1 day prior to admission, patient suddenly slipped and fell while trying to seat on her

chair in the bathroom and was found lying on the floor at around 8 am at their home in Quezon
City. Nausea was noted however no symptoms such as loss of consciousness, headache, blurring
of vision. Blood pressure was noted to be 200/100 mmHg. Hence, given Catapres 75 mg/tab.
Few hours prior to admission, patient was noted to be lethargic with BP of 170/100
mmHg. Patient was then rushed to FEU-NRMF Emergency for further evaluation.
1/23/2020; 11:58 PM
Plain Cranial CT Scan
- Post instrumentation study with a craniectomy defect in the right parietal bone with
adjacent malacic changes
- Acute Parenchymal Bleed (3.23 cc), left thalamocapsular region, with perilesional edema
and mass effect
- Rightward minimal subfalcine herniation
- No gross hydrocephalus
- Atherosclerotic, internal carotid arteries and vertebral carotid arteries
- Chronic small vessel ischemic changes
- Cerebrocerebellar atrophy
Creatinine: 100 umol/L – Above Normal
Sodium: 126 umol/L – Below Normal
o Conscious, coherent, not in cardiorespiratory distress
o BP: 170/100, PR: 96, RR: 22, T: 38 C
o Pink palpebral conjunctiva, anicteric sclera; no cervical lymphadenopathy, supple neck
o Symmetrical chest expansion, no retraction, clear breath sounds
o Adynamic precordium, normal rate, regular rhythm, no murmur
o Slightly globular abdomen, normoactive bowel sounds, soft
o No gross deformities, full and equal pulses, capillary refill time less than 2 seconds
o No active dermatoses
ACUTE PARENCHYMAL BLEEDING, LEFT THALAMOCAPSULAR REGION
 Refer to Cardiology and Neurology for further evaluation