Case referred from Hospital Pasir Mas.
Case of Spontaneous Right head of caudate haemorrhage secondary to hypertensive vasculopathy
Tuan Som bt Tuan Omar
460821035110


Referred case from hosp pasir mas

Name : Tuan Som Tuan Omar
IC : 460821035110

75 y/o/Malay lady

U/L hpt defaulted tx 
Prev adl independent
HOPI
P/w left sided body weakness today morning, preceded by headache, 
O/w no vomiting,
No chest pain/SOB
No fall/ trauma
No urti/uti sx


O/e : GCS e3v5m6on arrival, back from scan gcs e2v1m6
HMF: Not oriented 
Pupil 2/2 reactive
BP : 183/90 —> 122/70
PR : 60
T : 36.5
SPO2 : 100% hfm


Tone : normal
Power : 
- 4/5 over right side, 1/5 over left side
Reflexes : 
- normal bilaterally
Babinski : equivocal
Clonus : absent

FBC: twc 14.9, hb 14, plt 203
RP : ur 4.4, cr 134, na 138, k 3.7
INR : inr 1.1, pt 12, aptt 25

CT brain : right basal ganglia bleed with intraventricular bleed

Management given: given iv phenytoin 1g

Family expectation: conservative. Not keen for surgical intervention.