A

Case Presentation
On
Cerebrovascular
Accident

Group J
Marco Paul Velasco
Precious Jane Parungao
Rod Lambert de Leon
Carla Aleja Abijay
Mylene Narag
Jenalin Quilang
Krizzia Marie Palce
Jessica Datul

OBJECTIVES

General Objective:
At the end of the case presentation, the presenters together with the audience will
enhance our understanding on the disease process of CVA, its nursing management and
paves a way to us student-nurses appreciate our roles of being health care providers in
the countrys quest for health progress and development.

Specific Objectives:

At the end of the presentation, presenters and audience will be able to:
Define Cerebrovascular Accident.
Discuss and interpret data gathered through theoretical analysis of Nursing
History, Gordons 11 Functional Pattern, Physical Assessment and Laboratory
Results.
Explain the Anatomy and Physiology of Nervous System.
Trace the Pathophysiology of Cerebrovascular Accdident.
Create effective and efficient nursing care plan required by a patient with the
above mentioned disease process.
Discuss the medications taken by the client, its action, side effects and nursing
responsibilities.

INTRODUCTION
Cerebrovascular Accident
Cerebrovascular Accident is a sudden loss of function resulting from disruption of
the blood supply to a part of the brain. Stroke, also called brain attack or ischemic stroke,
happens when the arteries leading to the brain are blocked or ruptured. When the brain
does not receive the needed oxygen supply, the brain cells begin to die, a stroke can
cause paralysis, inability to talk, inability to understand, and other conditions brought on
by brain damage.
Four types of stoke:
1. Cerebral Thrombosis- caused by blood clots.
2. Cerebral Embolism- caused by blood clots.
3. Cerebral Hemorrhage- caused by bleeding inside the brain.
4. Subarachnoid Hemorrhage- caused by bleeding inside the brain.
Cerebral Thrombosis
The most common type of brain attack.
Occurs when a blood clot (thrombus) forms and blocks blood flow in an artery
leading to the brain arteries primarily affected by atherosclerosis and more
susceptible to blood clots.
Most often occurs at night or in the morning when blood pressure in low.
Often preceded by a transient ischemic attack (TIA) or mini-stroke.
Cerebral Embolism
Occurs when a wondering clot (embolus) or some other particle forms in a blood
vessel away from the brain, usually in the heart. The clot then travels and lodges in
an artery leading on the brain.
Cerebral Hemorrhage
Occurs when a defective artery in the brain busts.
Subarachnoid Hemorrhage
Occurs when a blood vessel on the surface of the brain ruptures and bleeds into
the space between the brain and the skull.
The World Health Organization (WHO) definition of stroke is rapidly developing
clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting
24 hours or longer or leading to death, with no apparent cause other than of (1) Noncommunicable disease. WHO Geneva (2) vascular origin (3) By applying this definition
transient ischemic attack (TIA), which is defined to less than 24 hours, and patients with
stroke symptoms caused by subdural hemorrhage, tumors, poisoning, or trauma, are
excluded.
Based from the data gathered from TCGPH records section, there were 10 reported
cases of CVA as of January 2009 until December 2009 comprises of 2 mortality cases and
8 morbidity cases.

Why this case?

We have chosen this case as our topic during the case presentation because we would
like that we, student-nurses, to be aware about CVA and also to broaden our
knowledge about the management and treatment of this disease.
Having awareness and gaining more knowledge about CVA would enhance our skills
and attitudes in handling patients suffering from this disease.

This case serves as a challenge for us student-nurses to be committed and dedicated

health professionals for the next days; we will take care of the health of the citizens.

PATIENTS PROFILE

Name:
Age:
Gender:

I.M.
80 y/o
Female

Civil Status:

Widower

Birth date:

Dec. 24, 1928

Nationality:

Filipino

Religion:

Roman Catholic

Address:

Ugac Norte, Tuguegarao City

Educational Background:

College Graduate

Occupation:

Retired Teacher

Date of admission:

November 19, 2009

Time of admission:

6:45 pm

Chief complaint:

loss of consciousness

Mode of arrival:

via stretcher

Admitting diagnosis:

HPN t/c CVA

Final Diagnosis:

CVA old recurrent

Sepsis secondary to pneumonia
NIDDM

Attending Physician:

Dr. Valeriano Combate, JR

Dr. Marlene Cinco
Dr. Gerardo Pagaddu, JR

Source of information:
Hospital:

SO, patients chart, Records section

TCGPH-Pay Ward

NURSING HISTORY
Past Health History
According to SO, when the patient suffered from headache, fever, and cough,
patient takes over the counter drugs like paracetamol, biogesic, alaxan and solmux.
Patient was diagnosed with Alzheimers disease on 2004, and undergone mastectomy
when she was 42y/o.
History of Present Illness
According to SO, at the evening of November 19, 2009, 45 minutes PTC, SO
noticed that patient was still sleeping at around 6:00pm. She then tried many times to
wake up the patient and called her to eat but she did not receive any response. The SO
was alarmed and decided to rush the patient to Peoples Emergency Hospital and was
admitted around 6:45pm. . At the age of 52 patient was hospitalized and diagnosed of
HPN and manages it by taking maintenance drugs such as amlodipine, simvastatin &
aspirin taken twice a day.
Family Health History
The patient has a history of Asthma on her paternal side. Her father died of Asthma
and her mother died due to hypertension.
Social Health History
Patient is a retired teacher; she lives with her daughter and grand children.
According to the SO before the patient was diagnosed of Alzheimers disease, the patient
loves to mingle with her neighbors and loves to take care of her grand children. SO also
verbalized that patient does not drink alcohol nor smoke cigarettes.

GORDONS 11 FUNCTIONAL PATTERN

Health Perception-Health Management Pattern
Before Hospitalization
During Hospitalization
According to the SO, her mother
According to the SO, she stated that her
has been pampered starting when she mother is not in good condition. She believes
was diagnosed with Alzheimers
that doctors, nurses and other medical
disease 5 years ago. When she
members will help her mother to recover. SO
suffered from the sickness, they
also added that they obediently follow all the
treated her immediately by taking OTC orders of the doctors.
drugs for cough, colds and fever. With
regards to her maintenance drugs to
her hypertension, they give it at right
time as prescribed.
Nutritional- Metabolic Pattern
Before Hospitalization
According to the SO, her mother eats
everything she wants and sees. She has no
preference diet. She eats 3 times a day
with mid afternoon snacks. She drinks 6-8
glasses of water a day. She has no difficulty
in swallowing and has no allergy with any
type of food.
Elimination Pattern
Before Hospitalization
According to the SO, she defecates once a
day with semi- formed and brown in color
and being eliminated in morning. She voids
6-8 times a day with yellowish in color.

During Hospitalization
Upon admission, the patient was
inserted NGT and was ordered with PNSS
1liter to run for 8 hours. The diet was
osteorized feeding with SAP.

During Hospitalization
During our shift, the patient didnt
defecate. She has IFC connected to urine
bag with 700 ml and yellow amber in color.

Activity Exercise Pattern

Before Hospitalization

According to the SO, the patient is like a

child. She plays with her neighborhood.
Sometimes walking around their house.
About her hygiene, they see to it that
cleanliness must maintain to her.
Sleep- Rest Pattern
Before Hospitalization
According to the SO, her mother sleeps at
around 8 in the evening and wakes up at
around 5 in the morning. She takes naps at
afternoon. She has no rituals before
sleeping she added.
Cognitive Perceptual Pattern
Before Hospitalization
According to the SO, her mother is a
retired teacher, she uses eyeglasses. She
speaks dialects such as Ilocano, Tagalog
and English.

During Hospitalization
The patient is in comatose state.
Student-nurses and SO initiated passive
range of motion for her to exercise.

During Hospitalization
Patient is comatose but can respond to
physical stimuli.

During Hospitalization
The patient responds to stimuli by means
of rubbing her sternum for her to wake up.

Self- Perceptual Pattern

Before Hospitalization
The patient suffers from Alzheimers
disease.

During Hospitalization
The patient is comatose.

Role- Relationship Pattern

Before Hospitalization
According to the SO, before her mother
was diagnosed with Alzheimers, she was a
loving mother and responsible to her
children. She provides their needs and sees
to it that they are comfortable in their way
of life.

During Hospitalization
Due to her condition, her daughter
stated that they will do all their best to take
care of their mother. They will make sure to
give back the care they have received from
her.

Coping- Stress Pattern

Before Hospitalization
When her mother is tired, she sleeps for
her to rest.

During Hospitalization
During her present condition, she is in a
stressful state. Her family is there to
comfort and give her necessary needs just
to show their love.

Sexual- Reproduction Pattern

The patient has five children and had her menopause at the age of 50.
Value Belief Pattern
She is a Roman Catholic. When she was diagnosed with Alzheimers disease, her
family never allowed her to go to mass, preventing her to lose her way home.

PHYSICAL ASSESSMENT

Date Assessed: December 03, 2009, 5:15 PM

Vital Signs:
BP: 140/90 mmHg
PR: 92 bpm
RR: 23 cpm
T: 36.8C

General Appearance:
Patient is lying on bed, comatose with ongoing IVF of PNSS 1L x 20 gtts/minute
at 500 cc level hooked at left metacarpal vein patent and infusing well.
With NGT patent.
With IFC connected to urine bag draining yellow amber.
AREA
ASSESSED
SKIN
- Color

Texture

METHOD
USED

NORMAL
FINDINGS

ACTUAL
FINDINGS

ANALYSIS

Inspection

Fair
complexion

Pale

d/t decreased
tissue perfusion
and peripheral
vasoconstriction

Wrinkled

d/t loss of elastic

fiber and
decreased
subcutaneous fat
from hypodermis
secondary to
aging

Inspection/
Palpation

Smooth

Inspection
-

Presence of
rashes

Temperature

d/t poor hygiene

Palpation

Normally warm

Moisture
Palpation

Cold and
clammy
Dry

d/t peripheral
vasoconstriction

Moist to dry
-

Turgor
Palpation

Sagged
Snaps back to
previous

HAIR

d/t decreased
activity of
sebaceous and
sweat glands
secondary to
aging
d/t loss of elastic
fiber and

distribution
Inspection/
Palpation

Texture

Color

Evenly
distributed

Inspection

Evenly
distributed

decreased
subcutaneous fat
from hypodermis
secondary to
aging

Resilient
Normal

Inspection
NAILS
- Color of the
nail bed
-

Capillary
refill time
Shape

EYES/EYEBROWS
- Shape
-

Symmetry

Movement

Silky, resilient

Black w/
white hairs

Black
Normal
Inspection

Palpation

Palpation

Pallor
Pink
transparent

Delayed 4
sec.

Delayed 1-2
sec.

Convex

d/t poor arterial

circulation

Convex

Round

d/t poor arterial

circulation

Inspection
Inspection

Ability to
blink

Equal in size
Inspection

Round
Equal in size

CONJUNCTIVA
- Color

PUPILS
- PERRLA

Normal
Symmetrical
in movement

Inspection

Normal
Symmetrical in
movement

Inspection

Absence of
blink

Blinks
involuntarily &
bilaterally

Size of the
pupil

EXTERNAL
AUDITORY
CANAL
- Hearing
NOSE
- Symmetry
-

Color

Normal
Normal

Pale
-

d/t decreased
melanocyte
production
secondary to
aging

d/t decrease
activity of CN V

Inspection
Pink-red
Very slow to
react to light
Inspection

Inspection

Response to
penlight
(dilates and
constricts)

d/t poor arterial

circulation

2mm
d/t compression
of CN III

Inspection

Hears equally
in both ears

Inspection

Symmetrical

LIPS & MOUTH

- Symmetry
-

Color (lips)

Hears equally
in both ears
Inspection

Symmetrical

Same color
as the face
and neck

Normal

Normal
-

Moisture

Inspection

Same color as
the face and
neck

Symmetrical

Symmetrical

Dry

Normal
Pale

Inspection
NECK
- Symmetry
-

Appearance

THORAX
- Chest
contour

Pink

Clavicle

Inspection

Chest wall

Inspection

Breathing
pattern

ABDOMEN
- General
contour

UPPER
EXTREMITIES
- Symmetry
-

ROM

LOWER
EXTREMITIES
- Size
-

d/t decrease
oxygenation

Palpation
Inspection

Inspection

Inspection

Moist

Normal

Symmetrical
No
distentions

d/t decreased
salivary
production r/t
loss of vagal
stimulation

Symmetrical
Symmetrical

Normal

Prominent

Normal

Full chest
expansion

Normal

Irregular

Normal

No distentions

Symmetrical
Prominent

Inspection
Auscultation
Percussion
Palpation

Full chest
expansion
Regular

Normal
Non-tender
d/t decreased
function of the
medulla

Inspection
Inspection/
Palpation

Inspection

Symmetry

Inspection

ROM

Inspection

Non-tender
Normal
Symmetrical

Symmetrical

(+) ROM
upon
movement
Normal

(+) ROM upon

movement

Normal
Equal in size
Symmetrical

Equal in size
Symmetrical

(+) ROM
upon
movement

Normal
Normal

(+) ROM upon

movement

Normal

LABORATORY RESULTS
HGT
Date
11-21-09 6am
11-21-09 6pm
11-22-09 6am
11-22-09
11-23-09
11-24-09
11-27-09
11-28-09
11-30-09
12-01-09

Result
284 mg/dl
155 mg/dl
186 mg/dl
153 mg/dl
170 mg/dl
215 mg/dl
172 mg/dl
152 mg/dl
120 mg/dl
133 mg/dl

Normal Range
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl
80-120 mg/dl

Analysis

Normal Range
135-145
mmOl/L
135-145
mmOl/L

Analysis
Normal

Normal Range
3.5-5.5 mmOl/L
3.5-5.5 mmOl/L

Analysis

Na
Date
11-24-09

Result
131 mmOl/L

11-29-09

132 mmOl/L

Normal

k
Date
11-24-09
11-29-09
CBC

Result
3.0 mmOl/L
4.0 mmOl/L

Normal

11-20-09
Parameters
WBC

Result
12.4x103 /mm3

Normal Range
3.5-10

RBC
Hgb
Hct
PLT

3.83x106 /mm3
11.4 g/dl
37.0%
188x103/mm3

3.8-5.8
11.0-16.5
35-50
150-390

Analysis
d/t increase
pyrogens
Normal
Normal
Normal
Normal

INTAKE AND OUTPUT MONITORING SHEET

12-05-09
Intake
Time

Oral

7-3
3-11
11-7

500
1000
660

Parenter
ral
100
430
200

Output
Other Total
s
600
700
800

Urine

Draina
ge

Others

600
700
800
Total: 2890

Total
600
700
800

Total: 2100
12-04-09
Intake
Time

Oral

7-3
3-11
11-7

720
1000
600

Parenter
ral
100
250
250

Output
Other Total
s
75
895
1250
850

Urine

Draina
ge

Others

200
500
200
Total: 2995

Total
250
500
200

Total: 950
12-03-09
Intake
Time

Oral

7-3

750

Parenter
ral
350

Output
Other Total
s
75
1175

Urine
290

Draina
ge

Others

Total
290

3-11

1000

200

1204

350
Total: 2379

350

Total: 640
12-02-09
Intake
Time

Oral

7-3
3-11
11-7

900
832
600

Parenter
ral
550
120
200

Output
Other
s
75
75
75

Total

Urine

Draina
ge

1525
1027
875

790
660
550
Total: 3427

Others

Total
790
660
550

Total: 2000
11-30-09
Intake
Time

Oral

7-3
3-11
11-7

600
890
550

Parenter
ral
340
475
200

Output
Other Total
s
940
1365
750

Urine

Draina
ge

Others

1000
1100
900
Total: 2055

Total
1000
1100
900

Total: 3000
11-29-09
Intake
Time

Oral

3-11

800

Parenter
ral
300

Output
Other Total
s
1100

Urine

Draina
ge

Others

400
Total: 1100

Total
400

Total: 400

11-28-09
Intake
Time

Oral

7-3
3-11
11-7

830
1030
700

Parenter
ral
550
700
700

Output
Other Total
s
1380
1730
1400

Urine

Draina
ge

Others

1350
600
1650
Total: 4510

Total
1350
600
1650

Total: 3600
11-27-09
Intake
Time

Oral

7-3

1030

Parenter
ral
600

Output
Other Total
s
1630

Urine
1630

Draina
ge

Others

Total
1630

3-11

600

450

1050

1050
Total: 2680

1050

Total: 2680
11-26-09
Intake
Time

Oral

7-3
3-11

860
1250

Parenter
ral
475
400

Output
Other Total
s
1335
1650

Urine

Draina
ge

Others

600
1250
Total: 2985

Total
600
1250

Total: 1800
11-25-09
Intake
Time

Oral

7-3
3-11
11-7

770
810
800

Parenter
ral
350
200
200

Output
Other Total
s
1120
1010
1000

Urine

Draina
ge

Others

500
800
1250
Total: 3130

Total
500
800
1250

Total: 2550
11-24-09
Intake
Time

Oral

7-3
3-11

715
850

Parenter
ral
400
200

Output
Other Total
s
1115
1050

Urine

Draina
ge

Others

350
1400
Total: 2165

Total
350
1400

Total: 1750
11-23-09
Intake
Time

Oral

7-3
3-11
11-7

1030
700
600

Parenter
ral
200
500
750

Output
Other Total
s
1230
1200
1350

Urine

Draina
ge

300
600
700
Total: 3780

Others

Total
300
600
700

Total: 1600

CRANIAL CT-SCAN
Plain and contrast-enhanced axial tomographic sections of the head shows ill defined
hypoattenvation in the both fronto-parietal periventrical and both occipital
periventricular areas.
The ventricles are unenlarged
The midline structures are undisplaced
The sulci and cisterns are prominent

No abnormal extra-axial fluid collection detected

The brain stem, pineal region and posterior fossa do not appear unusual
The internal carotid basilar and vertebral arteries are calcified
The sella turcica is not enlarged
Soft tissue attenvation is noted in the right maxillary sinus
IMPRESSION:
Acute infarcts, both fronto-parietal periventricular and both occipital
periventricular areas.
Cerebral Atrophy
Atherosclerotic Internal Carotid, basilar and vertebral arteries
Sinusitis vs polyp, right maxillary sinus

ANATOMY AND PHYSIOLOGY

Central Nervous System
The Central Nervous System (CNS) is composed of the brain and spinal cord. The
CNS is surrounded by bone-skull and vertebrae. Fluid and tissue also insulate the brain
and spinal cord.
Areas of the Brain

The brain is composed of three parts: the cerebrum (seat of consciousness), the
cerebellum, and the medulla oblongata (these latter two are part of the unconscious
brain).
The medulla oblongata is closest to the spinal cord and is involved with the
regulation of heartbeat, breathing, vasoconstriction (blood pressure), and reflex centers
for vomiting, coughing, sneezing, swallowing and hiccupping. The hypothalamus
regulates homeostasis. It has regulatory areas for thirst, hunger, body temperature,
water balance and blood pressure and links the nervous system to the Endocrine
System. The midbrain and pons are also part of the unconscious brain. The thalamus
serves as a central relay point for incoming nervous messages.
The cerebellum is the second largest part of the brain, after the cerebrum. It
functions for muscle coordination and maintains normal muscle tone and posture. The
cerebellum coordinates balance.
The conscious brain includes cerebral hemispheres, which are separated by the
corpus callosum. In reptiles, birds, and mammals, the cerebrum coordinates sensory
data and motor functions. The cerebrum governs intelligence and reasoning, learning
and memory. While the cause of memory is not yet definitely known, studies on slugs
indicate learning is accompanied by a synapse decrease. Within the cell, learning
involves change in gene regulation and increased ability to secrete transmitters.
The Brain
During embryonic development, the brain first forms a tube, the anterior end
which enlarges into three hollow swellings that form the brain, and the posterior of which
develops into spinal cord. Some parts of the brain have changed little during vertebrate
evolutionary history.
Parts of the Brain as seen from the Middle of the Brain
Vertebrate evolutionary trends include:
1. Increase in brain size relative to body size.
2. Subdivision and increasing specialization of the forebrain, midbrain and hindbrain.
3. Growth is relative in size of the fore brain, especially the cerebrum, which is
associated with increasingly complex behavior in mammals.
The Brain Stem and Midbrain
The brain stem is the smallest and from an evolutionary viewpoint, the oldest and
most primitive part of the brain. The brain stem is continuous with the spinal cord, and is
composed of the parts of the hindbrain and midbrain. The medulla oblongata and pons
control heart rate, constriction of blood vessels, digestion and respiration.
The midbrain consists of connections between the hindbrain and forebrain.
Mammals use this part of the brain only for eye reflexes.

The Cerebellum
The cerebellum is the third part of the hindbrain, but it is not considered part of the
brain stem. Functions of the cerebellum in clued fine motor coordination and body
movement, posture and balance. This region of the brain is enlarged in birds and controls
muscle action needed for flight.
The Forebrain

The forebrain consists of the diencephalon and cerebrum. The thalamus and
hypothalamus are parts of the diencephalon. The thalamus acts as a switching center for
nerve messages. The hypothalamus is a major homeostatic center having both nervous
and endocrine functions.
The Cerebrum
The cerebrum, the largest part of the human brain, is divided into left and right
hemispheres connected to each other by the corpus callosum. The hemispheres are
covered by a thin layer of gray matter known as the cerebral cortex, amphibians and
reptiles have only rudiments of this area.
The cortex in each hemisphere of the cerebrum is between 1and 4mm thick. Folds
divide the cortex into four lobes: occipital, temporal, pariental, and frontal. No region of
the brain functions alone, although major functions of various parts of the lobes have
been determined.
The occipital lobe (back of the head) receives and processes visual information.
The temporal lobe receives auditory signals, processing language and the meaning of
words. The pariental lobe is associated with the sensory cortex and processes
information about touch, taste, pressure, pain, and heat and cold. The frontal lobe
conducts three functions:
1. Motor activity and integration of muscle activity
2. Speech
3. Thought processes
Most people who have been studied have their language and speech areas on the left
hemisphere of their brain. Language comprehension is found in Wernickes area.
Speaking ability is in Brocas area. Damage to Brocas area causes speech impairment
but not impairment of language comprehension. Lesions in Wernickes area impair ability
to comprehend written and spoken words but not speech. The remaining parts of the
cortex are associated with higher thought processes, planning, memory, personality and
other human activities.

This is the case of a male, 50 years of age, who presented at the Palghar
Hospital OPD on 20th August 05 with tingling/numbness of the upper
and lower limbs on the left side. This had begun 10 days earlier and was
progressively getting worse. It began with weakness of the limbs on the
left side and he was now unable to move them. An episode of severe
anxiety and fear had precipitated this onset of symptoms. It had
progressed further and now he had slurred speech and was laughing
immoderately. He also had a strong feeling of being intoxicated ++.
Along with this there had been a recurrent headache that tended to be
worse in the morning, around 9-10 am.
2 months earlier he had developed hypertension. The symptoms at that
point were a similar tingling and numbness on the left upper and lower
limbs. This too, was precipitated by an episode of fear. He was put on
anti hypertensive medication which helped and he stopped this on his
own after a while.
There were no other CNS symptoms of unconsciousness, projectile
vomiting, convulsions, fever or head injury.

There was no Past History of diabetes, or ischemic heart disease as

possible precipitating factors.
On Examination:
Pulse:

84/min

BP:

150/100

RS:

Clear

CVS:

S1S2

Normal

PA:

NAD

CNS:

Conscious,

Higher

Cooperative,

Well

Functions,

oriented

in

time,

Cranial

space

Nerves:

and

person
Normal

No Palliloedema
Motor

Sensory

Right

Left

Tone: UL

Normal

Increased ++

Tone : LL

Normal

Increased ++

Muscle Power: UL

Normal

Proximal
Muscles:
Power
1/5
Distal
Muscles: Power 4/5

Muscle Power: LL

Normal

Complete
power: 0/5

Reflexes: UL

Normal

Hypertonic ++

Reflexes: LL

Normal

Hypertonic ++

Normal

Loss of fine touch in

Upper
and
Lower
limbs

loss

of

At this point in the OPD we had to decide whether this case needed to
be admitted as inpatient for homeopathic management. We follow a set
of criteria to make this decision for all cases, including this one. Here
are the criteria that indicate mandatory in-patient admission for a
homeopathic patient.

Close monitoring for a potentially fatal illness

Observation for developing complications.
Detailed investigation of the acute condition and risk factors.
Homoeopathic remedy reaction
Ancillary measure physiotherapy

In this case, hospital admission was a necessity for further

investigations and management to be carried out.
Investigations:

Hb : 15.2
T.L.C.: 7800 N 68 E 0 B 0 L 26 M2
RBS : 65.2
B .U. N. :9.0
S. CHOLESTROL : 300.2

S . TRIGLYCERIDES : 254
S. CREAT : 1.0

E.C.G. : L.V.H. Pattern

CT SCAN BRAIN (Pictures can be viewed in the attached slide
presentation)
E/o ill-defined hypodense lesion seen in the Rt high parietal lobe
involving centrum semi ovale, mostly suggestive of recent nonhemorrhagic infarct in Rt MCA area.
E/o multiple lacunar infarcts in Rt internal capsule & basal ganglia.
E/o old small size infarct in Lt anterior limb of internal capsule in Lt
MCA area. Periventricular white matter ischemic changes seen.
FINAL DIAGNOSIS:

LT SIDED HEMIPLEGIA, secondary to Right MCA (Middle Cerebral

Artery) non-hemorrhagic infarct involving the parietal lobe of the
cerebrum.
HYPERTENSION
HYPERLIPIDAEMIA
Management:

Once these preliminary medical observations are complete, we must

now appraoch the case from the homeopathic standpoint for
appropriate homeopathic management and care. In fact the
homeopathic diagnosis is an integrated ongoing process even through
the medical work being done above.
What is obvious from above, is that there already exists a chronic
process going on over many months that has precipitated now as a
hemiplagia (stroke). This is an acute complication of chronic disease.
Our plan was to decide on the acutely indicated remedy to overcome
this acute picture of symptoms, followed by the constitutional remedy.
This is how we reasoned it out:
There was a distinct change in the susceptibility during the
acute episode that presents with new symptomatology, a clear causative
factor and characteristic modalities and concomitants. These were
indications for an acute remedy.
Constitutional remedy: Is expected to continue with healing of the
infracted area of the brain. It is also expected to deal with the
underlying causes of hypertension and hyperlipidaemia so that such
episodes will not recur. In addition, the constitutional remedy must
Acute remedy:

deal with the excessive tendency to be morbidly anxious and fearful

over circumstances.
With this philosophical understanding of our approach, we
concentrated on the acutely presenting totality which was as below:
Ailments

From

FRIGHT

FEAR

<

ANXIETY

HEAD

PAIN

STUPEFACTION,

MORNING
AS

LAUGHING

IF

10

INTOXICATED,

a.
HEADACHE

TENDENCY,

PARALYSIS,

m.

<
DURING,

IMMODERATELY

NUMBNESS

PARALYSIS,

WITH,
PAINLESS

PARALYSIS ONE SIDED LEFT

These were the rubrics chosen. Our next step was to consider which
repertorization approach was appropriate to this case given the
characteristic picture. Since there was characteristic sensation,
modalities,
concomitants,
and
causation,
we
chose
the
Boenninghausans approach for repertorization.
The remedies that came up were: Nux Moschata, Gelsemium, Opium, Rhus
tox,Causticum.
Furthur discussion was required to decide on the appropriate remedy.
Along with this we also made an assessment of the Susceptiblity:

Susceptibility: Low Sensitivity: High

Pace: Slow
Characteristic: Few
Pathology: Structural Irreversible
Vital organ affected

Hence the choice of posology was: Low potency with frequent

repetition.
The next step was to evaluate the underlying Miasm:

10 a.m. <
SLOW PROGRESS
CONFUSION
INTOXICATED FEELING
IMMODERATE LAUGHTER
STIFFNESS
HYPERLIPDAEMIA

The miasm is SYCOTIC

The final choice of remedy was Gelsemium 30C.
Follow Up:
21/08/05:

No headache, no giddiness,
Mild nuchal pain.
TINGLING NUMBNESS > 50%O/E:
BP- 140/90

Lt:

UPPER

Hypertonia++
Power

left
knee & ankle 0/5

Plan:

LIMB

left

Continue

&

shoulder
hip

Gelsemium

LOWER

4/5

LIMB

>

30

++
3/5

QDS

23/08/05:
No TINGLING NUMBNESS.
Sensation of tightness in left upper and lower limbs > 75%
POWER: SAME

Plan: Gelsemium 200

QDS

26/08/05:
NO SUBJECTIVE COMPLAINTS
APPETITE, SLEEP NORMAL
POWER: SAME
The patient is now able to walk with support. But this support too is less that what he required
earlier.

Plan: To be Discharged and follow up in OPD regularly.

Continue: Gelsemium 1M QDS.

At this stage we also considered the Chronic totality for a similimum so

as to be able to appropriately begin with chronic treatment when
clinically indicated. Here is the chronic picture:
The patient as a person:

He has 5 duaghters whom he loves very much.

Of all these, his 3rd daughters situation worried him the most. This daughters husband
was alcoholic and had allegedly killed his first wife in a drunken rage.
Hence the patient remained constantly in touch with this daughter on the phone. He
remained tremendously anxious about her.
2 months ago when the hypertensive episode precipitated he had been unable to talk to
her on the phone. Not knowing the reason for this, his got very afraid and thought that her

husband had killed her. His BP went up with the intense anxiety and he began to have
tingling numbness on his left side.
Presently due to his deteriorating health, he remains very anxious about his daughters
future due to her alcoholic husband and his own wifes future, as he did not have any sons.
He was a conscientious and a hard worker in order to support his large family of
daughters.
In addition he is chilly, has aversion for sweets.

The Totality based on this information is:

ANXIOUS
INDUSTRIOUS
SYMPATHETIC
SENTIMENTAL
AVERSION SWEETS
CHILLY

The constitutional remedy chosen was Causticum.

Follow up:
29.8.05
On Gelsemium 1M, his gait improved further, there was no more tingling numbness, his BP was
120/80. But the weakness in his muscle power remained the same.
He was now put on Causticum 30C, 1 single powder at bedtime.
14.9.06
No intoxicated feeling
No headache
No Tingling Numbness
Power Improved:

Left Hip: 3/5

Left knee: 1/5
Left Shoulder: 4/5

Plan: Causticum 30C, 1 dose power daily at bedtime for 7 days.

His power continued to improve and he was normal with blood
pressure well within control, anxiety considerably lessened. His lipid
levels also began to reduce in time. The healing and resolution took
place over a period of just a few weeks which is remarkable in itself.
That the patient chose to begin homeopathic treatment right at the
outset was an important reason for such a quick resolution, before any
other medication interfered with response of the vital force to an
appropriate simillimum.
This is a clear example of how serious cases can be managed effectively
on homeopathic treatment and management without any need for
allopathic interventions, provided we have our principles of remedy
choice and management clearly in place.