A Case Study

Here is a case study from when I was treating patients in the village. This content will be most relevant and understandable by practitioners of Chinese medicine, but it is open for all to read!

77 y/o Male 

First Visit: 10/10/23

Chief Complaint: R side weakness and paralysis 

Onset: 17 days ago 

The stroke happened at 3 AM when he was grinding flour and he slowly couldn’t use his R arm and he couldn’t see at all and had a headache. He then took a shower and went to a local clinic and received saline water treatment. He then went to Kathmandu for further treatment. The patient lives in a village 3-4 hours from Kathmandu. The exact treatment was unknown by the patient, but he received a CT scan and was told he had a stroke, they were not clear on which kind of stroke it was; however, it seems it was an Ischemic stroke.

That night, the patient’s leg became weak and his head continued to hurt along with blurry vision.

The patient has noticed that since the onset drinking alcohol makes his head hurt worse and his vision gets blurry. 

The patient does have a history of drinking alcohol and eating meat. The patient primarily works in the fields as a farmer, so he has a long history of doing hard physical labor.

Objective 

ROM (Range of Motion) 

L hand: can make a fist

R hand: first 3 digits move but cannot make a fist

L arm: Abduction full ROM at 180 degrees

R arm: Abduction 15 degrees.

L foot: Plantar flexion full ROM at 60 degrees. Dorsiflexion half ROM at 30 degrees. He can point and curl the toes on this side. 

R foot: Plantar flexion 45 degrees ROM. Dorsiflexion 15 degrees. 

Pulse: B/L (bilateral): deep, thin, weak 

Tongue: Deviated to L, thick yellowish white coat on R side, red tip

Treatment 

Acupuncture: 

L: MS Line 1 in upper, 3 in middle

B/L: ST36, LI10

R: KI3

After Tx: Pulse improved → L side responded faster than R. Eventually, both sides became full and strong. The right side rose up after KI3 was inserted. 

*A main way that I checked on the state of the patient throughout the treatment was by checking the pulse, since I wasn’t able to verbally communicate with patient’s so much due to the language barrier. 

ROM after treatment: 

R hand: Could make a loose fist with all five digits

R arm: Abduction improved to 30 degrees

R foot: no change

Diagnosis/Hypothesis: Qi and blood stagnation in the Yangming with possible underlying Kidney weakness

___

10/12/24

Chief complaint: R side hemiparesis and weakness

After last tx (treatment), the patient is feeling better. He can still abduct the R arm about 30 degrees. He has almost full ROM for plantar flexion on R side and dorsiflexion is about 50 degrees, almost the full 60 degree ROM. He also is able to walk more easily and didn’t have to use a walking stick. Before the first tx he was using a walking stick. 

Secondary chief complaint: Temporal headache on R side

This area of his head feels burning and hot

Onset: 1 hour before tx
Tertiary chief complaint: Blurry vision

Both eyes are a bit blurry, not just with headache, but all the time. 

He also feel sensitive to light

Objective

Pulse: 

R: Deep, slow, thin

L: Deep, thin, hesitant

Tongue: Slight deviation to the L, thick white coat on R

Treatment

Acupuncture: 

B/L: ST43, SI3

R: GB41

L: LR8, MS Line 3 in upper, 3 in lower 

After tx: The patient was able to flex R arm half of ROM 45 degrees and abduct arm 50 degrees. He can also move all five digits on the R and make a fist with thumb and forefinger.

___

10/17/23

Chief complaint: R side weakness

Now, the patient can abduct R arm 120 degrees. He can also move all five digits on R hand and can make a full fist. He also has full sensation in R arm, the patient shared he was feeling numbness in R arm before this tx. The patient can still walk without walking stick, but he reports feeling slightly unsteady. 

From my point of view, the patient’s shen (spirit) seems much brighter at this treatment, he appears more clear-minded.

Objective

Pulse: 

L: Moderate

R: thin, less deep than past treatments

Tongue: Yellow whitish coat on R is much less thick, now it is thin, red tip, slightly deviated to L.

Treatment

Acupuncture: 

B/L: GB39, GB4, ST40, LI15

L: MS Line 2 upper, 3 middle

R: SJ15

___

10/19/23

Chief complaint: Mild temporal headache on R side

Onset: began when he first had the stroke, now it happens every day, worse at night. He reports 1-2 days of relief from the headaches after acupuncture, but then they return. 

Secondary chief complaint: Blurry vision

Onset: After the stroke, it comes in quick spurts and then it goes away. The blurry vision is accompanied by a feeling of overall weakness.

Tertiary chief complaint: R side weakness

Onset: with the stroke

Now the patient reports feeling stronger in his R hand and arm. He can wiggle all digits on his R hand and can make a full fist. He is now able to abduct the R arm the full ROM of 180 degrees, but he does have to strain a bit to do it. 

Objective

Pulse: 

R = weak overall 

L = thin, weaker than it has been in last treatments, deep guan and chi 

Tongue: Thin yellow coat (much thinner than it has been in the past), red tip, papules dispersed throughout the tongue

Treatment 

Acupuncture:

B/L: ST36, GB34, LI11

L: MS Line 6, 1 upper, 3 middle

In this treatment, I particularly used the pulse to find which points would strengthen it when I simultaneously palpated the point and felt the pulse. 

I wanted to call upon Yangming He Sea points to regulate and open the flow of qi and blood. 

___

10/30/23

Chief complaint: Temporal headache 

Patient reports feeling hot on the head and sometimes sweats from the head

The headache comes on at night

Patient reports no vision changes with headache

Secondary chief complaint: R side weakness

He can still abduct the arm full ROM

He can move all fingers on his R hand, but still has difficulty with small motor movements, for example, with unscrewing cap off plastic water bottle

He reports that his R leg feels heavy - he is able to still walk without walking stick

This treatment we check ROM of R side knee flexion and he could go 120 degrees of the full ROM of 180 degrees. L side knee flexion was full 180 degrees ROM. 

*Note: at this visit, the patient didn’t report any changes with the blurry vision.

Objective 

Pulse: 

L: overall slightly soft, deep guan 

R: deep chi (still more palpable than past treatments), the chi has a sensation of coming and going

Tongue: thick yellow coat toward the root, red tip

Treatment

Acupuncture: 

B/L: LR8, GB41, SJ5, ST36

L: MS Line 6 - 3 upper, 3 middle

___

10/31/23: 

Chief complaint: Temporal headache at night with blurry vision

The patient reports that he feels relief from pain and headache during acupuncture and for a while after, but when night time comes, the headache onsets. 

Secondary chief complaint: L side lateral upper arm pain

Tertiary chief complaint: R hand feels “sleepy” / numb 

Onset: The night before 

Patient reports that this sensation is worse today than it has been in the past 

Fourth chief complaint: Constipation and acid reflux

Patient reports that both of these symptoms worsen with meat, so now he has stopped eating meat

*did not note down pulse or tongue for this treatment

Treatment

Acupuncture: 

B/L: LR5, GB37, UB23, DU14

Midline: extra point above L5

L: SI11

R: LI15, LI10

This treatment, I took the approach of working on LR GB while also still working on Yangming and opening up the DU channel. 

___

11/01/23

Chief complaint: frontal/temporal headache

Patient reported no headache last night, which was an improvement, but then this morning he got a frontal/temporal headache. 

Patient reported blurred vision as well, but then it was shared at this visit that he believed he was having blurry vision because he hasn’t been wearing his glasses. I had never seen the patient wearing glasses, so I advised him to wear his glasses as prescribed. 

Patient reports that sleep, appetite, and urination are all good. 

Objective

Pulse: 

L: deep, thin, slippery 

R: deep, faint, weak chi

Tongue: red tip, central crack, less thick yellow coat at the root than the day before

Treatment

Acupuncture:

B/L: GB39, ST44, LR3, LI11, LI10, DU22 (found with EV local listening on head)

R: LI14

L: MS Line 6, 3 upper, 4 middle 
___

11/05/23

Chief complaint: Temporal Headache

Patient reports that the headaches are getting less severe and less frequent

Secondary chief complaint: Numbness on back of R knee

Onset: one month ago 

Patient reports that there is pain with R knee flexion

Tertiary chief complaint: Blurry vision

Patient reports that his eyes feel weak

He only wears his glasses for reading

*Note on R side weakness: R arm is feeling more strong, but still feels weaker to him than L 

Objective 

Pulse: 

R: stronger than it has been, weak and deep chi 

L: deep, thin, slightly weak

Tongue: thick yellow coat at the root, red tip, central crack 

Treatment

Acupuncture: 

B/L: ST36, LR3, GB41, SJ5, LI14, yu yao → halfway through tx added KI3 B/L after pressing the point and feeling the pulse strengthen, after KI3 insertion B/L the pulse strengthened B/L

L: MS Line 6, 2 upper, 4 lower

Herbal Rx (prescription): Xue Fu Zhu Yu Tang (XFZYT) → dosage 2 pills 2x/day 

___

11/07/23

Chief complaint: L temporal headache

The patient reported relief from pain, especially in the head, after starting XFZYT, but then the headache became concentrated in the L temporal region

Secondary chief complaint: Lumbar pain 

Onset: 3 days ago after the patient was in the field working 

Tertiary chief complaint: Blurry vision

Objective

Pulse: 

R: deep, soft, strongest the R side pulse has felt thus far in treatment

L: thin, dry, not weak overall, but weak guan 

Tongue: deviated L, thin yellow coat, red tip

Treatment

Acupuncture: 

B/L: LI14

R: ST40, SJ5

L: LI4, SP6, GB41, MS Line 6, 3 upper, 2 middle

Herbal Rx: XFZYT 3 pills 2x/day for three days

___

11/21/23:

The patient reports that overall he feels stronger and better on his R side.

Chief complaint: Numbness and weakness of R hand

Secondary chief complaint: Temporal headaches

Patient reports that the headaches are continuing to be less frequent and less severe 

He reports that after starting the herbal prescription the pain was lessened

Tertiary chief complaint: Feeling of heaviness in abdomen (around REN12) after eating

Objective

Pulse: 

L: moderate overall, deep guan

R: stronger overall than it has been in previous visits, deep chi

Herbal Rx: XFZYT → dosage 2 pills 2x/day for 6 days

*I didn’t note which acupuncture points I did for this tx

___

11/28/23

*This was the last treatment with the patient

Patient reports a continuing feeling of strength increasing on R side

Chief complaint: Numbness of R hand

This is slightly improving with treatments, but is still bothering the patient

Secondary chief complaint: Pain on posterior aspect of R knee

Patient points to KI10 area on R side where the pain is

Worse with knee flexion
Tertiary chief complaint: Temporal headaches

Patient reports he has a headache at the time of tx

He says that the headaches are still happening sometimes at night, but still less frequently 

He reports that his sleep is “ok”

* At this treatment he reports that he is finished taking the XFZYT

Pulse: 

L: deep, moderate overall

R: thin, deep, moderate, weak chi

Tongue: slightly red body, less thick yellow coat at the root, less deviation to the left side, but still some slight deviation

Treatment: 

Acupuncture: 

B/L: DU22, ST25, ST36, GB41, KI3

R: Ba xie, LI4
_________________________________________________________________________________________

Discussion: 

I wanted to highlight this case because in the US, we often don’t see semi-acute stroke patients. It was amazing to me to see the improvement of this patient, particularly with his ROM and increase in strength. Although there were definitely some symptoms that were difficult to resolve, the patient’s overall health and wellbeing increased during the duration of the treatment. 

In my choice of points and treatment plans, I relied mostly on Applied Channel Theory and palpation, Engaging Vitality (EV), and Orthopedic palpation. Every treatment I would palpate all 12 primary channels from the elbows and knees down and look for changes along the channels. After determining which channels had the most changes, taking pulse and tongue, and considering the patient’s chief complaint, I would then come up with a point prescription. The channels that I found the most changes in were primarily the Large Intestine, Stomach, Gallbladder and Liver. 

I would often use EV techniques to feel the Yang rhythm at all the major joints, particularly in the head. This would help me be able to determine how the patient was doing throughout the treatment by rechecking the head multiple times during treatment. I would also use local listening to find points on the head.

Also, from the pulse, I was considering the Kidney channel and organ throughout treatment. The chi position was weak or impalpable, especially on the R side, every treatment. 

So, overall, I was trying to move qi and blood along with strengthening the Kidneys. 

I also applied scalp acupuncture for almost every treatment. I was working with the MS Line 6, which is from the vertex, to the temporal region; from qian shen cong to GB6. The upper part of the MS Line 6 treats the lower body, the middle treats the upper limbs and the lower treats the head and face. In this style of needling, for paralysis or weakness on one side, we use the opposite side of the scalp/head. In the neurological acupuncture course I took in school, there was strong emphasis on treating the yangming (stomach and large intestine) and shaoyang (gallbladder and san jiao) in the recovery stage. 

When I was treating in the village I had a few select patent herbal formulas in pill form. I decided to use Xue Fu Zhu Yu Tang when I did because of the recurring headaches and the possibility of some blood stasis in the upper jiao. I also thought that the si ni san within XFZYT could be helpful to circulate the qi and regulate the Liver. Within XFZYT there are also some blood nourishing and moving herbs which I thought that it could be helpful to build some yin along with nourish and move the blood; which in turn, could support and strengthen the Kidneys.