BEACON FOUNDATION’S

CASE PRESENTATION CONTEST

2006

A

CASE

OF

CEREBRO- VASCULAR ACCIDENT

PRESENTED

BY

DR. NIRANJAN PAI

M.D. PART –2

DEPARTMENT OF MEDICINE

M.L.D.M.H.I.

PALGHAR

Preliminary Data:Mr. P. G, 50yrs/ Male 20/8/05Location Sensation Modality ConcomitantCNS:

Left upper and

lower limbs

since 10 d

Onset: sudden

gradually

increasing.

-Tingling

numbness

tightness++

-Weakness++,

unable to move

limbs

-Feeling of being

intoxicated+++

-Speech slurred

Immoderate

Laughter

A/F fright, fear

< anxietyHeadache

< morning++

< 9 – 10 am

Location Sensation Modality Concomitant

CVS:2 mths

ago

Lt. UL, LL

Accidentally

detected

Tingling

numbness

Vertigo

Diagnosed as

hypertensive

Put on anti -

hypertensives

Stopped on his

own

A/F fright, fear

>medication

No H/O: unconsciousness, convulsion, projectile vomiting, fever, head

injury.

Not K/C/O diabetes mellitus, I.H.D, etc

ON EXAMINATION:

General condition: Fair

P- 84/ min

BP- 150/100 mm hg

RS – clear

CVS – S1 S2 normal

P/A – NAD

CNS –Conscious, co-operative, well oriented in Time, Space and Person

Higher functions / Cranial nerves – normal

MOTOR: RIGHT LEFT

TONE: UL NORMAL

LL NORMAL

MUSCLE POWER

UL NORMAL PROXIMAL 1/5

DISTAL 4/5

LL NORMAL COMPLETE 0/5

REFLEXES

UL NORMAL HYPER ++

LL NORMAL HYPER ++

SENSORY: NORMAL LOSS OF FINE TOUCH

IN UPPER and LOWER LIMB

NO PAPILLOEDEMA.

INDICATIONS FOR ADMISSION

• 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

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

E/o ill-defined hypodense lesion seen in

the Rt high parietal lobe involving

centrum semi ovale, mostly suggestive of

recent non-hemorrhagic 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 Rt

MCA non-hemorrhagic infarct involving

Parietal lobe

HYPERTENSION

HYPERLIPIDAEMIA

APPROACH TO THE CASE

CLASSIFICATION : ACUTE COMPLICATION OF

CHRONIC DISEASE

PLAN:

AN ACUTE REMEDY FOLLOWED BY A

CONSTITUTIONAL REMEDY .

REASONS:ACUTE:

AS THERE IS A DISTINCT

CHANGE IN THE

SUSCEPTIBILITY AS

INDICATED BY THE CHANGE IN

SYMPTOMATOLOGY IN THE

FORM OF CAUSATIVE FACTOR

CHRACTERISTIC

CONCOMITANTS, MODALITIES

AND SENSATION

CONTITUTIONAL:

AS IT WILL HELP HEAL THE

INFARCT AND ALSO DEAL

WITH THE UNDERLYING

CHRONIC DISEASE OF

HYPERTENSION AND

HYPERLIPIDAEMIA WHICH IF

NOT CONTROLLED MAY LEAD

TO FURTHER COMPLICATIONS

1. A/F FRIGHT / FEAR

2. < ANXIETY

3. HEAD PAIN MORNING 10 a. m. <

4. STUPEFACTION, AS IF INTOXICATED, HEADACHE

DURING,

5. LAUGHING TENDENCY, IMMODERATELY

6. PARALYSIS, NUMBNESS WITH,

7. PARALYSIS, PAINLESS

8. PARALYSIS ONE SIDED - LEFT

ACUTE PRESCRIBING TOTALITY:

HOMOEOPATHIC APPROACH TO THE CASE

PRESENCE OF:

• CHARACTERISTIC CAUSATION

• CHARACTERISTIC CONCOMITANTS

• CHARACTERISTIC MODALITIES

• CHARACTERISTIC SENSATION

HENCE BOENNINGHAUSEN’S APPROACH

REMEDIES COMING UP FOR DISCUSSION

• NUX MOSCHATA

• GELSEMIUM

• OPIUM

• RHUS TOX

• CAUSTICUM

SUSCEPTIBILITY ASSESMENT CRITERIA

• Susceptibility: Low Sensitivity: High• Pace: Slow• Characteristic: Few• Pathology: Structural – Irreversible• Vital organ affected

Posology: low potency, frequent repetition.

MIASMATIC UNDERSTANDING

• 10 a.m. <

• SLOW PROGRESS

• CONFUSION

• INTOXICATED FEELING

• IMMODERATE LAUGHTER

• STIFFNESS

• HYPERLIPDAEMIA

SYCOTIC

FINAL REMEDY:

GELSEMIUM 30 C SINGLE DOSE

gradually in frequent doses

FOLLOW UPS:

21/08/05:• No headache, no giddiness, • Mild nuchal pain.• TINGLING NUMBNESS > 50%• O/E:• BP- 140/90• Lt: UPPER LIMB & LOWER LIMB• Hypertonia++• Power – left shoulder – 4/5 > ++• left hip - 3/5• knee & ankle - 0/5• GELS 30 QDS

FOLLOW UPS CONTINUED:

23/08/05:

No TINGLING NUMBNESS.

Sensation of tightness in left upper and lower limbs > 75%

POWER: SAME

GELS 200 QDS

26/08/05:

NO SUBJECTIVE COMPLAINTS,

APPETITE, SLEEP NORMAL.

POWER: SAME,

PATIENT CAN WALK WITH SUPPORT REQUIRES LESS

SUPPORT THAN BEFORE

DISCHARGED ON GELS 1M QDS.

PATIENT AS PERSON

• 5 DAUGHTERS – LOVE ALL OF THEM VERY MUCH.

• 3RD DAUGHTER’S HUSBAND ALCOHOLIC, ALLEGEDLY KILLED FIRST WIFE.

• PATIENT CONSTANTLY IN TOUCH WITH THE DAUGHTER ON PHONE. ANXIOUS+++

• 2 MONTHS AGO UNABLE TO TALK TO HER FEAR3 THAT HER HUSBAND KILLED HER ALSO BP , TINGLING NUMBNESS IN LEFT SIDE.

• ANXIETY ABOUT DAUGHTER’S AND WIFE’S FUTURE+++

TOTALITY

• ANXIOUS

• INDUSTRIOUS

• SYMPATHETIC

• SENTIMENTAL

• AVERSION SWEETS

• CHILLY

CAUSTICUM

FOLLOW ON 29/8/05

GAIT IMPROVED FURTHER

• NO TINGLING NUMBNESS.

• BP 120/80

• POWER: SAME

CAUSTICUM 3O IP HS

NO INTOXICATED FEELING

NO HEADACHE

NO TINGLING NUMBNESS

POWER: IMPROVED

Lt Hip: 3/5

knee: 1/5

Lt Shoulder: 4/5

CAUSTICUM 30 7P HS

FOLLOW UP ON 14/09/05

THANK YOU

YOU