Name : LIJAH BINTI CHE JID
RN : HRPZ899741
IC : 490911035154

71 years old malay lady
Underlying HPT-on single antiHPT

brought by family members todayaa painful she's ever had
Started over nape of neck and progress upwards
c/o right upper limb weakness


Otherwise
No LOC
No fever
No nausea / vomiting
No trauma



Current assessment
GCS : 14/15
Pupil : reactive bilaterally
BP : 203/97
PR : 77
SPO2 : 96% under RA

NEUROLOGY EXAMINATION

GCS E4V4M6

Cranial nerve examination
Pupil position central, equal
Facial asymetry nil
Gag reflex present

Tone : normal bilaterally
Power : rt normal, lt 4/5
- 
Reflexes : normal bilaterally
- 
Babinski : downgoing
Clonus : nil



CT brain :
Diffuse SAH over suprasellar and basal cistern
with SAH predominantly over right sylvian fissure
Acute hydrocephalus. No IVH

Modified Fischer score 3
WFNS 2


Impression : Spontaneous SAH 2* Possible Ruptured Aneurysm with hypertensive emergency.


EVD Done
Plan for DSA this morning