History Taking

• Male 65 yo come to Hospital.

• Chief complaint: suddenly unconsciousness 3 days before
admission.
• 3 days before admission, the patient suddenly loss of
consciousness, got slurred speech and weakness of right extremity
while he was working. The patient kept squeezing her head and
seemed in pain. After that the patient seemed sleepy, he still
responds when his family called but it's getting hard to understand
what's being said, then the patient has been difficult to wake up.
• Then he was admitted to the nearest hospital and perfomed brain
ct scan
History of Past illness

• History of illness like this before ( - )

• Hypertension ± 2 years, uncontrolled
• DM, Hypercholesterol, Heart Disease, and kidney disease were
denied.
• Smoking habit denied
• Alcohol habit denied
 Physical Examination

• General examination:
• General condition: moderate, Consciousness : somnolen
• BP: 200/110 mmHg, MABP : 140 HR: 93 x/m reg, RR: 24 x/m , T:
36.8 °C, SaO2 : 98%
• Conjunctiva : pale (-/-), sclera ikteric (-/-)
• JVP ; normal
• Thorax : Rale -/-, Wh -/-, heart sound I/II normal, gallop -, murmur –
• Abdomen : Flat, normal turgor, peristaltic normal
• Extremities : warm acral
 Neurologic examination
• GCS E4M5V4 (13), PERRL +/+, ø 2 mm2 mm
• Meningeal Sign: nuchal rigidity (-) Laseque >70/>70 Kerniq >135/>135
• Cranial Nerves: paresis N VII UMN D impression
• Motoric State : Hemiparesis D impression
MT : ↓ N PhyR : +/+/+ ++/++/++ PatR : - -
↓N +/+ ++/++ - -
• Sensoric State : can’t be evaluated
• Autonomic State : urine catheter (+)
• GMA : SH
• SSS : (2.5x1)+(2x1)+(2x1)+(0,1x110)-(3x0)-12 = 4.5
(SH)
WDx

• Unconsciousness ec Cerebral hemorrhage onset 3nd day

• Hypertensive emergency
Planning
• Family education
• O2 2-4 lpm via canule nasale
• Bed rest + head elevation 30 degree
• Mobilization lean to right/left every 2 hours
• Oral hygiene + chest physiotherapy
• Attach NGT ( Family approval )
• IVFD NaCl 0.9% 500cc  21 gtt/mnts (macro)
• IVFD NS 0.9% 100cc + nicardipine 10mg start 50gtt/min titrates up/down
25gtt every 15 minutes until target BP of 160/90
• Paracetamol 3x500mg via NGT
• Ranitidine 2x50mg iv
• Lactulose syr 0 – 0 – II C via NGT
• Lab
• ECG and expertise
• Chest X Ray
• Obs GC/GCS/Pupil/VS/increased ICP every 15 minutes
ECG expertise

• Normal Sinus Rhytm

Laboratory Examination
• Hb : 17.3 g/dl
• Ht : 49.4 %
• WBC : 11000 /ul
• PLT : 213.000 /ul
• RBC : 5.53 x 106 /ul
• Blood Sugar : 98 mg/dl
• Ur : 26 mg/dl
• Cr : 0.7 mg/dl
• Na : 139 mEq/L
•K : 4.9 mEq/L
• Cl : 105 mEq/L
• Osm : 297
WDx

• Unconsciousness ec CVD SH (ICH r/ thalamus dextra vol. ± 14cc)

onset 3nd day
• Emergency hypertension