case study on cva (2)

8/16/2019 Case study on CVA (2)

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ACase Presentation

On

CerebrovascularAccident

Group J

Marco Paul VelascoPrecious Jane ParungaoRod Lambert de Leon

Carla Aleja AbijayMylene Narag

Jenalin uilang!ri""ia Marie Palce

Jessica #atul


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OBJECTIVES

General Objective$

At t%e end o& t%e case presentation' t%e presenters toget%er (it% t%e audience (illen%ance our understanding on t%e disease process o& CVA' its nursing management andpaves a (ay to us student)nurses appreciate our roles o& being %ealt% care providers int%e country*s +uest &or %ealt% progress and development,

-peci.c Objectives$

At t%e end o& t%e presentation' presenters and audience (ill be able to$

• #e.ne Cerebrovascular Accident,

• #iscuss and interpret data gat%ered t%roug% t%eoretical analysis o& Nursing/istory' Gordon*s 00 1unctional Pattern' P%ysical Assessment and LaboratoryResults,

• 23plain t%e Anatomy and P%ysiology o& Nervous -ystem,

• 4race t%e Pat%op%ysiology o& Cerebrovascular Accdident,

• Create e5ective and e6cient nursing care plan re+uired by a patient (it% t%e

above mentioned disease process,

• #iscuss t%e medications ta7en by t%e client' its action' side e5ects and nursingresponsibilities,


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INTRODUCTION

Cerebrovascular Accident

Cerebrovascular Accident is a sudden loss o& &unction resulting &rom disruption o&

t%e blood supply to a part o& t%e brain, -tro7e' also called brain attac7 or isc%emic stro7e'%appens (%en t%e arteries leading to t%e brain are bloc7ed or ruptured, 8%en t%e braindoes not receive t%e needed o3ygen supply' t%e brain cells begin to die' a stro7e cancause paralysis' inability to tal7' inability to understand' and ot%er conditions broug%t onby brain damage,

1our types o& sto7e$0, Cerebral 4%rombosis) caused by blood clots,9, Cerebral 2mbolism) caused by blood clots,:, Cerebral /emorr%age) caused by bleeding inside t%e brain,;, -ubarac%noid /emorr%age) caused by bleeding inside t%e brain,

Cerebral 4%rombosis 4%e most common type o& brain attac7,

Occurs (%en a blood clot o( in an artery

leading to t%e brain arteries primarily a5ected by at%erosclerosis and moresusceptible to blood clots,

Most o&ten occurs at nig%t or in t%e morning (%en blood pressure in lo(,

O&ten preceded by a transient isc%emic attac7


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4%is case serves as a c%allenge &or us student)nurses to be committed and dedicated

%ealt% pro&essionals &or t%e ne3t daysF (e (ill ta7e care o& t%e %ealt% o& t%e citi"ens,

PATIENT’S PROFILE

Name$ ?,M,

Age$ E yo

Gender$ 1emale

Civil -tatus$ 8ido(er

Birt% date$ #ec, 9;' 0D9E

Nationality$ 1ilipino

Religion$ Roman Cat%olic

Address$ Hgac Norte' 4uguegarao City

2ducational Bac7ground$ College Graduate

Occupation$ Retired 4eac%er

#ate o& admission$ November 0D' 9D

4ime o& admission$ I$; pm

C%ie& complaint$ loss o& consciousness

Mode o& arrival$ via stretc%er

Admitting diagnosis$ /PN tc CVA

1inal #iagnosis$ CVA old recurrent-epsis secondary to pneumoniaN?##M

Attending P%ysician$ #r, Valeriano Combate' JR #r, Marlene Cinco #r, Gerardo Pagaddu' JR

-ource o& in&ormation$ -O' patient*s c%art' Record*s section

/ospital$ 4CGP/)Pay 8ard


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NURSING HISTOR

Past Hea!th Hist"#y

According to -O' (%en t%e patient su5ered &rom %eadac%e' &ever' and coug%'patient ta7es over t%e counter drugs li7e paracetamol' biogesic' ala3an and solmu3,Patient (as diagnosed (it% Al"%eimer*s disease on 9;' and undergone mastectomy(%en s%e (as ;9yo,

Hist"#y "$ P#ese%t I!!%ess

According to -O' at t%e evening o& November 0D' 9D' ; minutes P4C' -Onoticed t%at patient (as still sleeping at around I$pm, -%e t%en tried many times to

(a7e up t%e patient and called %er to eat but s%e did not receive any response, 4%e -O(as alarmed and decided to rus% t%e patient to People*s 2mergency /ospital and (asadmitted around I$;pm, , At t%e age o& 9 patient (as %ospitali"ed and diagnosed o& /PN and manages it by ta7ing maintenance drugs suc% as amlodipine' simvastatin Kaspirin ta7en t(ice a day,

Fa&i!y Hea!th Hist"#y

4%e patient %as a %istory o& Ast%ma on %er paternal side, /er &at%er died o& Ast%maand %er mot%er died due to %ypertension,

S"cia! Hea!th Hist"#y

Patient is a retired teac%erF s%e lives (it% %er daug%ter and grand c%ildren,According to t%e -O be&ore t%e patient (as diagnosed o& Al"%eimer*s disease' t%e patientloves to mingle (it% %er neig%bors and loves to ta7e care o& %er grand c%ildren, -O alsoverbali"ed t%at patient does not drin7 alco%ol nor smo7e cigarettes,


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GORDON’S '' FUNCTIONAL PATTERN

Hea!th Pe#ce(ti"%)Hea!th *a%a+e&e%t Patte#%Be&ore /ospitali"ation #uring /ospitali"ation According to t%e -O' %er mot%er

%as been pampered starting (%en s%e(as diagnosed (it% Al"%eimer*sdisease years ago, 8%en s%esu5ered &rom t%e sic7ness' t%eytreated %er immediately by ta7ing O4Cdrugs &or coug%' colds and &ever, 8it%regards to %er maintenance drugs to%er %ypertension' t%ey give it at rig%ttime as prescribed,

According to t%e -O' s%e stated t%at %er

mot%er is not in good condition, -%e believest%at doctors' nurses and ot%er medicalmembers (ill %elp %er mot%er to recover, -Oalso added t%at t%ey obediently &ollo( all t%eorders o& t%e doctors,

N,t#iti"%a!) *eta-"!ic Patte#%Be&ore /ospitali"ation #uring /ospitali"ation According to t%e -O' %er mot%er eatseveryt%ing s%e (ants and sees, -%e %as nopre&erence diet, -%e eats : times a day(it% mid a&ternoon snac7s, -%e drin7s I)Eglasses o& (ater a day, -%e %as no di6cultyin s(allo(ing and %as no allergy (it% anytype o& &ood,

Hpon admission' t%e patient (asinserted NG4 and (as ordered (it% PN--0liter to run &or E %ours, 4%e diet (asosteori"ed &eeding (it% -AP,

E!i&i%ati"% Patte#%Be&ore /ospitali"ation #uring /ospitali"ationAccording to t%e -O' s%e de&ecates once aday (it% semi) &ormed and bro(n in colorand being eliminated in morning, -%e voidsI)E times a day (it% yello(is% in color,

#uring our s%i&t' t%e patient didn*tde&ecate, -%e %as ?1C connected to urinebag (it% ml and yello( amber in color,

Acti.ity E/e#cise Patte#%Be&ore /ospitali"ation #uring /ospitali"ation According to t%e -O' t%e patient is li7e a

c%ild, -%e plays (it% %er neig%bor%ood,-ometimes (al7ing around t%eir %ouse,About %er %ygiene' t%ey see to it t%atcleanliness must maintain to %er,

4%e patient is in comatose state,

-tudent)nurses and -O initiated passiverange o& motion &or %er to e3ercise,

S!ee() Rest Patte#%Be&ore /ospitali"ation #uring /ospitali"ationAccording to t%e -O' %er mot%er sleeps ataround E in t%e evening and (a7es up ataround in t%e morning, -%e ta7es naps ata&ternoon, -%e %as no rituals be&ore

sleeping s%e added,

Patient is comatose but can respond top%ysical stimuli,

C"+%iti.e Pe#ce(t,a! Patte#%Be&ore /ospitali"ation #uring /ospitali"ation According to t%e -O' %er mot%er is aretired teac%er' s%e uses eyeglasses, -%espea7s dialects suc% as ?locano' 4agalogand 2nglis%,

4%e patient responds to stimuli by meanso& rubbing %er sternum &or %er to (a7e up,


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Se!$) Pe#ce(t,a! Patte#%Be&ore /ospitali"ation #uring /ospitali"ation 4%e patient su5ers &rom Al"%eimer*sdisease,

4%e patient is comatose,

R"!e) Re!ati"%shi( Patte#%Be&ore /ospitali"ation #uring /ospitali"ationAccording to t%e -O' be&ore %er mot%er(as diagnosed (it% Al"%eimer*s' s%e (as aloving mot%er and responsible to %erc%ildren, -%e provides t%eir needs and seesto it t%at t%ey are com&ortable in t%eir (ayo& li&e,

#ue to %er condition' %er daug%terstated t%at t%ey (ill do all t%eir best to ta7ecare o& t%eir mot%er, 4%ey (ill ma7e sure togive bac7 t%e care t%ey %ave received &rom%er,

C"(i%+) St#ess Patte#%Be&ore /ospitali"ation #uring /ospitali"ation 8%en %er mot%er is tired' s%e sleeps &or%er to rest,

#uring %er present condition' s%e is in astress&ul state, /er &amily is t%ere tocom&ort and give %er necessary needs justto s%o( t%eir love,

Se/,a!) Re(#"0,cti"% Patte#% 4%e patient %as .ve c%ildren and %ad %er menopause at t%e age o& ,

Va!,e Be!ie$ Patte#% -%e is a Roman Cat%olic, 8%en s%e (as diagnosed (it% Al"%eimer*s disease' %er&amily never allo(ed %er to go to mass' preventing %er to lose %er (ay %ome,


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PHSICAL ASSESS*ENT

• #ate Assessed$ #ecember :' 9D' $0 PM• Vital -igns$• BP$ 0;D mm/g• PR$ D9 bpm• RR$ 9: cpm• 4$ :I,EC

General Appearance$

Patient is lying on bed' comatose (it% ongoing ?V1 o& PN-- 0L 3 9 gttsminute

at cc level %oo7ed at le&t metacarpal vein patent and in&using (ell, 8it% NG4 patent,

8it% ?1C connected to urine bag draining yello( amber,

AREA

ASSESSED

*ETHOD

USED

NOR*AL

FINDINGS

ACTUAL

FINDINGS

ANALSIS

S1IN

) Color

) 4e3ture

) 4emperature

) Moisture

) 4urgor

HAIR

?nspection

?nspection

Palpation

?nspection

Palpation

Palpation

Palpation

1air

comple3ion

-moot%

Normally (arm

Moist to dry

-naps bac7 to

previous

Pale

8rin7led

Presence o&

ras%es

Cold and

clammy

#ry

-agged

dt decreased

tissue per&usion

and perip%eral

vasoconstriction

dt loss o& elastic

.ber and

decreased

subcutaneous &at

&rom %ypodermis

secondary toaging

dt poor %ygiene

dt perip%eral

vasoconstriction

dt decreasedactivity o&

sebaceous and

s(eat glands

secondary to

aging

dt loss o& elastic

.ber and


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) distribution

) 4e3ture

) Color

NAILS

) Color o& t%e

nail bed

) Capillary

re.ll time

) -%ape

EES2EEBROWS

) -%ape

) -ymmetry

) Movement

) Ability toblin7

CONJUNCTIVA

) Color

PUPILS

) P2RRLA

) -i"e o& t%e

pupil

E3TERNAL

AUDITOR

CANAL) /earing

NOSE

) -ymmetry

) Color

?nspection

Palpation

?nspection

?nspection

?nspection

Palpation

Palpation

?nspection

?nspection

?nspection

?nspection

?nspection

?nspection

?nspection

?nspection

?nspection

?nspection

2venly

distributed

-il7y' resilient

Blac7

Pin7transparent

#elayed 0)9

sec,

Conve3

Round

2+ual in si"e

-ymmetrical in

movement

Blin7s

involuntarily Kbilaterally

Pin7)red

Response to

penlig%t


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LIPS 4 *OUTH

) -ymmetry

) Color


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Date Res,!t N"#&a! Ra%+e A%a!ysis'')5:)67


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'')56)67

Pa#a&ete#s Res,!t N"#&a! Ra%+e A%a!ysisWBC '5:/'6< 2&&<


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:)00 0 9 ; 09; : : 4otal$ 9:D

4otal$ I;

09)9)D

?nta7e Output

4ime Oral Parenterral

Ot%ers

4otal Hrine #rainage

Ot%ers 4otal

): D 09 D D:)00 E:9 09 09 II II00) I 9 E 4otal$ :;9

4otal$ 9

00):)D

?nta7e Output

4ime Oral Parenter

ral

Ot%er

s

4otal Hrine #raina

ge

Ot%ers 4otal

): I :; D; 0 0:)00 ED ; 0:I 00 0000) 9 D D 4otal$ 9

4otal$ :

00)9D)D

?nta7e Output

4ime Oral Parenter

ral

Ot%er

s

4otal Hrine #raina

ge

Ot%ers 4otal

:)00 E : 00 ; ; 4otal$ 00

4otal$ ;

00)9E)D

?nta7e Output

4ime Oral Parenter

ral

Ot%er

s

4otal Hrine #raina

ge

Ot%ers 4otal

): E: 0:E 0: 0::)00 0: 0: I I00) 0; 0I 0I 4otal$ ;0

4otal$ :I

00)9)D

?nta7e Output

4ime Oral Parenter

ral

Ot%er

s

4otal Hrine #raina

ge

Ot%ers 4otal

): 0: I 0I: 0I: 0I:


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:)00 I ; 0 0 0 4otal$ 9IE

4otal$ 9IE

00)9I)D

?nta7e Output


Ot%ers


Ot%ers 4otal

): EI ; 0:: I I:)00 09 ; 0I 09 09 4otal$ 9DE

4otal$ 0E

00)9)D

?nta7e Output


Ot%ers


Ot%ers 4otal

): : 009 :)00 E0 9 00 E E00) E 9 0 09 09 4otal$ :0:

4otal$ 9

00)9;)D

?nta7e Output

4ime Oral Parenter

ral

Ot%er

s

4otal Hrine #raina

ge

Ot%ers 4otal

): 0 ; 000 : ::)00 E 9 0 0; 0; 4otal$ 90I

4otal$ 0

00)9:)D

?nta7e Output

4ime Oral Parenter

ral

Ot%er

s

4otal Hrine #raina

ge

Ot%ers 4otal

): 0: 9 09: : ::)00 09 I I00) I 0: 4otal$ :E

4otal$ 0I

CRANIAL CT)SCAN

Plain and contrast)en%anced a3ial tomograp%ic sections o& t%e %ead s%o(s ill de.ned%ypoattenvation in t%e bot% &ronto)parietal periventrical and bot% occipitalperiventricular areas,

4%e ventricles are unenlarged 4%e midline structures are undisplaced 4%e sulci and cisterns are prominent


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No abnormal e3tra)a3ial >uid collection detected 4%e brain stem' pineal region and posterior &ossa do not appear unusual 4%e internal carotid basilar and vertebral arteries are calci.ed 4%e sella turcica is not enlarged-o&t tissue attenvation is noted in t%e rig%t ma3illary sinus

?MPR2--?ON$Acute in&arcts' bot% &ronto)parietal periventricular and bot% occipital

periventricular areas,Cerebral Atrop%yAt%erosclerotic ?nternal Carotid' basilar and vertebral arteries-inusitis vs polyp' rig%t ma3illary sinus

ANATO* AND PHSIOLOG

Ce%t#a! Ne#.",s Syste&

4%e Central Nervous -ystem


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4%e brain is composed o& t%ree parts$ t%e cerebrum


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4%e &orebrain consists o& t%e diencep%alon and cerebrum, 4%e t%alamus and%ypot%alamus are parts o& t%e diencep%alon, 4%e t%alamus acts as a s(itc%ing center &ornerve messages, 4%e %ypot%alamus is a major %omeostatic center %aving bot% nervousand endocrine &unctions,

4%e Cerebrum

4%e cerebrum' t%e largest part o& t%e %uman brain' is divided into le&t and rig%t

%emisp%eres connected to eac% ot%er by t%e corpus callosum, 4%e %emisp%eres arecovered by a t%in layer o& gray matter 7no(n as t%e cerebral corte3' amp%ibians andreptiles %ave only rudiments o& t%is area,

4%e corte3 in eac% %emisp%ere o& t%e cerebrum is bet(een 0and ;mm t%ic7, 1oldsdivide t%e corte3 into &our lobes$ occipital' temporal' pariental' and &rontal, No region o& t%e brain &unctions alone' alt%oug% major &unctions o& various parts o& t%e lobes %avebeen determined,

4%e occipital lobe


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There was no Past History of dia!etes, or ischemic heart disease aspossi!le precipitating factors"

On /'amination

Pulse 1min

3P #50#00

4- +lear

+- -#-2 ormal

PA AD

+- +onscious, +ooperati$e, 6ell oriented in time, space and person

Higher 7unctions, +ranial er$es ormal

o Palliloedema

Motor Rig%t Le&t

4one$ HL Normal ?ncreased

4one $ LL Normal ?ncreased

Muscle Po(er$ HL Normal Pro3imal Muscles$

Po(er 0 #istal

Muscles$ Po(er ;

Muscle Po(er$ LL Normal Complete loss o&

po(er$

Re>e3es$ HL Normal /ypertonic

Re>e3es$ LL Normal /ypertonic

-ensory Normal Loss o& .ne touc% in

Hpper and Lo(er

limbs

At this point in the OPD we had to decide whether this case needed to

!e admitted as inpatient for homeopathic management" 6e follow a setof criteria to ma&e this decision for all cases, including this one" Hereare the criteria that indicate mandatory in*patient admission for ahomeopathic 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

%n this case, hospital admission was a necessity for furtherin$estigations and management to !e carried out"

%n$estigations• 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


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• S . TRIGLYCERIDES : 254

• S. CREAT : 1.0

/"+"8" 9""H" Pattern

+T -+A : 34A% ;Pictures can !e $iewed in the attached slidepresentation<

/o ill*defined hypodense lesion seen in the 4t high parietal lo!ein$ol$ing centrum semi o$ale, mostly suggesti$e of recent non*hemorrhagic infarct in 4t =+A area"

/o multiple lacunar infarcts in 4t internal capsule > !asal ganglia"

/o old small si?e infarct in 9t anterior lim! of internal capsule in 9t=+A area" Peri$entricular white matter ischemic changes seen"

FINAL DIAGNOSIS:

9T -%D/D H/=%P9/8%A, secondary to 4ight =+A ;=iddle +ere!ral Artery< non*hemorrhagic infarct in$ol$ing the parietal lo!e of thecere!rum"

H@P/4T/-%O

H@P/49%P%DA/=%A

Management:

Once these preliminary medical o!ser$ations are complete, we mustnow appraoch the case from the homeopathic standpoint forappropriate homeopathic management and care" %n fact thehomeopathic diagnosis is an integrated ongoing process e$en throughthe medical wor& !eing done a!o$e"

6hat is o!$ious from a!o$e, is that there already e'ists a chronicprocess going on o$er many months that has precipitated now as ahemiplagia ;stro&e


20/22

deal with the e'cessi$e tendency to !e mor!idly an'ious and fearfulo$er circumstances" 6ith this philosophical understanding of our approach, weconcentrated on the acutely presenting totality which was as !elow

Ailments 7rom 74%8HT 7/A4

AB%/T@

H/AD PA% =O4%8 #0 a" m"

-TCP/7A+T%O, A- %7 %TOB%+AT/D, H/ADA+H/ DC4%8,

9AC8H%8 T/D/+@, %==OD/4AT/9@

PA4A9@-%-, C=3/-- 6%TH,

PA4A9@-%-, PA%9/--

PA4A9@-%- O/ -%D/D : 9/7T

These were the ru!rics chosen" Our ne't step was to consider whichrepertori?ation approach was appropriate to this case gi$en thecharacteristic picture" -ince there was characteristic sensation,modalities, concomitants, and causation, we chose the3oenninghausan’s approach for repertori?ation"

The remedies that came up were Nux Moschata, Gelsemium, Opium, Rhustox ,Causticum"

7urthur discussion was reuired to decide on the appropriate remedy"

Along with this we also made an assessment of the Susceptiblity • S!"#$%&b&'&%(: L)* S#+!&%&,&%(: H&-

• /"#: S')*

• C"%#&!%&": #*

• /%)')-(: S%"%' I#,#!&b'#

• &%' )-+ #"%#

Hence the choice of posology was 9ow potency with freuentrepetition"

The ne't step was to e$aluate the underlying Miasm• 10 ..

• SLO /ROGRESS

• CONUSION

• INTOICATED EELING

• IMMODERATE LAUGHTER

• STINESS

• HY/ERLI/DAEMIA

The miasm is -@+OT%+

The final choice of remedy was Gelsemium 3C!Follo" #p:

$%&'&(:• N) #"#; +) -&&+#!!;

• M&' +"' $&+.

• TINGLING NUMBNESS < 50=O>E:

• B/? 140>90


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• L%: U//ER LIMB @ LOER LIMB

Hypertonia((

Power : left shoulder 5 E ((

left hip F5

&nee > an&le 05

Plan +ontinue 8elsemium F0 GD-$3&'&(:

o T%89%8 C=3/--"

-ensation of tightness in left upper and lower lim!s E 5I

PO6/4 -A=/

Plan Gelsemium 200 GD-$)&'&(:

O -C3J/+T%/ +O=P9A%T-

APP/T%T/, -9//P O4=A9

PO6/4 -A=/

The patient is now a!le to wal& with support" 3ut this support too is less that what he reuiredearlier"

Plan To !e Discharged and follow up in OPD regularly"

+ontinue Gelsemium #= GD-"

At this stage we also considered the +hronic totality for a similimum soas to !e a!le to appropriately !egin with chronic treatment whenclinically indicated" Here is the chronic picture

*+e patient as a person:• H# ! 5 -%#! *) # '),#! ,#( ".

• O '' %#!#; &! 3 -%#! !&%%&)+ *) & %# )!%. T&! -%#! !b+

*! '"))'&" + ''#-#'( &''# &! &!% *&# &+ +#+ -#.

• H#+"# %# $%+% #&+# ")+!%+%'( &+ %)" *&% %&! -%# )+ %# $)+#. H#

#&+# %##+)!'( +&)! b)% #.

• 2 )+%! -) *#+ %# ($#%#+!&,# #$&!)# $#"&$&%%# # b##+ +b'# %) %' %)

# )+ %# $)+#. N)% +)*&+- %# #!)+ ) %&!; &! -)% ,#( & + %)-% %% #


22/22

!b+ &''# #. H&! B/ *#+% $ *&% %# &+%#+!# +%( + # b#-+ %) ,#%&+-'&+- +b+#!! )+ &! '#% !&#.

• /#!#+%'( # %) &! #%#&)%&+- #'%; # #&+! ,#( +&)! b)% &! -%#!

%# # %) # '"))'&" !b+ + &! )*+ *&#! %#; ! # & +)% ,# +( !)+!.

• H# *! ")+!"+%&)! + *)# &+ )# %) !$$)% &! '-# &'( )

-%#!.

• I+ &%&)+ # &! "&''(; ! ,#!&)+ ) !*##%!.

The Totality !ased on this information is

• ANIOUS

• INDUSTRIOUS

• SYM/ATHETIC

• SENTIMENTAL

• AERSION SEETS

• CHILLY

The constitutional remedy chosen was +austicum"

Follo" up:

$,!'!(

On Gelsemium #=, his gait impro$ed further, there was no more tingling num!ness, his 3P was

#2010" 3ut the wea&ness in his muscle power remained the same"

He was now put on Causticum F0+, # single powder at !edtime"

%-!,!)

o into'icated feeling

o headache

o Tingling um!ness

Power %mpro$ed

• L#% H&$: 3>5

• L#% +##: 1>5

• L#% S)'#: 4>5

Plan Causticum F0+, # dose power daily at !edtime for days"His power continued to impro$e and he was normal with !loodpressure well within control, an'iety considera!ly lessened" His lipidle$els also !egan to reduce in time" The healing and resolution too& place o$er a period of .ust a few wee&s : which is remar&a!le in itself"That the patient chose to !egin homeopathic treatment right at theoutset was an important reason for such a uic& resolution, !efore any other medication interfered with response of the $ital force to anappropriate simillimum"

This is a clear e'ample of how serious cases can !e managed effecti$ely on homeopathic treatment and management without any need forallopathic inter$entions, pro$ided we ha$e our principles of remedy choice and management clearly in place"

case study on cva (2)

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