UC 2. Mr.

Wildan Fadli / ♂ / 43 yo / 0002122511 / Vascular Division / FZ

The Patient was Consulted from Neurology Department
CC : History of Decrease of Consciousness
Consult Time : 20.37
History :
+- 1 day prior to admission, the patient's family complained that the
patient looked drowsy and difficult to be awaken. The complaint was preceded
by severe and sudden headaches that getting worse since the last 30 minutes
that could not be relieved with oral medication. The complaints was
accompanied by a history of coughing up phlegm since the previous 2 days.
History of vomiting (-), seizures (-), weakness of extremities (-), history of
slurred speech (-), history of facial asymmetry (-), fever (-) and trauma (-).
Because of the complaint, the patient was brought to the Neurology
Emergency Unit of Hasan Sadikin Hospital Bandung, was oxygenated and given
medication, then gain improvement in consciousness, then underwent Non-
Contrast Head CT Scan (11/03/2023), diagnosed with Subarachnoid
Hemorrhage, then consulted to the Neurosurgery Department for further
management.
History of hypertension (+) with the highest systolic pressure of 160 mmHg
since 2 years ago, not routinely controlled. History of DM (-), History of
previous stroke (-), history of taking anticoagulant drugs (-), smoking (-), and
history of consuming alcohol (-).
 Physical Examination
General state :
BP: 140/71 mmHg HR: 89 x/m RR : 25x/mnt T : 36.8oC

Local State :
At Thorax : VBS right = left, Rh +/+, Wh -/-

Neurological States :
GCS 15, Nuchal rigidity (+)
Pupil : RLO round, equal, 3mm/3mm, LR +/+
Visus : RLO > 6/60
Funduscopy: Define papil border
Eye ball movement : Good to all direction
Other cranial nerve : Within normal limit
Motoric: Paresis -/-
Sensoric : Within normal limit
Physiologic Reflex : +/+
Pathologic Reflex : Babinski -/-
Hunt and Hess : 2
Clinical Picture
Laboratory Findings at Hasan Sadikin Hospital, Bandung
March 11th, 2023

Lab Results Lab Results

Hb 15.5 Na/K 142/ 2.8
Ht 45.5 Ur/Cr 22.5/1.28
L 17.190 RBG 186

Tr 379.000

Lab Result
Swab Antigen
Negative
SarsCov 2
Thorax X- Ray at at Hasan Sadikin Hospital, Bandung
March 11th, 2023

- Bilateral Pneumonia
- Cardiomegaly
Non-Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung
March 11th, 2023
Non-Contrast Head CT Scan at Hasan Sadikin Hospital, Bandung
March 11th, 2023
• Sulcus and gyrus are
compressed
• Sylvian fissure are compressed
• Ventricle are not compressed
• Cystern are compressed
• Hyperdens shadow (+) at
bilateral sylvian fissure, lamina
terminalis cystern,
interpeduncular, crural,
ambient, and prepontine cistern
• Midline shift (-)
• mFisher : 4
• mGraeb score : 3
 Modified Graeb Score
Right Temporal Tip 0

Right Lateral Tip 0

Right Posterior Tip 0

Left Temporal Tip 0

Left Lateral Tip 1

Left Posterior Tip 0

3rd 1

4th 1

total 3
WD/ Spontaneous SAB + Spontaneous IVH due to Suspect Aneurysm
Rupture DD/ Hypertension + Hypertension Stage I +
Hypokalemia + Bilateral Pneumonia

ICD 10: Nontraumatic subarachnoid hemorrhage (160.9); Cerebral

aneurysm (I67.1); Hypertension (I10.0); Non-traumatic
intraventricular cerebral hemorrhage (I61.5);
Hypokalemia(E87.6); Bronchopneumonia (J18.0)

Th/ Neurosurgery : Closed Observation, 3DCTA, DSA Elective

Neurology (Leader) : Improvement of General Condition,
Blood Pressure Regulation
Internal Medicine : Electrolyte Correction and Antibiotic
Therapy

ICD 9: 3D CT Angiography (S9022); Arteriography of cerebral arteries

(88.41);

GCS this morning 15 HCU Fresia