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It is a chronic Autoimmune inflammatory disorder of involving many joints and also affects other systems of body.

*JOINTS INVOLVEMENT'*
All the synovial joints may be involved but smaller joints involve first than larger joint.

After smaller joint involved , larger joints (like; Knee, elbow, hip joints) are involved

Most common involvements are joints of hands and feet
Proximal interphalangeal Joint (PIP).

Metacarpophalangeal Joint (MCP).

NOTE :
*“ DIP JOINTS ARE NOT INVOLVED IN RHEUMATOID ARTHRITIS BUT IT INVOLVED IN OSTEOARTHRITIS & PSOROTIC ARTHRITIS).”*

*VERTEBRAE INVOLVEMENT ARE RARE IN RA BUT CERVICAL (C1&C2) SPINE INVOLVED MOST COMMON AMONG SPINE.*

*DEFORMITIES ASSOCIATED WITH RHEUMATOID ARTHRITIS;*

▶Swan neck deformity : Hyper-extension of PIP & MCP with flexion of DIP.

▶Buttonhole deformity: Hyper-extension of DIP & MCP with flexion of PIP.
Radiological or X-ray feature of Rheumatoid Arthritis :
i) Juxta-articular osteopenia or bone erosion.
ii) Sclerosis in non-inflammatory arthritis
iii) Narrow joint space due to destruction of articular cartilage.
*Extra Articular Menifestations:*
1. SYSTEMIC
Low Grade-Fever
Fatigue
Weight loss

2. PULMONARY :
Pleural effusion
Pulmonary nodule

3.EYES
Sjogren syndrome(Kerato-cunjuctivitis)
Sicca (Dry eyes)
Scleritis

4.NEUROLOGICAL:
Peripheral nerve entrapment syndrome
"Carpal Tunnel Syndrome".
"Tarsal Tunnel Syndrome".

5. CARDIOVASCULAR:
Pericardial effusion
Conatrictive Pericarditis

*Antibody associated with RA:*
i) Auto Antibody
⏩Usually of IgM class directed against Fc fragment of IgG.
⏩Not specific for diagnosis of RA i.e it may be negative in RA case.
⏩If RA Factor +VE, it dosen’t mean diagnosis of RA confirmed, it has only prognostic value.
⏩If RA Factor +VE , RA Severe i.e bad prognosis.
⏩If RA Factor –VE, RA less severe i.e good prognosis.
⏩It may be +ve in SLE, Sarcoidosis, Sjogren syndrome, Hepatitis B.
⏩Most commonly associated with HLA-DR4 antigen.
ii) Anti- CCP antibodies :
Specific for diagnosis of RA. It may be positive from early stage.

*TREATMENT OF RHEUMATOID ARTHRITIS:*

*ACTEA RACEMOSA :
Rheumatic pains in muscles of neck and back ; feelstiff, lame, contracted ; spine sensitive, from using arms in sewing, type writing, piano playing e.t.c.Rheumatism affecting the bellies of the muscles ;pains stitching, cramping.
*BRYONIA ALBA :
Rheumatic pains of chest. Pains : stitching, tearing, worse at night ; < by motion, inspiration, coughing ; > by absolute rest,and lying on painful side.

*CAUSTICUM :
Rheumatic affections, with contraction of the flexors and stiffness of the joints ; tension and shortening of muscles.

*CHAMOMILLA :
Violent rheumatic pains drive him out of bed at night, compel him to walk about.

*LEDUM PALUSTRE :
Pains are sticking, tearing, throbbing ; rheumatic pains are < by motion ; < at night, by warmth of bed and bed-covering (Mer.) ; > only when holding feet in ice-water.

*MEDORRHINUM :
Pains : arthritic, rheumatic, a sequel of suppressed gonorrhoea; constricting, seem to tighten the whole body ; sore all over, as if bruised.

*NUX MOSCHATA :
Rheumatic affections ; from getting feet wet ; from exposure to drafts of air while heated;<
in cold, wet weather, or cold wet clothes; of left shoulder.

*PHYTOLACCA :
Patients of a rheumatic diathesis ; rheumatism of fibrous and periosteal tissue. In rheumatism and neuralgia after diphtheria, gonorrhoea, mercury or syphilis. Pains flying like electric shocks ; shooting, lancinating
; rapidly shifting; worse from motion and at night.

*RHODODENDRON :Rheumatic drawing, tearing pains in all the limbs, worse at rest and in wet, cold, windy weather (Rhus). Cannot get asleep or remain asleep unless legs are crossed.

*SANGUNARIA : Rheumatic pain in the right arm and shoulder ; cannot raise the arm, < at night

BY
Dr. Saurabh Suman Prasad
INTERN
Dr. Yadubir Sinha Homoeopathic Medical
College& Hospital , Laheriasarai, Darbhanga
Bihar.

21/12/2018

* & *

Enlargement of the liver beyond its normal size due to any pathological changes are termed as Hepatomegaly.

*Headings under which hepatomegaly is to be defined are :
1. Edge – Sharp / Irregular : Cirrhosis
Round with soft consistency : Kwashiorkor
2. Surface :
Smooth : Congestion
Granular : Portal Cirrhosis
Nodular : Post Necrotic Cirrhosis)
Regular
Irregular
3. Consistency
Soft : CCF, Acute hepatitis,Anaemia
Firm : Chronic active hepatitis.
Hard : CML, Hepatoblastoma
Cystic : Hemangioma
4. Tenderness : Cirrhosis, Malignancy, Liver abscess, infected cyst.
5. Pulsation : Due to tricuspid insufficiency.
6. Friction sound : Liver abscess, Syphilitic Hepatitis
7. Bruit : Malignancy, Alcoholic liver disease

*Grades of Hepatomegaly :
Mild : 7cms below Right subcostal margin.

*Causes of hepatomegaly*
Tender – CCF
Amoebic hepatitis
Viral hepatitis
Pyogenic abscess liver

*Causes of nodules in liver*
1. Secondaries
2. Primary
3. Hepar lobatum (tertiary syphilis)
4. Macronodular cirrhosis
5. Polycystic disease
6. Hydatid disease

*Differential Diagnosis in Clinical Examination:*

Nontender
1. Cirrhosis/Portal hypertension
2. Malaria
3. Hodgkin’s disease
4. Leukemia
5. Amyloidosis
6. Sarcoidosis
7. Fatty infiltration
8. Malignancy – Primary/Secondary
9. Hydatid

Tender hepatomegaly
1. CCF
2. Viral hepatitis
3. Amoebic abscess
4. Pyemic abscess
5. Hepatoma
6. Actinomicosis of liver
7. Weil’s disorder
8. Hepatic vein thrombosis

Hard liver
1. Malignancy
2. Cirrhosis

Soft liver
1. Congestive liver - CCF
Small liver
1. Late stages of cirrhosis
2. Acute liver failure

Tender liver
1. Infection – Viral
2. Infestation – Amebic
3. CVS – CCF

Liver dullness is reduced in
1. Right sided pneumothorax
2. Severe emphysema
3. Large collection of gas under right hemidiaphragm
Abdomen.

Liver pulsation
Systolic ▶Tricuspid incompetence
Diastolic ▶Tricuspid stenosis

Palpable liver without hepatomegaly
1. In young children
2. Riedel’s lobe of liver (common in female)
3. Visceroptosis
4. Right-sided pleural effusion
5. Right-sided subdiaphragmatic diseases

*Facts about Hepatomegaly :

▶Hepatomegaly results if the extravascular hemolysis occurs in liver.

▶Hepatomegaly, usually indicates that edema results from heart failure.

▶Enlargement of the intra-abdominal organs, specifically the liver (hepatomegaly).
Hepatomegaly is seen in Acute malnutrition and Vitamin A excess.

▶Those with liver metastases may present with hepatomegaly, right upper quadrantpain, fever, anorexia, and weight loss.

▶Hepatomegaly is the most common physical sign, occurring in 50–90% of the patients suffering from hepatocellular carcinoma.

▶Hepatomegaly, splenomegaly, ascites, peripheral edema, are signs of liver failure.

▶Metastatic NETs (carcinoids) in the liver frequently presents as hepatomegaly in
a patient who may have minimal symptoms and nearly normal liver function test results.

▶When thrombosis affects the hepatic veins, it may produce acute hepatomegaly and ascites,
i.e., a full-fledged Budd-Chiari syndrome.

▶In case of Polycythemia Vera hepatomegaly may accompany the splenomegaly but is unusual in the absence of splenic enlargement.

▶In Amyloidosis hepatomegaly, splenomegaly, andautonomic neuropathy can also occur as the disease progresses.

▶Only 50% of patients with liver abscesses, however, have hepatomegaly, right-upper-quadrant tenderness or jaundice; thus, one-half of patients have no symptoms or signs to direct attention to the liver.

▶The liver is usually the first organ to be affected, and hepatomegaly is present in more than 95% of symptomatic patients of hemochromatosis.

▶CESD is heterogeneous and presents with hepatomegaly and hepatosteatosis at any age in childhood or adulthood.

▶Type III GSD disease, hepatomegaly improves with age; however, liver cirrhosis and hepatocellular
carcinoma may occur in late adulthood.

*HOMOEOPATHIC TREATMENT*

CHELIDONIUM MAJUS : Pneumonia of right lung with liver complications having desire for hot food & drinks

CALCAREA CARBONICA : Obese & chilly person with excessive sweating from head.

LAC DEFLORATUM : Dropsy : from organic heart disease ; from chronicliver complaint.

LYCOPODIUM CLAVATUM: Affects right side, especially liver region with bloating and belching with burning sensation. Cravings for sweets & hot drinks.

MAGNESIA MURIATICA : Pressing pain in liver, when walking and touching it, liver hard, enlarged, < lying on right side.

MERCURIUS SULPHURICUS : Hydrothorax, if occurring from heart or liver diseases; dyspnoea, has to sit, cannot lie down.

NATRUM SULPHURICUM: Hepatitis with icterus and vomiting of bile; Liver sore to touch with sharp stitching pain.

PODOPHYLLUM : Patient is constantly rubbing and shaking the region of liver with his hands.

TARAXACUM : Jaundice with enlargement and induration of liver.

*Dr. Saurabh Suman Prasad*
*INTERN*
Dr. Yadubir Sinha Homoeopathic Medical & Hospital, Laheriasarai, Darbhanga (BIHAR)

Ref :
Differential Diagnosis in ClinicalMedicine_R_Deendayal.
Harrison's_Principles_of_Internal_Medicine_19th_Edition.

21/12/2018

A disorder of purine metabolism in which serum uric acid level increased i.e Production of uric acid level is increased and excretion of uric acid is decresed.
*Serum uric acid level greater than 7.0mg/dl (Hyperuriceamia).*

Accumulation of urate crystal alongwith inflammatory cells like; Lymphocyte, macrophage, Giant cell it form *“TOPHI”* i.e pathogenmicfeature of gout.It is present as mono-sodium urate crystal. On synovial fluid aspiration from joint.

Only increased in serum uric acid level can not diagnosed the gout. Uric acid level may be normal or increased or decreased during acute attack of gouty arthritis.
Gouty arthritis risk mainly depends upon magnitude and duration of Hyperuricaemia.

Hyperuricaemia person may be asymptomatic for 15-30 years.

*Cause :
A) Diminished renal excretion
• Increased renal tubular reabsorption*
• Renal failure
• Lead toxicity
• Lactic acidosis
• Alcohol
• Drugs
Thiazide and loop diuretics
Low-dose aspirin
Ciclosporin
Pyrazinamide

Over-production of uric acid
• Myeloproliferative and lymphoproliferative disease
• Psoriasis
• High fructose intake
• Glycogen storage disease
C) Increased intake
• Red meat
• Seafood
• Offal

*JOINTS INVOLVEMENT:*
The first MTP joint involved and other common sites are the ankle, midfoot,knee, small joints of hands, wrist and elbow. The axial skeleton and large proximal joints are rarely involved.

*NOTE :” MOST COMMON JOINT INVOLVED IN GOUT IS GREAT TOE.”*

*CLINICAL FEATURE*

Affected joints becomes red, hot, swollen & tender.
Worse pain in affected joints especially in morning for several hours.
Joints becomes stiff.

*DIAGNOSIS:*
Definitive diagnosis by synovial fluid aspiration from joints with the presence of monosodium urate crystal in the synovial fluid confirms the diagnosis.

Only hyperuricaemia can not confirm the diagnosis.

Serum uric acid level measurement is only important during uricosuria or xanthonine oxidase inhibitor treatment.

HOMOEOPATHIC TREATMENT FOR GOUT :

ABROTANUM :Gout : joints stiff, swollen, with pricking sensation ;
wrists and ankle-joints painful and inflamed.
Very lame and sore all over.

ARNICA MONTANA : Gout and rheumatism, with great fear of beingtouched or struck by persons coming near him.

ACTAE SPICATA: Swelling of joints after slight fatigue , especially ankle, toe and joints of hands are involved.

BARYTA CARBONICA : especially when fat; or those who suffer from gouty complaints.

BENZOIC ACID : A gouty, rheumatic diathesis engrafted on a gonorrhceal
or syphilitic patient. Gouty concretions; arthritis vaga; affects all thejoints, especially the knee, cracking on motion ; nodosities. Pains, tearing, stitching, in large joints of big toe; redness and swelling of joints ; gout Agg at night.

COLCHICUM AUTUMNALE : Adapted to the rheumatic, gouty diathesis ; personsof robust vigorous constitution ; diseases of oldPeople. It is also used in acute attack of gout.

EUPATORIUM PERF : Specific medicine in the swelling of the left great toe. Soreness an inflammation of the joints associated with headache. The pain becomes so worse as if bone is breaked.

KALMIA LATIFOLIA : Adapted to acute neuralgia, rheumatism, gouty
complaints, especially when heart is involved as a sequel
of rheumatism or gout.

LEDUM PAL : Adapted to the rheumatic, gouty diathesis ; constitutionsabused by alcohol.

RHODODENDRON : Gout with fibrous deposit in great toe-joint, rheumatic,
often mistaken for bunion.

*Dr. Saurabh Suman Prasad*
INTERN
Dr. Yadubir Sinha Homoeopathic Medical College and hospital laheriasarai Darbhanga Bihar.

09/11/2018

"ISCHAEMIC HEART DISEASE"
*INTRODUCTION*
It is a condition in which there is inadequate supply of blood and oxygen to a portion of myocardium. It occurs when there is imbalance between supply and demand.
The most common cause of myocardial Ischemia is atherosclerotic disease of epicardial coronary artery causing reduction in myocardial blood flow and also decrease perfusion to the myocardium.

IHD is characterized into two categories:
1. CAD- Coronary Artery Disease.
2. ACS- Acute coronary syndrome.

*Angina pectoris* – It is defined as the chest pain because of episodic myocardium ischemia. It is the most common manifestation of IHD. It is a clinical syndrome characterized by episode of pain or pressure over the anterior part of chest. This is usually due to insufficient coronary blood flow which results in decrease oxygen supply to heart and increase myocardial demand in response to physical exertion & emotional stress.

In angina pectoris, carotid sinus massage causes decrease HR and
angina pain subsides, whereas it has no change if it is nonanginal pain. This is called LEVINE test.

*PATHOPHYSIOLOGY*
Myocardial Ischemia results from a reduction in coronary blood flow cause epicardial artery stenosis.
Abnormal constriction or deficient relaxation of coronary artery.

*Causes of ischemic cest pain*
1. Coronary atherosclerosis
2. Aortic stenosis
3. Anemia
4. Atrial tachycardia
5. Thyrotoxicosis
6. Coronary artery spasm
7. Coronary aterial embolism (or) thrombosis
8. Coronary ostial stenosis
9. Arteritis of coronary artery
10. Restrictive cardiomyopathy (IHSS)
11. MVPS
12. Mitral stenosis
13. Primary pulmonary hypertension
14. HOCM
15. SVT
16. AR – due to syphilis

*Cardiac causes of chest pain*
1. Angina pectoris
2. Myocardial infarction
3. Acute pericarditis
4. Cardiomyopathy
5. Acute dissection of aorta
6. Aneurysm of thoracic aorta – erosion of vertebra
7. Shoulder hand syndrome
8. Pulmonary embolism

*Types of angina*
1. Stable Angina
2. Unstable angina
3. Prinzmetal angina.

 Stable Angina: It occurs on exertion and relieved by rest.

 Unstable angina: Symptoms occur more frequently and longer than stable angina.

 Prizmetal anaemia: This angina occurs at rest caused by coronary artery vasospasm.

 Silent Angina: It gives evidence of ischemia on E.C.G but patient report no symptoms.

*Various forms of angina*:
1. Classical angina pectoris (Heberden’s angina) (effort angina)
2. Prinzmetal angina (Atypical angina)
3. Decubitus angina

4. Reversed angina
5. Second wind angina
6. Preinfarction angina
(Intractable angina)
7. Unstable angina
8. Ingravescent angina

*Risk factor of atherosclerosis*:
i. Family History of Coronary artery disease.
ii. Diabetes mellitus
iii. Systemic Hypertension
iv. Smoking
v. Hypercholestraemia.
vi. Obesity

*Forms of presentation of ischemic heart disease*:
1. Chest pain or chest discomfort
2. Syncope and sudden death
3. Pulmonary edema
4. CCF
5. Cardiac arrhythmias No chest pain
6. Abnormal ECG
7. Profound fatigue
8. Abnormal X-ray chest.

*Clinical Feature of IHD* :

Pain in chest which vary in severity and radiate to neck , jaw , shoulder and inner aspect of arm even umbilicus.
Numbness in arm, wrist and Hands.
Shortness of breathe ( Dyspnoea).
Feeling of Tightness in the middle of chest like band around the chest.
It is induced by exertion and relieved by rest.
Nausea and vomiting ( Mainly associated from Medula oblongata and CTZ .

*Diagnosis:*

Angina pectoris is generally diagnosed on the basis of patient’s history , Sign and Symptoms but the following investigations helps in evaluating the disease:

i) E.C.G
ii) TMT(Stress Test)
iii) Echo cardiography
iv) X-ray Chest
v) Coronary angiography

*Differential diagnosis:*
1. Musculoskeletal Pain
2 Pericardial Pain
3. Oesophageal Pain.

*Common noncardiac causes of chest pain*:
Gastroesophageal reflux/peptic ulcer disease: Look for a relation to certain foods (spicy foods,chocolate), smoking, caffeine, or lying down. Pain is relieved by antacids or acid-reducing medications. Patients with peptic ulcer disease often test positive for Helicobacter pylori.

Chest wall pain (costochondritis, bruised or broken ribs): Pain is well localized and reproducibleon chest wall palpation..

Esophageal problems (achalasia, nutcracker esophagus, or esophageal spasm): Often a difficultdifferential. The question will probably give a negative workup for MI or mention the lack of atherosclerosis risk factors.
Look for abnormalities with barium swallow (achalasia) or esophageal manometry. Treat achalasia with pneumatic dilatation or botulism toxin administration; treat nutcracker esophagus or esophageal spasm with calcium channel blockers. If medical treatments are ineffective, surgical myotomy may be needed.

Pericarditis: Look for viral upper respiratory infectionl prodrome. The ECG shows diffuse ST segment elevation, the erythrocyte sedimentation rate is elevated, and a low-gradel
fever is present. Classically, the pain is relieved by sitting forward. The most common cause is infection with coxsackievirus.

Other causesinclude tuberculosis, uremia,
malignancy, and lupus erythematosus or other autoimmune diseases.

Pneumonia: Chest pain is caused by pleuritis. Patients also have cough, fever, and/or sputum
production. Ask about possible sick contacts.

Aortic dissection: Associated with severe tearing or ripping pain that may radiate to the back.

Look for hypertension or evidence of Marfan syndrome (tall, thin patient with hyperextensible joints).Blunt chest trauma can cause aortic laceration and which are different conditions that are often managed similarly

Management :
Complete Bed rest result im reduction in heart rate, Blood Pressure and it also reduce myocardial activity.
Prophylaxis :
Avoid Smoking
Reduce Weight
Reduction in heavy meal and fatty food.
Increase Exercise.
Avoid emotional stress.

Homoeopathic Treatment of IHD :

1. ACONITUM NAPELLUS : For an acute attack with fear ,. Anxiety and severe pain. Worse with activity.

2. ARSENICUM ALBUM : For the thin, tense , perfectionistic, obessional, industrious fastidious worker . Chilly, fear of the present and uncertain of the future.

3. CACTUS GRANDIFLORUS : For angina pectoris. The chest feels tight and constricted, as if heavy weight is presaing down with squeezing the chest wall. Worse after excercise.

4. DIGITALIS PURPUREA An effective remedy for collapse and a slow, weak pulse, worse with motiob and emotions.

5. LACHESIS : Indicated in senile heart disease, when the ankles are swollen and the heart feels constricted by chest wall.

6. NUX VOMICA : In case of high-presaured, over-worked, ambitious executive. Excessive use of alcohol and other narcotics.

7. SPIGELIA MARILANDICA : Useful for palpitations. Usually the patient is worse with motion. Pain in the chest radiating to the back of the trunk.

Suman Prasad
*INTERN*
Dr. Yadubir Sinha Homoeopathic Medical College and hospital, Laheriasarai, Darbhanga.
Bihar.

29/09/2018