SHEE "Ivano-Frankivsk National Medical University"

Department of Neurology
Head of Department - Professor Gryb Victoria Anatoliyivna

Teacher of group____________________________________________

Case history

Patient_________________________________________________________
/surname, name, patronymic, age/

Clinical diagnosis:
Main__ Subarachnoid hemorrhage with lesion of oculomotor nerve
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Complications___________________________________________________________
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Comorbidities____________________________________________
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Curator: the student ___Swetha Kolathekkat Menon_____ of the __4th___course

____59H__ group_______________________________________faculty
_____Foreign Medical Faculty________________________
                      /student’s name/
Start of curation (date) ________________________
End of curation (date) ________________________

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 I. Passport part

Patient’s surname, name, patronymic___ Michael Andrew James

Age __32____ Birth date ____01-08-1991_________________
Home address____Apartment 302, kale highway 3, independent square, Ukraine
Place of work____________Business_____________________________
Date of admission _____02-04-2023________________________
Date of discharge _________________________________
End of the disease: recovery, improvement, without changes, deterioration, death.
Who sent the patient_________________________________________
Diagnosis in the refferal _________________________________________
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Diagnosis at admission ________________________________________
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Clinical diagnosis:
main Subarachnoid hemorrhage with lesion of oculomotor nerve
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complications ___________________________________________________
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comorbidities ___________________________________________
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Bed-days _____21days______

II. PATIENT COMPLAINTS

_______ Severe headache, diplopia, dizziness and vomiting
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III. Disease anamnesis
(Disease duration. Dynamics of the process. What factors does the patient connect with
the onset of disease and its exacerbation? Treatment that was carried out, its results and
tolerability.)
__________nil___________________________________________________________
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IV. Life anamnesis

(Heredity, development in childhood, working life, working and living conditions, family
history, earlier diseases).
____nil_________________________________________________________________
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Viral hepatitis _____________________________________________________
Tuberculosis__________________________________________________________
Venereal diseases______________________________________________
Malaria _____________________________________________________________
Bad habits______________________________________________________
Allergic anamnesis_______________________________________________

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 V. OBJECTIVE EXAMINATION
The general condition (satisfactory, medium severity, severe, very severe)
- Patient’s contact with the surrounding people
- Position in bed (active, passive, involuntary)
- Consciousness (clear, impaired, lost)
- Mood (calm, depressed, euphoric)
- Sleep (normal, impaired)
- Appetite (lost, excessive, normal)

Skin: color and its disorders (pallor, icterus, flushing, cyanosis), elasticity (reduced,
normal), humidity (increased, dry skin, normal skin), rash
(_____________________________________________),
hemorrhage(_____________________________________________),
scars(_______________________________________________), hair (hair loss,
hypertrichosis), nails (peeling).

Mucous membranes: color, bleeding, and other features.

The subcutaneous fat layer: (not) uniformly distributed, swelling, tissue turgor.

Muscular system: muscles poorly developed, satisfactorily developed, muscle

defects (atrophy, hypertrophy, hypotonia, hypertonia), muscle strength.

Bone System:
- Head shape, its deviations (frontal, occipital, parietal humps, craniotabes, etc.)
____________________________________________________;
- Curvature of the spine and extremities, flat feet;
- Joints - pain, swelling and redness.

Lymphatic System: Lymph nodes are (not) palpable.

Respiratory system:
- Respiratory rate per minute (normal, bradipnea, tachypnea) _______ ;
- Rhythm (rhythmic, arrhythmic);
- Types of abnormal breathing (chaotic, Biot, Kussmaul, Cheyne -Stokes);
- Breathing type (thoracic, abdominal, mixed);
- Nasal breathing (free, difficult, absent);
- Voice (aphonia, dysphonia, raucous);
- Coughing, sputum;
- Shortness of breath (inspiratory, expiratory, mixed).

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 The cardiovascular system :
- External examination and palpation (carotid arteries pulsation, protrusion and
pulsation of the neck veins___________________________, the pulse of the radial
artery – rate per minute_________ (not) synchronous, (not) rhythmic);
- Blood pressure__________________________ ;

The digestive system:

- Examination of the mouth - mucosa (moist, dry, clean, colour_________); tongue
(clean, moist, colour_________);
- Examination of the abdomen - the shape and size of
abdomen___________________, veins of the anterior abdominal wall
____________________ , liver (bottom edge sharp, rounded, soft, tight, tender, smooth,
painful, surface is smooth, bumpy, rough)

The system of kidneys and the urinary tract:

- Examination: the presence of the characteristic pallor, "kidney" edema,
examination of the lumbar area________________ ;
- Pasternatsky symptom ________________________;
- The frequency and characteristics of urination (pain, incontinence, etc.)
_________________.

Endocrine system: violation of growth (gigantism, dwarfism, hipostatura) and body

weight (malnutrition, exhaustion, paratrophy, obesity), sexual development (degree of the
secondary sexual features development_______________, is it appropriate to
age_______________ , menstrual cycle_____________________).

VI. Neurological status

General cerebral symptoms

Consciousness - clear, degree of consciousness impairment:
• stun (superficial and deep) - the loss of attention, concentration difficulties,
questions are answered after multiple repetitions, rapid exhaustion during an interview,
etc.
• sopor - eyes opening after loud sound, painful stimulation; localization of the
irritation source (purposeful motor response);
• coma I - absence of eye opening in response to any stimuli; unpurposeful motor
response;
• coma II - absence of eye opening and motor responses to any stimuli ;
• coma III - absence of eye opening and motor responses to any stimuli; muscles
atonia and areflexia, absence of meningeal syndrome, dysfunction of the respiratory and
cardiovascular systems.

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 Orientation in place, time, self-personality (normal/impaired). The availability of
productive language (verbal) contact_______________ .
Headache - localization, character, frequency, associated symptoms, daytime
_______________________________________________________.
Vertigo (sensation of falling through, fragility, instability).
Nausea, vomiting.
Seizures.
Meningeal symptoms (rigidity of the neck muscles, Kernig symptom, Brudzinsky
symptom (upper, middle, lower), zygomatic Bekhterev symptom)
Photophobia, fonofobia; hypersensation of the skin and mucous membranes.

Focal symptoms
Cranial nerves
I pair (n. olfactorius). Smell is not impaired; hiposmia, anosmia (right-side, left
side); dysosmia, hiperosmia; olfactory hallucinations – present/absent.
II pair (n. opticus). Visual acuity - not impaired; amblyopia (reduced visual acuity)
______, amaurosis (blindness) _______ ; visual fields:

Scotoma (visual field defect); hemianopsia: homonimous (right, left), heteronimous

(bitemporal, binasal); visual hallucinations – present/absent.
III (n. oculomotorius) IV (n. trochlearis, VI (n. abducens). Eye slit OD> <= OS
Voluntary eye movements - in full,
restricted_____________________________________, strabismus (squint): convergent,
divergent, vertical. Pupils OD > <= OS, deformed, pupils width: appropriate to light,
miosis (narrow), mydriasis (wide) - OD / OS. Photoreaction direct, consensual: retained,
reduced, absent (right , left) . Paresis of gaze, tonic deviation of eyes to right, left.
V (n.trigeminus). Facial sensation - present, reduced: neural Paresis of gaze, tonic
deviation of eyes to right, left.type (I, II, III branches); segmental type (inner, middle,
outer brackets of Zelder zones); conductive type (right, left). Masticatory muscles
strength - normal; reduced (right, left). Corneal reflexes - present, reduced, absent (right,
left). Mandibular reflex - present , reduced, absent.
VII (n. facialis). Facial muscles. Face is symmetric, facial muscles paresis: OD / OS
central – leveling of nasolabial folds, peripheral - the inability of eyebrows raising, eyes
closing, nasolabial folds are levelled (right, left). Taste violation on the anterior 2/3 of the
tongue; lacrimation, dry sclera; hiperakusia (increased sound perception).
VIII (n.vestibulocohlearis). Hearing is normal, reduced, absent (right, left).
Vestibular syndrome - absent; systemic dizziness; nausea, vomiting; nystagmus
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(horizontal, vertical, rotatory, large- /smallsweeping), ataxia (OD / OS), decreased
muscle tone.
IX (n.glossopharingeus), X (n. vagus). Swallowing - normal, a-/dysphagia.
Phonation - normal, a-/dysfonia. Bulbar syndrome - paresis of the soft palate (right, left),
reduced pharyngeal reflex (right, left). Pseudobulbar syndrome - paresis of the soft palate
on 2 sides (present/absent), pharyngeal reflexes (present/absent), oral automatism
reflexes (dystans-oral, palmomental, nasolabial, snout), involuntary laughing/cry. Taste
violation on the posterior 1/3 of the tongue (right, left). Mouth dryness (present/absent).
XI (n.accessorius). Trapezoidal muscle strength, sternocleidomastoideal muscle
strength (not modified, reduced, absent, right, left).
XII (n.hypoglossus). Tongue in the midline, tongue deviation to the right, left;
malnutrition tongue fibrillation (there is not). Articulation - normal, a-/dysartria.

Motor system: normal

The amount of active movements of the limbs - full, limited (Barre test upper/
lower; pronation phenomenon; Bogolepov symptom (rotated foot) etc.)
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Hemiparesis, monoparesis , tetraparesis , paraparesis (central, peripheral, mixed,
right / left , upper / lower) with a muscle strength decreasing do___ points in the arm and
___ points in the leg (right, left).
Muscle tone – without changes, increased: spastic, plastic; reduced (in which muscle
groups _________________________________________ ).
Tendon reflexes - without changes, reduced, increased (from biceps tendon C5 - 6,
triceps C7 - 8, knee L2 – 4, achilles S1 - 2) right, left .
Clonuses - chin, hand, patella, foot (right, left).
Periosteal reflexes - carporadial C5 - 8 (without changes, reduced, increased, right,
left).
Superficial reflexes - abdominal (upper, middle, lower), cremaster, plantar (without
changes, reduced, absent, right, left).
Pathological reflexes - extensor (Babinsky, Oppenheim, Gordon, Shaffer etc.),
flexor (Rossolimo, Bekhterev, Zhukovsky, etc.).
Protective reflexes - shortening, longening (the level reflex
evoking____________________________ ).
Pathological synkynezies - global, coordynatory, imitative.
Fasciculations, fibrillations (in which muscular groups ______________________).
Hypotorophy, hypertrophy (in which muscular groups_______________________).
Tremor (resting, during movement, postural, frequency).
Hyperkinesis - chorea, athetosis, tremor, myoclonus, tics, dystonia
(blepharospasmus, oromandybulyar, laryngeal, spastic torticollis, writer's cramp, foot
dystonia, torsion dystonia).

Coordination system : normal

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 Static ataxia – Romberg pose_________________________, Babynsky synergy test
___________________________.
Dynamic ataxia – finger-nose____________________, heel-knee
test___________________, Stewart - Holmes symptom __________________, Shilder
test ___________________, diadochokinesis test ___________________, dysmetria tests
(negative, positive).
Scanded speech. Nystagmus. Micro- or macrography.
Gait - without changes, ataxia, steppage, stamped.

Sensation system : normal

Sensation types:
• superficial sensation: pain, temperature, tactile;
• deep sensation: joint and muscle sensation, vibration, kinesthetic, pressure and
weight feeling;
• complex sensation types: discriminatory sensation, localization feeling,
dimensional and spatial feeling.
Sensation disturbances:
• Anesthesia - complete loss of sensation;
• hypoesthesia - decreased sensation;
• hyperesthesia - increased sensation;
• hyperpathia - sensation distortion to unpleasant pain;
• dysesthesia - sensation distortion (cold seems hot, touch seems like pain);
• paresthesia - coldness, numbness, tingling, "ants" crawling;
• pain - aching, dull, stabbing, throbbing, cutting etc.
Types of sensation disturbances:
• neural – specify the nerve_______________________________________;
• polyneuritic - "socks" and / or " gloves";
• segmental (radicular) – specify the segment__________________________ ,
presence of pain, symptoms of tension;
• segmental dissociated - specify the segment________________________ ;
• spinal conductive – mono-, hemi-, para-, tetra- type;
• cerebral conductive - mono, hemi type tetra type.

Higher mental functions :normal

Aphasia:
• efferent motor (Brock) - complete absence of expressive speech / embolus /
perseverations;
• sensory (Wernicke) - violation of impressive speech (literal and verbal
paraphasias, "verbal salad");
• amnestic aphasia -
• semantic - violation of the understanding of complex logic and grammar
constructions ("Father's brother, brother's father. Is it the same person?"), temporary and

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comparative relations ("Square under the circle, circle over the square. Which object is
above?"), prepositions.
• total: sensory and motor .
Apraxia:
Agnosia: visual (subject, facial, literal), auditory, olfactory, gustatory, astereognosis,
anosognosia, autotopagnosia.
Amnesia: violation of short- or long -term memory.

The autonomic system : normal

Dermographism - red, white, diffuse, increased.
Bernard - Horner symptom (sympathetic denervation of the eye) - a narrowing of
the eye slit, miosis, enoftalmus (right, left).
Clinostatis test - HR_________, BP________ standing; HR_________ ,
BP___________ lying.
Orthostatic test - HR____________ , BP___________ lying; HR__________ ,
BP__________ standing
Ashner test______________________________ .
 

TOTAL PATHOLOGY (specify the syndromes)

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___1.Meningeal_syndrome_~_headache
_____________________~_photophobia______________________________________
_____________________~__neck_muscle_stiffness_____________________________
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_______kernigs_symptom__________________________________________________
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VII. Topical diagnosis and the picture of the nervous system lesion
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__Focus_of_the_lesion_is_aneurism_of_the_middle_cerebral_artery________________
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 VIII. Additional examination methods data

Laboratory examination
General blood analysis
Dat Er.Hb C Leuc Eos Bas. Youn R Segm Mon Lymph ES
e . I . . g . . . . R
4.8*10 15 6000 2% 0.4 55 5 25 13
5
%

Urine analysis
Date Color Transp. pH Spec. Sugar Prot Epith. Erythr. Leuc. Salt Bact.
gravity ein
Pale transpar 6 1.015 50mg 20 2 3 none
yello ent mg
w

Waserman reaction ___________________________________________________

Blood sugar level________________________________________________________
Fecal helminth eggs _________________________________________

Other analyzes
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_______Lumbar_puncture:_presence_of_blood_in_CSF__________________________
_____________________________colour=_red_________________________________
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_______________________________________________________________________
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Instrumental examination methods
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______CT_scan__________________________________________________________
______MRI______________________________________________________________
______Angiography_______________________________________________________
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Consultations of related specialists
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 IX. Differential diagnosis

Diseases Common features Distinctive features

1.Meningitis Headache, presence of Kernig’s Lumbar puncture:
or Brudzinski’s signs, Protein for meningitis
meningeal signs Blood for SAH

CT scan

2.Cerebral Headache, vomiting and CT scan and MRI

haemorrhage depressed level of
consciousness from increased
ICP

3.Intracranial Headache, inability to move CT venography, MRI, Cerebral

venous limbs, weakness of one side of angiography
thrombosis face, seizures, depressed level
of consciousness

 
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 X. Clinical diagnosis
On the basis of:
Complaints
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__________Severe_headache,_diplopia,_meningeal_signs_________________________
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______,
Anamnesis ___________________________________________________
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____________________________________________________________,
Clinical and neurological examination ____________________________
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______meningeal_signs,_kernigs_signs_______________________________________
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Additional examination methods
data____________________________________________________________________
______MRI_and_Lumbar_puncture__________________________________________
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clinical diagnosis was determined:
main __Subarachnoid_hemorrhage_with_the_lesion_of_occulomotor_nerve
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complications ___________________________________________________
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comorbidities ___________________________________________
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 XI. Treatment of the disease
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_____The first step in management of patients with SAH is aimed to ensure the vital
functions. The treatment of SAH is mainly surgical (removal or exclusion of the
aneurysm from blood circulation using neurosurgical clipping and endovascular
coiling) as soon as possible. The conservative management of patients is the same as
treatment of hemorrhage stroke. The traditional treatment of vasospasm is «triple-H»
therapy, denoting hypertension, hypervolemia, and hemodilution. Also, all patients
should be started on the oral calcium channel blocker (nimodypin 30 mg 2 tab 5
t/d)._addressed_bedrest_for_21_days_appr_3_weeks.____________________________
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 Prescribed treatment

NIMODIPINE Rp.:Nimodipine 60mg in tablets

PO every 4 h/ 21 days

DICYNONE Rp.:Dicynone 500mg in tablets

PO 1t/ day

DEXKETOPROFEN Rp.:Dexketoprofen 100mg in

tablets
PO 3times/ day

Rp.:

Rp.:

Rp.:

 
XII. Daybook
Date, t ºC Dynamics of symptoms Prescription
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05-04-2023 Decrease in headache. Nimodipine
Diplopia disappeared. Dicynone

Dexketoprofen

Signature________________

Signature________________

XIII. Prognosis
For life______________________________________________________
For recovery_______________________________________________
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For function restoration__________________________________
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XIV. Epicrisis
- Patient’s name, age__________________________________________________
____________________________________________________________________ ;
- Date of admission __________________________________________________;
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- Diagnosis in the refferal _____________________________________________
____________________________________________________________________
- Complaints and basic clinical data on admission date_________________________
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- Diagnosis at admission__________________________________________
____________________________________________________________________ ;
- Data of clinical examination_________________________________
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- Clinical diagnosis__________________________________________________
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______________________________________________________________;
- Treatment________________________________________________
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________________________________________________________;
- The dynamics of the patient's condition and the progress of
diasese_____________________________
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______________________________________________________________;
- On which day of the disease the patient was discharged, and the condition on the
discharge day _______
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- Recommendations______________________________________________________
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_______________________________________________________________________.
Literature

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