Nn´n-¨m kz`m-h-ao-izcw Ime-sa-¶p-Xp-S§p¶ aäv As©®-s¯-¡qSn DÄs¡mÅp¶-XmsW¶ kp{ip-X-h-N-\-{]-Imcw  tcmK-{]-IrXn \nÀ®-bn-¡p-¶-XmWv ka-{K-amb kao-]-\w. tcmK-]p-tcm-KXn C¶s¯ Ah-Ø-bn-se-¯nb hgn hn`m-h\w sNbvXm CXn-te-XmWv \mw kzoI-cn-t¡-­-sX¶v \ap¡v hyà-am-Ipw.

]mWvUp-hn D­mb cà-[m-Xp-£b¯mepÅ hmX-hr-²nbpw AXn-\p-tijw am{Xw hmX-þ-c-à-§Ä¡p-­mb ]c-kv]-cm-h-c-W-¯m-epÅ hmX-c-à-hp-am-Imw. hmX-þ-c-à-§Ä ]c-kv]cw _Ô-s¸-SmsX, Ah-c-h-cp-tS-Xmb Imc-W-§-fm kzX-{´-am-bn-¯s¶ Zpjn-¨v, ]o¶oSv  ]c-kv]cw Bh-c-Ww-sNbvXv hmX-c-à-am-Ip-Ibpw, cà-þ-hm-bp-¡-fpsS k½n-{i-Ww-sIm­v cà-¯n-\p-­m-Ip¶ {lmk-¯m hnfÀ¨ D­m-b-Xp-am-Imw.

]mWvUp, hmX-càw XpS-§nb càm-{in-X-amb tcmK-§-sf-s¡m­v cà-hm-ln-t{km-X-Êp-I-fpsS aqe-amb bIr-¯v _m[n-¡-s¸-SpI F¶Xv kzm`m-hn-I-am-Wv. hmXamWv IqsS-\n¡p¶ tZmj-sa-¶-Xn-\m hmbp-hnsâ JcXzw bIr-¯n ImTn\yw D­m-¡n-s¡m­v AhnsS kntdm-knkv cq]-¯n {]Xy-£-s¸-Sp-¶p. kzØm-\-amb kam-IrXn-bnÂ\n¶v hen¸w hbv]n¨v CtX hmbp-Xs¶ sl¸-täm-sa-Kfn D­m-¡p-¶p. ]mWvUp-hnsâ D]-{Z-h-amb \ocv apJ-¯m-bmepw ]n¯-k-©n-bn-em-bmepw asä-hn-tSbpw Ft¸mgpw {]Xo-£n-¡m-hp-¶-Xp-am-Wv. bIr-Zp-Z-c-sa-¶Xnsâ Ah-Øm-t`-Z-ambn DZ-tIm-Zcw hcm-hp-¶-Xn-\m Assk-änIv {Zhw D­m-Ip-¶p.

hmX-c-à-ap-­m-Ip-¶Xv s]mXpsh hymbm-a-¡p-dhpw t¢iw kln-¡m-\m-Im¯ kpIp-am-cÀ¡p-am-sW-¶-Xn-\m Cu tcmKnbpw A¯-c-¯n-em-bn-cp-¶n-cn-¡m-\mWv km²y-X. A§n-s\-bp-Å-hÀ¡v Øuey-ta-tZm-tcm-K-{]-ta-l-§-fpsS {]h-WX Ds­¶v Duln-¡m-hp-¶-tX-bp-Åq. ÌotdmbvUv D]-tbm-Kn-¡p-¶-hÀ¡v Øqe-tim-^-Xbpw {ItaW {]ta-lhpw D­m-Ip¶p F¶Xv sXfn-bn-¡-s¸«n«p-Å-Xn\m ChnsS I­n-sÃ-¦nte AÂ`p-X-ap-Åq. A¯-c-¯n¯s¶ hcm-hp¶ H¶mb HmÌntbm t]mtdm-knkpw Chn-sS-bp-­v. Øueyw, {]talw XpS-§n-b-h-bn-ep-­m-Ip¶ tatZm-hm-ln-t{km-tXm-Zp-jvSn-sIm­v AXnsâ aqe-amb hr¡-IÄ _m[n-¡-s¸-«-Xnsâ sXfn-hmWv t{]m«o-\yq-dn-b.

ck-Zp-jvSn-bpsS sXfn-hmb Øuey-hpw, {]mW-hm-l-t{km-X-Ênsâ ZpjvSn-e-£-W-ap-­m-¡p-hm-\mbn, ]mWvUp kqNn-¸n-¡p¶ cà-ZpjvSn hgn cà-¯nsâ ]X-sIm-­p-­m-¡n-bn-cn-¡p-¶, AYhm cà[mXp-X-s¶-bmb izmk-tIm-i-¯nÂ, cà-a-e-amb ]n¯-¯nsâ {Zh-kz-`m-h-apÄs¡m-­, ck-a-e-amb I^w Hgp¡n \nd¨v, I¬tkm-fn-tU-j-\p-­m-¡p-¶p. AØn, aÖm, tÇj-I-I^w F¶n-h-bpsS £bw, HmtPmhn{kwkw F¶n-h-sbÃmw kqNn-¸n-¡p¶ kÔn-hn-tÇ-jhpw Pm\paÀ½m-{in-X-am-b-Xnsâ kqN-\-I-fmWv HmÌntbm BÀss{X-änkv ImWn-¡p-¶-Xv.


Discharge summary -- 24-10-2005                  Date of admission - 21-9-2005
Smt.Rajeswary R. 54yrs female
Chennai
Diagnosis - Cirrhosis liver with ascitis, type 2 diabetes mellitus, protineuria, right basal consolidation, Osteo arthritis - both knee
History - Patient is a known case of Rheumatoid arthritis treated with Ayurvedic drugs, developed more abdominal pain and distension ( 2 days) and loose motion for the past 10 days. One and half years back she was on steroids for 3 months, from then there was central obesity. Now she has more gaseous distension, alternative days watery diarrhoea, belching, distension, and puffiness of face for the past 10 to 15 days. Not able to walk, feels tired.  She also has increased frequency of urination.
Past history- Known RA and Anaeminc patient.  On Globac AC.  NOt a known HT
O/E patient conscious, puffiness of face, anaemic, dry scaly skin, no pedal oedema and no breathlessness.  Bp- 130/80mmhg
Ascitic fluid smear reports chronic inflamatory status.  Hb% 10.5gms/dl
Urine culture report - Escherichia coli > 1 million
USG report - Hepatomegaly with oedematous distednded gall bladder, free fluid in the abdomen, Early cirrhosis of liver with ascitis ++. atrophied uterus and overies.

Imw

Discharge summary - 28/11/ 2005  Date of admission 22/11/2005
Diagnosis- Cirrhosis of liver with ascitis/ Ischemic heart disease/ hypertension/ severe osteoporosis in x-rays
ECG on all leads - anterior wall ischaemia
Certificate on 23 -11 2006 - had IHD/HT/Hypothyroidism, Varus deformity in need of knee joint replacement B/L

MRI study of whole spine on 7-2-2007 - Intervertibral discs between c4 to c7, D8-9, L1-2 discs dehydrated and reduced in height.  Diffuce bulges and protrusion at multiple leves in lumbar area
The manifestations can be stringed together and a sequential flow chart with appropriate explanations can be developed in order to understand the disease.  The sequence can have 3 possibilities.  All the manifestations can be well connected in order to picturise them as manifestations of a single disease.  Those manifestations which cannot have connections each other can stand apart and considered as co-existing separate diseases.  Thirdly some diseases can become the cause of another disease, in which either both can continue to manifest or the original disease no more continues.  All these three possibilities can also be seen in the same case either in a mixed way or can be separately seen unmixed.

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