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Alabang-Zapote Road, Pamplona 3, Las Pias City, Metro Manila 1740, PHILIPPINES

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College of Nursing

OBJECTIVES
GENERAL
The primary concern of this case study is to further enhance the understanding of
subarachnoid hemorrhage in congruence with the learned concepts.

SPECIFIC
This case study seeks to provide different information about the disease being considered
with the following specific objectives:
1. Give a brief introduction about subarachnoid hemorrhage together with a clinical manifes
tation.
2. Present the clients demographic and health history.
3. Present the abnormal result of the physical assessment and compare it to the normal.
4. Present the different laboratory test and result done to the clients with its interpretation.
5. Discuss the normal anatomy and physiology of central nervous system.
6. Explain the pathophysiology of subarachnoid hemorrhage.
7. Discuss the drug study.
8. Present a nursing care plan.
9. Show a discharge planning that the client may use upon discharge to the hospital.

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INTRODUCTION

Subarachnoid Hemorrhage (SAH) is bleeding into the area between the arachnoid
membrane and the pia matter surrounding the brain. SAH may occur as a result of a head injury
for spontaneous cases included high blood pressure, smoking, family history, alcoholism and
cocaine use. Generally, the diagnosis can be determining by a CT scan of the head if done
within six hours. Occasionally a lumbar puncture is also required. After confirmation further
tests are usually done to determine the underlying cause.
SAH occurs in about one percent in 10,000 people per year. And it so happens that the
patient handled in the ICU was diagnosed with the same diagnosis, hence the reason for the
case study.
The doctors have confirmed that the main caused is by the presence of stretch in one
of the main arteries feeding the brain, and that 90% of cases as there are up to 5% of normal
people are predisposed to occurrence of this expansion and there are 10 transition bloody
phase, which precedes the bleeding or explosion, and the best treatment of these cases before
entering into this phase where increasing the chances of successful surgical treatment to 99%
if caught early. 10-12% die before receiving the medical attention.
Females are more commonly affected than males. While it becomes more common
with age, about 50% of people present under 55 years old. It is a form of stroke and
compromises about 5% of all strokes. The classic symptom of SAH is thunder clop headache
a headache described as like being kicked in the head or the worst ever developing over
seconds to minutes. About 1/3 of people have no symptoms apart from the characteristic
headache, and about 1 in 10 people who seek medical care with this symptom are later
diagnosed with SAH. Vomiting may be present and 1 in 14 have seizures, confusion, decreased
level of consciousness or coma may be present, as may neck stiffness and other signs of
meningitis.

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Most cases of SAH are due to trauma. In 85% of cases, the cause rupture of a cerebral
aneurysm a weakness in the wall of one of the arteries in the brain that becomes enlarged
while most cases are due to bleeding from small aneurysms, larger aneurysms (which are less
common) are most likely to rupture.
The initial steps for evaluating a person with a physical examination. The diagnosis
cannot, however, be made on clinical grounds alone and in general medical imaging and
possibly a lumbar puncture is required to confirm or exclude bleeding.
Subarachnoid Hemorrhage is classified according to 5 grades as follow:
Grade I: Mild headache with or without meningeal irritation.
Grade II: Severe headache and a nonfocal examination with or without mydriasis.
Grade III: Mild alteration in neurologic examination including mental status.
Grade IV: Obviously depressed level of consciousness on focal deficit.
Grade V: Patient either posturing or comatose.
This cases study is focused on a patient diagnosed with subarachnoid hemorrhage
secondary to ruptured aneurysm.

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CHIEF COMPLAINT
Headache

PATIENTS PROFILE

Name: A.A. G
Age: 65 years old
Gender: Female
Birthdate: May 10, 1952
Nationality: Filipino
Place of Birth: Cavite
Civil Status: Married
Address: Dasmarinas
Religion: Roman Catholic
Admission Date and Time: August 31, 2017 04:50PM
Attending Physician: Dr. Medardo Joseph E. Millares
Admitting Diagnosis: Subarachnoid Hemorrhage probably secondary to ruptured
aneurysm, mild cerebral edema, UTI
Final Diagnosis: Subarachnoid Hemorrhage secondary to ruptured aneurysm

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Nursing History
Gordons Functional Pattern of Assessment
HISTORY OF PRESENT ILLNESS

Patient is a known hypertensive who apparently, 2 days prior to consultation, patient

was washing clothes when she suddenly experienced headache. Throbbing in character

radiating to the right shoulder and upper back. Patient had one episode of vomiting

approximately one table spoon in amount. Patient was rushed to Emilio Aguinaldo Hospital in

Dasmarias for management. From then, the patient had another episodes of vomiting filing

half of the kidney basin. Relative claimed that the patient was drowsy and groggy during that

time.

One day prior to consultation, patient was diagnosed to have aneurysm and was

advised to see a neurosurgeon. Transferred of hospital followed for management patients was

drowsy, afebrile. (+) pain at upper back and right shoulder, but no headache.

Few hours prior to consultation, patient was transferred to university of perpetual

help medical center. She was then seen and examined by the attending physician, hence

admission.

PAST MEDICAL HISTORY

The only past medical history of the patient that the relative could remember was

that she was admitted twice before at the EAC Hospital for cesarean delivery of her third child.

She also underwent bilateral cataract removal last 2015 on the same institution.

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HEALTH PERCEPTION/ HEALTH MANAGEMENT PATTERN

According to the relative, patient AAG used to value health more than anything

else. She was very compliant with the medications for her hypertension. The patient relative

claimed that the patient believed that the most important thing in the world is life, that is why

she makes sure all the time that her children receives quality medical assistance whenever in

need.

NUTRITIONAL/ METABOLIC PATTERN

The relative stated that patient loves to drink coffee every morning, she added that

patient AAG also carbonated beverages occasionally. The patient eats 4 times daily and she

preferred eating fatty foods, fresh vegetables and fish. Her family was the ability to provide

her nutritional needs. She has known allergies to shrimp and some medications such as

mefenamic acid and ibuprofen

ELIMINATION PATTERN

Patient AAGs relative mentioned that the patient has no problems when it comes to

elimination. During confinement, patient was in indwelling foley catheter with light yellow

urine and inadequate in amount. The only accumulated urine was less than 20 cc every hour

which suggest alteration.

ACTIVITY AND EXERCISE PATTERN

The relative stated that patient AAG used to be active, She usually walks going to the

market. She also capable of doing the activities of daily living. During confinement patient

was in bed due to her present condition with a GCS 3/15.

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SLEEP AND REST PATTERN

Before hospitalization, the relative mentioned that the patient AAG do not have

difficulty of sleeping. She normally sleeps at 9:00 pm and wakes up at 5:00 am routinely.

During confinement was in bed with GCS of 3/15.

COGNITIVE PERCEPTUAL PATTERN

Patients relative is claiming that she was a college graduate. She was used to work in

a Municipal hall. Due to her age, she was having difficulty seeing for objects without lenses.

During confinement patient was unresponsive. She was unconscious with a GCS of 3/15.

SEXUALITY AND REPRODUCTIVE PATTERN

Patients relative refused to say anything with regards to patients sexual life, but

mentioned that patient AAG has 2 daughters and a son.

FAMILY GENOGRAM

FATHER MOTHER

HYPERTENSION HYPERTENSION
BRONCHIAL ASTHMA

BROTHER SISTER PATIENT SISTER


AAG
HYPERTENSION ARTHRITIS
DIABETES
HYPERTENS
ION
CEREBRAL
ANEURYSM

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COURSE IN THE WARD

Upon admission, patient was admitted under neurosurgery service. Patient was on NGT

feeding 1,000 kcal in 6 equal feedings with oxygen via nasal cannula at 1 LPM. Diagnostics

ordered were CBC, FBS, cranial CT scan, lipid profile, HBA1C, CBG, SGPT, PT, PTT, UA,

and Ct angiogram. Patient was given mannitol 100cc IU every 6 hours. Citicholine 1gm IV

every 12 hours and ceftriaxone 2 gm IU every 12 hours, furosemide 40 mg IV every 12 hours,

vitamin B complex IV, OD, Piracitam IV, lactulose 30 cc ODHS, tramadol 2.5 mg IV every 8

hours, pipranhydramine 2.5 mg IV every 8 hours, omeprazole 40 mg IV every 8 hours,

minodipine 50 mg every 12 hours. Patient was scheduled for clipping of aneurysm the next

day and was put on NPO for 8 hours PTOR, hooked PNSS 1L to run for 8 hours. Patient was

referred to internal medicine for CP clearance and co management. Patient was seen by

neurologist and was advised to continue present management. Patient was seen by cardiologist.

12 lead ECG and repeat creatinine was done. Patient was seen by attending physician.

On the first day of hospitalization patient was seen by anesthesiologist. Patient was

cleared by a neurologist and was ordered to have CBG every 4 hours. Patient has undergone

clipping of aneurysm and craniotomy in which the patient has tolerated the procedure.

Mannitol was increased to 200cc IV every 4 hours and was maintained on positive fluid

balance. Patient was given keppav.

On the second day of hospitalization, patient was GCS 9/15 (E3V1M5) and present

management was continued to KCL drip was started; 10 meqs KCl in 100 cc, PNSS to run for

1 hour x 3 cycles. Patient was for repeat plain cranial CT scan and for CBC, PT and PTT, CT

scan results revealed cerebral edema and was advised for hemicraniotomy.

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On the third day of hospitalization patient was for hemicraniotomy and 1 whole blood

PRBC was prepared. Vitamin K and trenaxemic acid was also started. Hemicraniotomy was

done with the patient tolerating the procedure and was subjected to mechanical ventilator.

Patient was also given pain medication. IVF was shifted to NaCl 2L to 40 meqs KCL to run

for 12 hours. Present management was continued.

On the fourth day of hospitalization, patient was GCS 7. Patient was for bedsore

precaution and for regular suctioning. Patient was referred to pulmonologist for co-

management. Present management was done.

On the fifth day of hospitalization, patient was for UA and CXR. Patient was given

piptaz 4.5 IV every 8 hours as replacement of ceftriaxone. Budesonide nebulization was

ordered to be done every 12 hours and for ETA GS. Patients JP drain was removed. Patients

CBG was discontinued. KCL tablets were increased to 2 tablets TID for 6 doses and for transfer

to medical ICU. Present management was continued.

On the sixth day of hospitalization, patient was GCS 6 (E1V1M4) correct mechanical

ventilation setting were continued. Kalium was discontinued and IVF was shifted to D5W 1L

to run for 12 hours. Patient was later given paracetamol 500 mg IV every 4 hours RTC for

fever. Present management was continued.

On the seventh day of hospitalization, patient was still GCS 6. Present management

was continued. Later patient become GCS 3 (E1V1M1). A family conference was held. The

condition of the patient was explained to the relative and supportive care was continued.

Nicardipine was held an early tracheostomy was suggested.

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On the eight day of hospitalization present management was continued and was

suggested for plain cranial CT scan. Patient was still GCS 3. Early tracheostomy was deferred

and feeding was administered through feeding bag. Patient was given PNSS 500cc fast drip,

atropine ampule IV and norepinephrine drip 16 mg + PNSS to complete 100 cc x 0.2 meql

kg to titrate accordingly maintaining MAP 890 mmhg. FiO2 was decreased. Monoperem

was increased to 2g IV every 8 hours, suggested to shift citicholine to oral 500 mg BID.

Cerebrolysin to add vancomycin 1g IV every 12 hours, repeat creatinine and decrease mannitol

to 100 cc every 4 hours.

On the ninth day of hospitalization, patient was still GCS 3 present management was

continued. On the tenth day of hospitalization, present management was continued. DNR

waver was signed on the eleventh day, present management was continued and DNR consent

was noted. Daily wound care was done and continued present management. Supportive care

was continued. Relatives decided not to resuscitate in case of arrest.

On the twelve day of hospitalization, supportive management was continued. Bedsore

precaution was maintained.

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PHYSICAL EXAMINATION
VITAL SIGNS during the assessment September 15, 2017 at 12:00 PM

AREA TECHNIQUE ACTUAL NORMAL


ANALYSIS
ASSESSED USED FINDINGS FINDINGS
Temperature Measured using 34.3 36-37.5 Temperature changes are common in
thermometer degrees degree patients in a neurosurgical intensive
celcius Celsius care unit. The aneurysm is located in
the right internal carotid artery near
the Circle of Willis affecting the
Hypothalamus.
Reference:
Stretti & Gotti 2014 Bramed Central
2014
Pulse rate Seen in cardiac 46 bpm 60-100 bpm SA has been associated with non-
monitor; double neurologic medical complication
checked through which cardiac and pulmonary
palpitation
complication are most common.
SAH has been attributed to
myocardial ischemia which may be
caused of artery spasm and
thrombosis and oxygen supply
demand mismatch in the setting of
hypertension and bradycardia
Reference:
The harmful effect of Subarchnoid
Hemorrhage Cren, Li. Et.al 2014
Seen in cardiac
Patient is attached to a mechanical
Respiratory monitor; double
16 cpm 12-20 cpm ventilator with the settings of FiO2=
rate checked through
60%, Tv=360, BUR=16
inspection
Blood Seen in cardiac 60/30 90/60 Traditional treatment of SAH from
Pressure monitor; double mmhg 120/80 ruptured aneurysm included strict
checked with mmHg blood pressure control and
sphygmomanometer antihypertensive drugs.
and stethoscope 5-10 days after SAH, patient may
develop vasopasm and cause
narrowing of arteries and reduces
blood flow.
Reference:
Mayfield brain & Spine
Subarachnoid Hemorrhage and its
Complications, 2016

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GENERAL APPEARANCE

AREA TECHNIQUE ACTUAL NORMAL


ANALYSIS
ASSESSED USED FINDINGS FINDINGS
Body built Inspection Proportionate Proportionate Normal

Posture Inspection Not Assessed Coordinated Patient is unconscious with GCS


and gait and erect of 3/15 (E1V1M1)

Hygiene Inspection Clean and Clean and Normal


and
grooming neat neat

Body odor Inspection No body No body Normal


odor
odor

Signs of Inspection No distress No distress Normal


distress

Effect of Inspection No mood or Cooperative Patient is unconscious with GCS


mood facial of 3/15 (E1V1M1)
expression
showed
Speech Inspection Not Assessed Coherent Patient is unconscious with GCS
of 3/15 (E1V1M1)
SKIN

AREA TECHNIQUE ACTUAL NORMAL


ANALYSIS
ASSESSED USED FINDINGS FINDINGS
Color Inspection Brown Light brown Normal
to brown
Edema Inspection Presence of Absent Edema after SAH may
Edema in both reflect diffuse ischemic
arms injury due to transient
ictal cerebral circulatory
arrest, diffuse
inflammatory or
neurotoxic effects of
blood and its degradation
products on brain tissue,
or abnormal
autoregulation due to
microvascular damage or

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dysfunction of vasomotor
centers in the brain stem.
Reference:
http://stroke.ahajournals.org
/content/strokeaha/33/5/
1225.full.pdf
Skin lesions Inspection Presence of lateral No lesion Patient undergone
clean surgical clipping of aneurysm at
wound with the the right internal carotid
length of artery and insertion of
approximately 3 ventriculostomy tube on
cm on the left side September 01, 2017.
of the neck
Temperature Palpation Cold and clammy Warm to Temperature changes are
common in patients in a
touch neurosurgical intensive
care unit. Fever is
frequent among severe
cases and hypothermia is
used after cardiac arrest
and is currently tested in
clinical trials to lower
ICP
Reference:
Stretti & Gotti 2014 Bramed
Central 2014
Skin Turgor Palpation Good skin turgor Good skin Edema after SAH may
turgor reflect diffuse ischemic
injury due to transient
ictal cerebral circulatory
arrest, diffuse
inflammatory or
neurotoxic effects of
blood and its degradation
products on brain tissue,
or abnormal
autoregulation due to
microvascular damage or
dysfunction of vasomotor
centers in the brain stem.
Reference:
http://stroke.ahajournals.org
/content/strokeaha/33/5/
1225.full.pdf

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NAILS

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Nail Inspection Convex Convex Normal
curvature

Texture Inspection and Firm Firm Normal


palpation
Nail bed Inspection Bluish Pinkish Decreased oxygen
color supply

HEAD

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Shape Inspection Round, Round, Hydrocephalus is a common
Normocephal Normocephal complication in patient with
ic, ic with subarachnoid hemorrhage. It
Assymetrical smooth occurs in 1/5 of patients in early
contour course of SAH while Chronic
Hydrocephalus happens in the
course of SAH.
Reference:
Blomed Research Intl. 2017
HCP after SAH:
Pathophysiology, Diagnosis
and Treatment
Nodule/ Palpation Absent Absence of Normal
Masses nodule/
masses
Facial Inspection Asymmetrical Symmetrical Patient has NGT on the left
features nostril, and endotracheal tube
attached to mechanical
ventilator.
Facial Inspection No facial Symmetrical Patient is unconscious with
movements movements GCS 3/15 (E1V1M1)
manifested

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EYES

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Pupils Inspection Dark brown, 3mm Dark brown, One of the causes of
pupil equally pupils equal, bilateral non-reactive
round, nonreactive round, pupils is extensive ICP
to light and reactive to such as Subarachnoid
accommodation light Hemorrhage. A unilateral
accommodati fixed dilated pupil in
on comatose patients
indicates poor prognosis,
especially when present
bilaterally.
Reference:
Pupil Abnormalities 2017
Dr. Mary Lowth
Peripheral Inspection No, Peripheral Intact Patients is unconscious
Vision Vision with GCS of 3/15
(E1V1M1)
Extra ocular Inspection No ocular Coordinated Patients is unconscious
movement movement with GCS of 3/15
(E1V1M1)
Visual acuity Inspection No visual acuity Able to read Patients is unconscious
printed with GCS of 3/15
handwriting (E1V1M1)
Eyebrows Inspection Evenly Evenly Normal
Distributed Distributed
Eyelids Inspection Intact skin but no Intact skin Patients is unconscious
bilateral blinking with no with GCS of 3/15
noted bilateral (E1V1M1)
blinking
Eyelashes Inspection Evenly Evenly Normal
Distributed Distributed
Conjunctiva Inspection Pinkish Pinkish Normal
Cornea Inspection Clear Clear Normal
Sclera Inspection White White Normal
Lacrimal Palpation No tenderness No Normal
glands tenderness

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EARS
AREA TECHNIQUE ACTUAL NORMAL ANALYSIS
ASSESSED USED FINDINGS FINDINGS
Pinna Inspection Uniform in color, Uniform in color, Normal
symmetrical symmetrical
Ear canal Inspection Presence of Presence of Normal
cerumen/earwax cerumen/earwax
Hearing Inspection No Response Responds when Patients is
acuity when called called unconscious with
GCS of 3/15
(E1V1M1)
NOSE

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
External nose Inspection Presence of NGT Symmetrical Patient has inability to
on the left nostrils swallow and cannot
tolerate oral intake since
patient is unconscious
with GCS 3/15 (E1V1M1)
Nasal cavity Inspection Dark pink, dry, Dark pink, Normal
free of exudates. dry, free of
exudates.
Sinus Inspection No tenderness No Normal
Tenderness tenderness
Nasal mucosa Inspection Intact and midline Intact and Normal
midline
MOUTH

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Lips Inspection Dry and pale, lip Symmetrical Patient is attach to
pits are normal mechanical ventilator
causing the lips to remain
open and exposed to air
causing it to dry
Teeth Inspection Incomplete 32 pearly Patient has dentures
normal teeth;
yellowish
color

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Gums Inspection Pinkish, dry, firm Pink, moist, Patient is attach to


and intact firm, intact mechanical ventilator
leaving the mouth to
remain open and exposed
to air causing the gums to
become dry.
Tongue Inspection Midline and Midline, Patient is unconscious
immovable pinkish, with GCS of 3/15
movable (E1V1M1)
Palate Inspection Light pink, intact Light pink, Normal
intact

NECK

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Muscles Palpation Presence of Symmetrical Patient undergone
surgical wound on clipping of aneurysm at
the right side of the right internal carotid
the neck artery on September
01,2017
Movement Inspection Coordinated Coordinated Normal
Range of Inspection Normal power Full Normal
motion
Muscle Inspection Absence of Equal Patient is unconscious
strength muscle strength with GCS of 3/15
(E1V1M1)

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CHEST AND LUNGS

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Breathing Inspection Regular but Regular Direct brain injury
pattern attached to depressed level of
mechanical consciousness and
ventilator. inability to protect
airway, disruption of
natural defense barriers,
decreased mobility and
secondary neurological
insults inherent to severe
brain injury are the main
cause of pulmonary
complications in
critically ill neurological
patients, hence the need
for mechanical
ventilator.
Reference:
Pulmonary
Complications in patient
with Severe Brain Injury.
Kiwon & Rincon 2014
Symmetry Inspection Symmetrical Symmetrical Normal
Spinal Inspection and Aligned Aligned, in Normal
alignment palpation midline
Skin Inspection Smooth, no Smooth, no Normal
tenderness and tenderness and
lesions lesions

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Breath sounds Auscultation Wheezes and Clear Pulmonary


Crackles complications are
prevalent in the critically
ill neurologic patients.
Respiratory failure,
pneumonia, acute lung
injury and acute
respiratory distress
syndrome, pulmonary
confusions and
pneumo/hemothorax and
pulmonary embolism are
frequently encountered
in patient with SAH.
Reference:
Pulmonary
Complications in patient
with Severe Brain Injury.
Kiwon & Rincon 2014

ABDOMEN

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Skin integrity Inspection Unblemished Unblemished Normal
Contour Inspection Slightly rounded Flat/Rounded Normal
Symmetry Inspection Symmetrical Symmetrical Normal
Bowel sounds Auscultation With bowel High pitched, Normal
sounds irregular
gurgles
Palpation Palpation No tenderness No tenderness Normal

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BACK AND EXTREMETIES

AREA TECHNIQUE ACTUAL NORMAL ANALYSIS


ASSESSED USED FINDINGS FINDINGS
Muscle size Inspection Equal Equal Normal

Muscle tone Palpation Firm Firm Normal

Muscle Inspection No response to Equal Patient is unconscious


any stimuli. with GCS of 3/15
strength
(E1V1M1)
Bones Palpation No tenderness No tenderness Normal

Joints Palpation No tenderness No tenderness Normal

Range of Inspection No range of Full Patient is unconscious


motion with GCS of 3/15
motion
manifested. (E1V1M1)

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DIAGNOSITICS/LABORATORY EXAMINATIONS
BRAIN CT SCAN
September 8, 2017
Clinical Data: Diagnose case of aneurysm at the right internal carotid artery, s/p clipping
(09/01/2017)
Comparison: Previous CT scan dated (08/31/17)
Technique: Multiplanar CT scan of the brain without IV contrast
Findings:
Follow up since 8/31/2017 shows craniectomy defect in the right frontal bone. Underlying
minimal extra-axial blood collection is appreciated measuring 0.7 cm in thickness. Soft
tissue swelling in the right frontal area with a drainage tube in place. Metallic density is
now seen along the area of the right sylvian fissure representing the surgical clip.
There is still subarachnoid hemorrhage now seen in the area of the surgical clip, right
sylvian fissure, suprasellar and right cerebro-pontine angle cisterns, left frontal and both
parietal cortical sulci. These show interval increase since the previous study.
Intraventricular hemorrhage is now appreciated within the ventricular system. The left
lateral ventricle is mildly dilated. Ventriculostomy tube is noted coursing through the right
frontal lobe with the tip at the atrium of the left lateral ventricle.
Midline shift at about 0.6 cm to the left is noted.
Wedge shaped hypodensities are now appreciated in the right frontal and right temporal
lobes. There is decrease in attenuation of the subcortal layer of the right parietal lobe.
Minimal pneumocephalus in the right prepontine cistem.
Impression:
s/p clipping of aneurysm, craniectomy and ventriculostomy tube insertion
subarachnoid hemorrhage, showing interval increase
mild hydrocephalus (non-communicating)
midline shift to the left

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interval appearance of a small extra-axial hemorrhage at the craniectomy site,


intraventricular hemorrhage, acute infarctions (right frontal lobe, right temporal lobe and
right parietal subcortical regions, minimal pneumocephalus)
atherosclerotic vessel disease

COMPLETE BLOOD COUNT


September 3, 2017

EXAMINATION RESULT NORMAL VALUE ANALYSIS

Red Blood Cell 3.71 4.50-5.50 x 10^12/L Patient with SAH commonly
(L) develops anemia and requires
blood transfusion.
Reference:
(Gresenbaum & Ruskin, 2015)
Hematocrit 0.38 0.37-0.47 L Normal

Hemoglobin 112 110-150 g/l Normal

White Blood Cell 9.00 4.50-10 x 10^gl Normal

Segmenters 0.68 0.50-0.70 Normal

Eosinophils 0.01 0.00-0.05 Normal

Lymphocytes 0.24 0.20-0.40 Normal

Monocytes 0.06 0.00-0.07 Normal

Platelet Count 178 150-400 x 10^g/L Normal

MCV 88.00 80-100 fl Normal

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MCH 26.82 26-34 pg Normal

MCHC 305 320-260 g/L Normal

URINALYSIS
September 5, 2017

Color: Light Yellow Microscopic:


Transparency: Hazy RBC: 0-2/HPF
pH: 6.0 Pus Cells: 2-4/HPF
Protein: Negative Epithelial Cells: Few
Glucose: Negative Bacteria: Few
Specific Gravity: 1.015

PARTIAL THROMBOPLASTIN TIME


September 1, 2017
Test: 40.33 seconds
Control: 31.90 seconds

PROTHROMBIN TIME
September 2, 2017
TEST RESULT NORMAL VALUES ANALYSIS

Bleeding Time 2 minutes 1-3 minutes Normal

Clotting Time 6 minutes 3-7 minutes Normal

45 seconds

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CLINICAL CHEMISTRY SECTION


September 9, 2017
EXAMINATION RESULTS NORMAL VALUES INTERPRETATION

Creatinine 115.37 49-90 umol/L Elevated creatinine level


signifies impaired kidney
functions.

Chloride 131.00 98-104 mmol/L Usually indicates


dehydration. Causes of
hypercholemia may induce
high level of blood sodium.

Potassium 4.50 3.5-5.1 mmol/L Normal

Sodium 163.00 137-145 mmol/L Usually results from


dehydration caused by water
intake less than water losses.
Hypernatremia is a water
problem not a problem of
sodium homeostasis.

IMMUNOLOGY SECTION
September 5, 2017
HBA1C 5.40% (NV: 4.3 6.4)

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CLINICAL FINDINGS

HEMATOLOGY SECTION

RBC 3.71 x 10^12/L


Hematocrit 0.33 L
Hemoglobin 100 g/l
WBC 12.00-10 x 10^gl
Segmenters 84

CLINICAL CHEMISTRY SECTION

Creatinine 115.37 umol/L


Chloride 131.00 mmol/L
Sodium 163.00 mmol/L

DIGESTIVE SYSTEM

Lips Dry and pale, lip pits are normal


Gums Pinkish, dry, firm and intact

INTEGUMENTARY SYSTEM

Skin Lesions Presence of surgical wound on the left side of the neck
Temperature Cold and clammy
Nail bed bluish

CARDIOVASCULAR

Pulse Rate 46 bpm (Bradycardia)


Blood pressure 60/30 mmhg (Hypotension)

RESPIRATORY

Respiratory Rate 16 cpm attached to Mechanical Ventilator

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Anatomy and Physiology


The brain
The brain is an organ that serves as the center of the nervous system in all vertebrate
and most invertebrate animals. The brain is located in the head, usually close to the sensory
organs for senses such as vision.
The brain is the most complex organ in a vertebrate's body. In a human, the cerebral
cortex contains approximately 1533 billion neurons, each connected by synapses to several
thousand other neurons. These neurons communicate with one another by means of long
protoplasmic fibers called axons, which carry trains of signal pulses called action potentials to
distant parts of the brain or body targeting specific recipient cells.

Functions of the Brain


The human brain is the powerhouse and control center for all physiological and
cognitive functions. This is the major control network for the body's functions and abilities,
and enables conscious communication with our body and automatic operation of vital organs.
The brain controls unconscious physiological activities such as breathing, pulse and
digestion and higher conscious activities such as thinking, reasoning and feeling. The brain is
divided into four sections which are known as lobes. The frontal lobe, parietal lobe, occipital
lobe and temporal lobe.

Frontal Lobe- associated with reasoning, planning, parts of speech, movement,


emotions, and problem solving
Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli
Occipital Lobe- associated with visual processing
Temporal Lobe- associated with perception and recognition of auditory stimuli,
memory, and speech

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Parts of the Brain

The Hindbrain
The hindbrain is the structure that connects the spinal cord to the brain.
The medulla is located directly above the spinal cord and controls many vital autonomic
functions such as heart rate, breathing, and blood pressure
The pons connects the medulla in the cerebellum and helps coordinate movement on
each side of the body
The reticular formation is a neural network located in the medulla that helps control
functions such as sleep and attention

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The Midbrain
It controls many important functions such as the visual and auditory systems as well as
eye movement. Portions of the midbrain called the red nucleus and the substantia nigra are
involved in the control of the body movement.

The Cerebellum
Sometimes referred to as the little Brain, it lies on top of the pons, behind the brain
stem. The cerebellum is comprised of small lobes and receives information from the balance
system of the inner ear, sensory nerves and the auditory and visual systems. It involves in the
coordination or motor movements as well as the basic parts of the memory and learning.

The Thalamus
Located above the brainstem, the thalamus processes and relays movement and sensory
information. It is essentially a relay station, taking in sensory information and then passing it
on the cerebral cortex, the cerebral cortex also sends information to the thalamus to other
systems.

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The Hypothalamus
The hypothalamus is a small area in the center of the brain that has many jobs. Its
underneath the thalamus and above the pituitary gland. It plays an important role in hormone
production and helps to stimulate many important processes in the body. the hypothalamus
acts as the connector between the endocrine and nervous systems. It plays a part in many
essential functions of the body such as:
Body temperature
Blood pressure and heart rate
Production of digestive juices
Balancing bodily fluids
Appetite and Weight control

The Limbic System


Its a set of brain structures located on both sides of the thalamus, immediately beneath
the cerebrum. It has also been referred to as the paleomammalian cortex. It supports a variety
of functions including emotion, behavior, motivation, long-term memory, and olfaction.
Emotional life is largely housed in the limbic system, and it has a great deal to do with the
formation of memories.

The Basal Ganglia


It is a group of subcortical nuclei, of varied origin, in the brains of vertebrates including
humans, which are situated at the base of the forebrain. Basal ganglia are strongly
interconnected with the cerebral cortex, thalamus, and brainstem, as well as several other brain
areas. The basal ganglia are associated with a variety of functions including: control of
voluntary motor movements, procedural learning, routine behaviors or "habits" such as teeth
grinding, eye movements, cognition, and emotion.

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The Meninges
The meninges refer to the membranous coverings of the brain and spinal cord. There
are three layers of meninges, known as the dura mater, arachnoid mater and pia mater.
These coverings have two major functions:
Provide a supportive framework for the cerebral and cranial vasculature.
Acting with cerebrospinal fluid to protect the CNS from mechanical damage.

Layers of the Meninges


Dura Mater
The dura mater is the outermost layer of the meninges, lying directly underneath the
bones of the skull and vertebral column. It is thick, tough and inextensible.
Within the cranial cavity, the dura contains two connective tissue sheets:
Endosteal layer Lines the inner surface of the bones of the cranium.
Meningeal layer Lines the endosteal layer inside the cranial cavity. It is the only layer
present in the vertebral column.
Between these two layers, the dural venous sinuses are located. They are responsible
for the venous vasculature of the cranium, draining into the internal jugular veins.

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Arachnoid Mater
It is interposed between the two other meninges, the more superficial and much thicker
dura mater and the deeper pia mater, from which it is separated by the subarachnoid space. The
delicate arachnoid layer is attached to the inside of the dura and surrounds the brain and spinal
cord. The arachnoid mater is one of the three meninges, the protective membranes that cover
the brain and spinal cord. The arachnoid mater is a derivative of the Neural crest mesectoderm
in the embryo.

Pia Mater
It is often referred to as simply the pia, is the delicate innermost layer of the meninges,
the membranes surrounding the brain and spinal cord. Pia mater is medieval Latin meaning
"tender mother. The other two meningeal membranes are the dura mater and the arachnoid
mater. Both the pia and arachnoid mater are derivatives of the neural crest while the dura is
derived from embryonic mesoderm. Pia mater is a thin fibrous tissue that is impermeable to
fluid. This allows the pia mater to enclose cerebrospinal fluid. By containing this fluid, the pia
mater works with the other meningeal layers to protect and cushion the brain. The pia mater
allows blood vessels to pass through and nourish the brain. The perivascular space created
between blood vessels and pia mater functions as a lymphatic system for the brain. When the
pia mater becomes irritated and inflamed the result is meningitis
It is the movement of blood through the network of cerebral arteries and veins
supplying the brain. The rate of the cerebral blood flow in the adult is typically 750 milliliters
per minute, representing 15% of the cardiac output. The arteries deliver oxygenated blood,
glucose and other nutrients to the brain, and the veins carry deoxygenated blood back to the
heart, removing carbon dioxide, lactic acid, and other metabolic products.

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Blood supply
Cortical areas and their arterial blood supply
Blood supply to the brain is normally divided into anterior and posterior segments,
relating to the different arteries that supply the brain. The two main pairs of arteries are the
Internal carotid arteries (supply the anterior brain) and vertebral arteries (supplying the
brainstem and posterior brain).

The anterior and posterior cerebral circulations are interconnected via bilateral
posterior communicating arteries. They are part of the Circle of Willis, which provides backup
circulation to the brain. In case one of the supply arteries is occluded, the Circle of Willis
provides interconnections between the anterior and the posterior cerebral circulation along the
floor of the cerebral vault, providing blood to tissues that would otherwise become ischemic.

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Anterior cerebral circulation


The anterior cerebral circulation is the blood supply to the anterior portion of the brain.
It is supplied by the following arteries:
Internal carotid arteries: These large arteries are the medial branches of the common
carotid arteries in the neck which enter the skull, as opposed to the external carotid branches
which supply the facial tissues. The internal carotid artery branches into the anterior cerebral
artery and continues to form the middle cerebral artery.

Anterior cerebral artery (ACA)


Anterior communicating artery: Connects both anterior cerebral arteries, within and along
the floor of the cerebral vault.
Middle cerebral artery (MCA)
Posterior cerebral circulation
The anterior and posterior circulations meet at the Circle of Willis, pictured here, which
rests at the top of the brainstem
The posterior cerebral circulation is the blood supply to the posterior portion of the brain,
including the occipital lobes, cerebellum and brainstem. It is supplied by the following arteries:

Vertebral arteries: These smaller arteries branch from the subclavian arteries which primarily
supply the shoulders, lateral chest and arms. Within the cranium the two vertebral arteries fuse
into the basilar artery.
Posterior inferior cerebellar artery (PICA)
Basilar artery: Supplies the midbrain, cerebellum, and usually branches into the
posterior cerebral artery
Anterior inferior cerebellar artery (AICA)
Pontine branches
Superior cerebellar artery (SCA)
Posterior cerebral artery (PCA)

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