Referral from hosp jeli on 3/2/21 at 9.30am

Patient name: Zainab bt yazid
B761003
IC: 591022-03-5472
Diagnosis: 
1. Hypertensive bleed 

62yo Malay lady

K/C/O
HPT

Presentation:
Sudden onset of loss of consciousness at 12.30am
Preceded by headache and dizziness
No hx trauma
No chest pain/sob
No fever

Systemic review
On arrival: 
Gcs e1v1m2 pupils 2mm sluggish bilaterally
Vitals BP 219/109
PR 92
T 37
RR 22
Spo2 100%HFM

Neurological exam :
Tone normal bilaterally
Reflex normal
Babinski 
Cranial n exam  : unable to assess
CVS drnm
Lung crepts bilateral LZ 
PA soft non tender, not distended



CT brain finding: caudate bleed with IVH Haemorrhage 

Blood:
Hb 18  twc 11. 9plt 282
Na 138, K 3.1 Urea 8.6 Cr 94 
LFT normal

Imp : Spontaneous IVH 2* Uncontrolled HPT

EVD Inserted

Post op done CTA

A1 Aneurysm
ModifIed Fisher 4, WFNS 5


PLAN
For GCS Reassessment
For DSA today