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MSPH110 Public Health Practice

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Introduction

This 81-year-old grandmother is presented for treatment with complete right-sided hemiplegia after an attack by ischemic stroke 4 months ago. Within the six weeks of acupuncture treatment, the grandmother has regained limited plantar flexion and voluntary dorsi on her right foot. She has also regained an extension and flexion of her elbow and knee as well as indicating signs of increased sensation of her right arm. The patient developed and experienced a cough 5 weeks after the stroke following the existence of a fluid in the lower right lobe of her lungs.  This is a frequent concern among patients who rarely move in the damp and cold houses of Nepal. The cough was however successfully using the locally available Chinese herbs (Administration. 2012, p. 65).

The 81-year-old grand woman is presented with hemiplegia of the right side as a sequel of ischemic stroke. A week before the first assessment, the patient woke from a rest and found she is unable to move with her right leg and arm being numb. She could as well neither open her right eye nor talk. She had problems sitting upright by herself and needed support in order to sit up (Bruyere 2014, p. 152). The family took the initiative of transporting her to the hospital so as to seek medication.  She was admitted to the hospital for five days and upon being discharged, she was able to open her right eye lid besides regaining significant but limited speech.

An examination is conducted on her progress a week after the stroke attack. The reports from the examination indicate she has problems with moving her right limb and moving the right side of her face (Gauthier 2011, p. 288). She says she feels the right side of her body is numb and heavy. She feels very hot especially in the evening hours and sweats a lot at night. She has lost appetite, experiences dizziness, dry throat, blurry vision and thirst for cold drinks (Butler 2016, p. 564).

Among the medication she receives upon the first examination include Ranitidine 150mg QD, 10mg QD of Atorvastatin and75mg QD of Aspirin.

Objective

The patient looks weak, thin and overpowered by the disease at the first time of evaluation. She cannot sight upright without being assisted. She records no atrophy of muscles on her right side (Bulechek 2013, p. 167). She has dry skin when touched and indicates a significant level of loss of hearing which is assumed to be normal bearing her age. She has no control of her right limbs. In most cases, her right hand and forearm are contracted and can't easily be extended upon a little force. She is able to lift her right shoulder with ease and move her right arm using her left arm (Bertorini 2013, p. 197).

No contracture is noticeable on her right leg and thigh and the joint of her right hip can move to a small degree. The resultant temperature difference on either side of the body is zero meaning there is not a significant difference in the temperature on either side of the body. The either sides of the body i.e. the left and the right sides become warm when covered with blankets.

There is a significant decrease in sharp touch on dermatomes S1 and C7 at the distal tips on the right side but this difference is not experienced when C8, L5, and C6 dermatomes are used. The DTR's measure +2 on the left side and +3 on the right side and dull sensation are found to be equal and intact on both the left and right legs and arms (Dworkin 2013, p. 697). There was a significant droop in the patient’s right eyelid lateral corner and right mouth side. She has problems smiling equally on both sides of the mouth and is able to puff out both the cheeks. She has some moisture collected at the lateral corners of her right eye and mouth. The tongue is red and thin with a dry, thick and yellow-gray coat. She has a rapid and floating pulse which is thin taught and thin across every position of her body.

Assessment

The following deductions were made from her assessment:

Prognosis: she was guarded due to her age and being that she was suffering from ischemic stroke. Factors such as dedication by the family to support her in her recovery process, significant continuous progress in the mobility of her right foot upon the first 35 treatments and acupuncture treatments worked in her favor (Wagner 2015, p. 631).

TCM DX: wind-stroke sequel accompanied with wind-phlegm which obstruct the collaterals and channels.

Initial Treatment Plan

5 days per week of acupuncture treatment this was associated with regular and frequent assessment at intervals of 3 weeks. The acupuncture treatment mainly focused on the clearance of wind-phlegm from the collaterals and channels (Bramwell 2009, p. 521). This was made more effective by frequent monitoring of the important signs that would indicate pneumonia or heart attack. This is because either of these conditions would put the patient at a greater risk of life.

Another treatment plan involved counseling of the patient to engage in physical exercises so as to flex and extend the muscles of the right side of her body (DiZazzo-Miller 2010, p. 158). The patient was to physical exercise twice as much as she was doing it before she was attacked by the disease. The exercises would see a flexure and extension of her right fingers, hands, toes, feet, and arm. The routine exercise was to be encouraged despite the lack of a joint movement of the patient's body organs.

The patient is to be encouraged to go outside the house every day and sit upright in the sunshine with the help of the family members (Li 2015, p. 666). She was encouraged to take short walks around her home to improve on the extension and flexure of the right side of her body. The members of the family are to be educated to gently massage the left limbs of the patient using mustard oil by moving the forearm and arm to their fullest extension so as to reduce contraction.

Continuing Treatment Plan

5 weeks of continuous treatment, the patient is found to develop a cough and unable to expectorate (Stefan 2012, p. 451). She rules out experiencing chills, headache, sore throat or tension in her upper back and neck. She can expectorate very little sputum which is found to be stick, yellow and thick. She resides on the ground floor of her house which is constructed of mortar and bricks. She uses 3 blankets that are put over the plastic tarp to protect her against the cold weather during winter. She is occasionally taken outside the house in the sun by her family members so as to have a rest in the warmth as well as do exercise for a few hours every day (Kaufman 2012, p. 187). When not in the sun, the patient is usually in her room which has no electricity or any other form of heating.

An assessment indicates a possibility of consolidation of the lower right lobe of her lungs most probably due to her immobility. The coughs are a result of phlegm-heat that is experienced in the lungs. The condition is detected early enough thereby enhanced monitoring at every administration of acupuncture treatment. In as much as the living environment of the patient may not change, she would be educated on how to cope with the prevailing conditions (Meleca 2014, p. 238). The unchanging environmental conditions would long term challenges that she may need to overcome throughout her recovery period.

Updated Treatment Plan

In addition to the initial acupuncture plan, ST40 and LU5 are included. She is also administered with 8 pills of Qing Qi Hua Wan for a period of three weeks. She is referred to an allopathic physician who administers her with 5mg QD of Amlodipine (Bramwell 2015, p. 502). The family and the patient are as well counseled to maintain regular and adequate water and balanced diet so as to lower hypertension and phlegm levels.

Results

There are notable changes in the movement of the right limb and arms of the patient following the 40 treatments administered. She now feels her limbs are lighter as opposed to the initial conditions in which the limbs were numb and heavy. The patient is able to successfully walk slowly around her home with the assistance of her family members. She became livelier with brighter mode expressing joy (George A. Mashour 2011, p. 369). She could smile during treatments and began walking around with her animals in the field once again.

Her right knee could extend and flex up to 90-degree motion range. She was able to dorsiflex and plantar her ankles to the level of 5 degrees and flex her right elbow to the range of 10 degrees (Bruyere 2014, p. 357). She was still unable to move her right fingers freely and required slight simulation. As a result of the home massages, she recorded a significant reduction in the contraction of the right forearm even though she experienced pain in her right arm after she was massaged.

She was able to sit upright though not for a very long time without assistance. She developed clearer speech and could easily be understood by her listeners.

Conclusion

It is important to maintain a routine acupuncture treatment so as to effectively monitor and control hemiplegia. In collaboration with physical exercises and home care support, acupuncture treatments have proved to be very helpful when it comes to containing right side hemiplegia. An acupuncture physician is placed at a unique position in the provision of daily acupuncture treatments. The physician acts as the primary health care provider hence checking on any other physical conditions and diseases whose quick development may lead to a significant threat to the recovery process of the patient. Early diagnosis of the various conditions and diseases, as illustrated in the case study, help in quickened restoration of the normal health conditions of the patient.

References

Administration., USSS 2012, Understanding SSI disability for children, 3rd edn, Social Security Administration, Office of Disability, New York.

Bertorini, TE 2013, Neuromuscular Case Studies E-Book, 6th edn, Elsevier Health Sciences, Manchester.

Bramwell, SB 2009, Studies in Clinical Medicine: May to October 1889, 3rd edn, Y. J. Pentland, Oxford.

Bramwell, SB 2015, Studies in Clinical Medicine: A Record of Some of the More Interesting Cases Observed, and Some of the Remarks Made, at the Author's Out-patient Clinic in the Edinburgh Royal Infirmary. Volume First, Volume 1, 4th edn, Y.J. Pentland, Chicago.

Bruyere, HJ 2014, 100 Case Studies in Pathophysiology, 2nd edn, Lippincott Williams & Wilkins, Salt Lake.

Bulechek, GM 2013, Nursing Interventions Classification (NIC)6: Nursing Interventions Classification (NIC), 10th edn, Elsevier Health Sciences, Chicago.

Butler, SW 2016, Medical and Surgical Reporter, Volume 40, 7th edn, University of Michigan, London.

DiZazzo-Miller, R 2010, Preparing for the Occupational Therapy National Board Exam: 45 Days and Counting, 5th edn, Jones & Bartlett Publishers, Manchester.

Dworkin, JP 2013, Vocal Pathologies: Diagnosis, Treatment, and Case Studies, Part 1, 5th edn, Singular Publishing Group, New Delhi.

Gauthier, S 2011, Case Studies in Dementia: Common and Uncommon Presentations, 3rd edn, Cambridge University Press, New York.

George A. Mashour 2011, Case Studies in Neuroanesthesia and Neurocritical Ca, 3rd edn, Cambridge University Press, New York.

Kaufman, DM 2012, Kaufman's Clinical Neurology for Psychiatrists E-Book, 7th edn, Elsevier Health Sciences, Chicago.

Li, H 2015, Radiology of Infectious Diseases:, Volume 1, 2nd edn, Springer, Beijing.

Meleca, RJ 2014, Clinical Studies, Volume 2, 4th edn, R. & R. Clark, California.

Stefan, H 2012, Case Studies in Epilepsy: Common and Uncommon Presentations, 3rd edn, Cambridge University Press, New York.

Wagner, C 2015, MEDICAL TIMES AND GAZETTE VOL 2 FOR 1876, Oxford University, London.

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