Case of Spontaneous Left thalamus and pontine haemorrhage secondary to hypertensive vasculopathy
Daud bin Yaacob
491012035235

Referral from HSIP at 23/2/2021@ 6:25PM

Patient name:Daud bin Yaacob
IC:491012035235
Diagnosis: hypertensive emergency with left basal ganglia bleed 
72 yo/Malay/male

K/C/O hpt 
H/o TIA 2 months ago,under kk temangan f/up

Presentation:
Slurred speech-sudden onset 7am 23/2/21
A/w left sided body weakness
No facial asymmetry,no recent head trauma,no vomiting,no blurring of vision,no sob,no chest pain
Went to kk temangan ,noted BP:157/75, HR :74 G.M:7.7,
CNS examination: absent gag reflex,power 4/5 over left side 

At HSIP: alert,conscious,gcs:15/15 pupils 2mm reactive,slurred speech

BP:171/93
PR :69
T: 36.9
SPO2: 99% under room 

Neurological exam:
tone: normal
reflex :normal 
Babinski:downgoing
Clonus absent 
Cranial n exam:all cn intact 
Gag reflex: present 

CVS:drnm 
/resp:equal ae,clear
abdomen: soft,non tender


CT brain finding: left basal ganglia bleed 1.75cm x 1.75 cm 
Volume :0.94ml


For BP Control <140/90
conservative management