The patient explained a number of symptoms to the Doctor during a phone consultation. His problems were hyperacidity and extreme heartburn that disturbs his sleep and he gets up at night many times. The upward movement of gas causes pain in the arms. Burping, flatulence, and mild constipation symptoms were present. He also complained of headaches and hasn’t been taking any medication. Specific History (H/0 Present Illness)Patient has been experiencing these problems for 8-10 years. He had to work in changing shifts as part of his private job which affected his digestion. To get out of this prolonged trouble, in past years, he periodically followed different medicines but did not continue due to lack of recuperation.
Physical/ Systemic Findings
Bowels: Regular but not clear, hard consistency
Appetite: Normal;
Gas: Yes;
Acidity: Yes
Sleep: Disturbed;
Mind: Normal;
Digestion: Weak
Urine: Normal
H/0 Past illness/ Family HistoryPatient was recently diagnosed with HTN and he feels it might be because of gas formation. He started taking medicine for HTN on and off. His father has high blood pressure and heart problem.
Samprapti Ghataka
Dosha:
Pitta-Vata; Dushya: Ras; Srotas: Anna vaha, Ras vaha; Adhishthan: Amashaya, Pachyamanashaya
Nidana:
Working during night, awakening till late night, sleeping during the day, unwholesome dietary things, improper eating timings, lack of water consumption, disturbed sleep, stress, anxiety etc.
Chikitsa Sutra
Nidana parivarjan: Avoidance of factors in diet and routine that increase symptoms by aggravating
doshas
Shaman Chikitsa: Pitta-Vata shaman, ama pachan, srotoshodhan, rechan
Shodhan Chikitsa: Natural home-based processes are shared
Sattvavjay Chikitsa: Patient education, expectation management and approach of treatment is shared
JIVA TREATMENT PLAN IN FEB 2016
Yashtimadhu Churna
Pachak Vati
Yakrada Churna
Udaramrit Vati
Amlapittantak Rasayan
Kapardika Bhasma
Specific Advice:
Pathya: Regular practice of gentle walk after meals instead of sitting, increased water consumption, maintain the proper gap between meals that should not be more than three hours, drinking coconut water, sweet-tasting fruits, old rice, barley, wheat, sattu, petha, mishri, amla murabba, gulkand, raisins, pomegranate, parval, lauki, turai, cow milk, butter/ghee, lemon water etc.
Apathya: Fried, oily, spicy, acidic, and heavy foods, hot potency things, tea-coffee, white flour products, potato, brinjal, vinegar, non-veg, tobacco, alcohol, pickles, fast foods, junk foods, stress, anger, irritation, curd, etc.
Modifications/changes made in prescription during the course, below-changed medicines are given as per patient’s feedback:
In March 2016
In products, two separate medicines Punarnavadi Kwath and Mukti supplement pack is given this time in addition to continuing previous combinations.
In April 2016
Pachak Vati is replaced with Leela Vilas Ras and Yashtimadhu compound, Triphala tablets and Amlapittantak Rasayan is added with previous medicines.
In May 2016
Only one change, Kapardaka Bhasma is replaced to Kamdudha Ras, which is made in a mixture. No other changes are done in the rest of the combination.
Outcome
Since July 2016 based on complete recovery, the patient’s medicine dosages were tapered and in August, he reported no complaints regarding his chronic problems. Being free from any medicine, now he is enjoying 100 % improvement with the suggested diet and routine. Parameters before, during, and after treatment were recorded.
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