WEST VISAYAS STATE UNIVERSITY

College of Medicine
La Paz, Iloilo City

Joao Artemio Lorenzo P. Pama

MED III-A | SGD 6 | Group C

HISTORY
I. GENERAL DATA

Name: E. C. Sex Female

Address: Pal-agon, Sta. Barbara Nationality Filipino
Birthday: October, 1967 Religion Roman Catholic
Age: 55 years old Admission Date September 17, 2021
Occupation: Laundry Service

II. CHIEF COMPLAINT

“Nag uy-uy lawas ko kag panan-aw ko daw galibot ang balay”

III. HISTORY OF PRESENT ILLNESS

4 years PTA, E.C. sought consult at ‘Cibac’ because she noted of mass on her clavicular area. Her vital signs were
taken in the said consult and an incidental finding of an elevated blood pressure with unrecalled values was noted.
She was brought to Western Visayas Sanitarium for admission. Her attending physician prescribed her with Losartan
and Amlodipine as her maintenance medication. There were also no pertinent findings on the mass and patient E.C.
claimed that it spontaneously regressed without any medical/surgical intervention.

5 hours PTA, around 11AM, E.C. was doing her laundry outside her house. She had a sudden onset of generalized
weakness on her entire body which she described as ‘nag uy-uy’ with numbness of both hands and feet, she lost
balance but was able to lean on a nearby wall. An acute episode of dizziness in which she described as ‘galibot ang
balay’ and doubling of vision followed immediately. She vomited approximately 2 cups of vomitus in which she
described was the food she ate for breakfast. A ringing sound that she described as ‘like a mosquito flying near her
ear’ or “daw gaburo” was heard before she experienced a headache which she describes as throbbing localized on
her the left temporal side with a pain rating scale of 10 out of 10. She claims that the dizziness and headache is
relieved when she closes her eyes. She asked helped from her cousins at her house and was brought to Aganan. She
claimed that no medications or other procedures were done but she was immediately referred to a Hospital.

At the time of admission, she was brought to WVSU-MC. She was given medications that brought relief to her
complaint of headache and dizziness however these were unrecalled. CT Scan was and other laboratory procedures
that were unrecalled were done to the patient. She verbalized that she started to feel a pain on her neck which she
describes as ‘gapalanghugot’ that persisted for hours and an onset of weakness on her lower extremities was noted.

Thus, this admission

IV. PAST MEDICAL HISTORY

A. Previous Illness
4 years ago, she was found out to be hypertensive by an incidental finding
B. Previous Hospitalizations
4 Years ago – admitted at WV Sanitarium
 C. Medications

Maintenance Medications: Amlodipine, Losartan (4 years on maintenance) – Compliant

Supplements: vitamin B3, Enervon C, no herbal medicine

D. Immunization
COVID Vaccine - 1st dose (1st week of September) no side effects
E. Allergies
None as claimed by the patient

V. OBSTETRIC HISTORY
UNASSESED

VI. FAMILY HISTORY

E.C’s father was hypertensive and deceased with unrecalled cause of death but verbalized “ natumba nahuman”.
She also has siblings who are known hypetensive

VII. PERSONAL AND SOCIAL HISTORY

E.C. is a non-smoker and non-alcoholic drinker whose usual diet is composed of vegetables, porl and chicken.
She currently loves with here husband and her 25-year-old son. Her usual activities of daily living are composed of
cleaning and doing the laundry which stays true to her occupation which is doing laubry services on Saturdays

PHYSICAL EXAMINATION
I. GENERAL APPEARANCE
E.C. is awake, lying Semi-Fowler’s position attached to _____________________. She was awake, kempt, dressed
appropriate for the weather, conscious and relaxed. No signs of cardiopulmonary stress was noted.

II. VITAL SIGNS

Parameter Results Normal Values Interpretation

Temperature 36.0C 36.4-37.4 °C Within normal limits
Cardiac Rate 88 beats per minute 60-100 beats per minute Within normal limits
Respiratory Rate 20 – 21 cycles per minute 12-20 breaths per minute Within normal limits
Prehypertension.
Blood Pressure 130/80 mmHg 90-120/60-80 mmHg
Patient is a known hypertensive
Greater than or equal to
Oxygen Saturation 98% Within normal limits
95%

III. ANTHROPOMETRIC DATA

Parameter Results
Height 5’1’’
Weight 65 kg
27.1
Body Mass Index
Interpretation: Overweight
 IV. CEPHALOCAUDAL ASSESSEMENT
A. Skin, hair, and Nails
Skin is brown, evidence of skin discoloration on the distal part of the fingers. No Cyanois or jaundice was observed.
No edema was noted.
Hair is short, black, no alopecia, no presence of flaking ang infestation noted.
Fingernails clean. Nail beds are pink, No clubbing was observed with prompt capillary refill of <seconds. Note of
white patches of skin discoloration.

B. Head and face

Head is normocephalic and symmetrical in shape, No masses, lesions, and tenderness noted
Face is symmetrical with no apparent lesions. No edema, masses, lesions and tenderness noted.

C. Eyes
Eyebrows are symmetrical, in line and evenly distributed. Eyelids blink bilaterally, no lesions, swelling and periorbital
edema noted.
Eyes are bilaterally symmetrical. Anicteric sclera, Pinkish conjunctiva, no lesions or discharges were noted.
Ptosis on left eye was noted

D. Ears
Auricles are symmetrical, with same color as the facial skin, and aligned with the outer canthus of the eye No lesions
swelling, tenderness, and discharges were noted.

E. Nose
Nares are patent and free of obstruction and discharges. No lesions, tenderness and discharges were noted.

F. Mouth/Throat
Lips are brownish in color; Tongue is moist in midline and moves freely. Incomplete set of teeth were noted. Tonsils
are grade +1 ;
Uvula found at midline no lesions, ulcerations and other discharges noted.

G. Neck
Neck is color brown consistent with the entire body midline and able tot turn freely without pain and stiffness. No
palpable mass or lesions present. No lymphadenopathies noted. Neck veins not distended.
Trachea is midline. No tenderness and no deviation noted.

H. Chest
No chest deformities, no retractions, symmetrical chest expansion, APL normal. No tenderness, Clear breath sounds
(vesicular), no adventitious sound noted.

I. Cardiac
Point of maximal Impulse is found at the 6th Left ICS, displaced Heart Rate: normal rate, regular rhythm. No
murmurs noted
J. Breast and Axilla
No masses palpated, No axillary lymphadenopathies No tenderness No nipple secretions, lesions

K. Abdomen
Abdomen is slighty protruded appropriate for body size. Umbilicus inverted at midline; no abdominal distention, scar (CS),
no striae, no note of organ enlargement, no rebound tenderness noted normoactive bowel sounds tympanitic upon
percussion

L. Inguinal Region
Unassessed

M. Genital, Anus, and Rectum

Grossly normal, No note of discharges, Findings unremarkable
Digital Rectal Exam: good sphincter tone, no bloody discharges on examining finger, only fecal discharge

N. Extremities
Upper extremities - no rashes or skin lesions
Elbow - no pain upon flexion and extension
Wrist - no pain upon flexion and extension
No cyanosis or nail dystrophies

Lower extremities - whitish lesions

Knee - no limitation in ROM
No bipedal edema no tenderness noted.

NEUROLOGIC EXAMINATION
I. MENTAL STATUS EXAMINATION

A. General Behavior and Appearance

EC was relaxed kempt lying on her bed. She did not complain despite the long process of the Physical Examination
and participated attentively.
B. Stream of Talk
EC’s speech has anormal pace and tone and appropriate to the content of her speech. She was spontaneous in
delivering her words.
C. Mood and Affective Responses
EC’s mood was appropriate fort he situation. Her mood was appropriate to the topic of the conversation and is
congruent to her affect
D. Content of Thought
EC was able to perceive reality. There were no content that was beyond the topic of the conversation. No signs of
hallucionations, delusions, misinterpretations and obsessions
E. Intellectual Capacity
EC has an average intellectual capacity
F. Sensorium
EC conscious, coherent, and oriented to person, place, time, and person.
 G. Speech
EC has no difficulty in producing sounds (phonating), articulating the individual sounds or the units, melody and
rhythm of speech, accent of syllables, inflections, and intonations. She has no difficulty on expressing or
understanding words as the symbol of communication.

II. CRANIAL NERVES

Cranial Nerve Patient Findings Interpretation

EC was able to identify the familiar scent of coffee with each
I: Olfactory nostril with eyes closed. Nares are patent and no presence INTACT
of obstruction

Visual Acuity: EC doesn’t use prescription glasses. No

history of eye surgery or presence of cataracts examination,
she could identify objects and faces.
Pocket Snellen’s Chart was used – She can only
INTACT except for Visual
read the first 2 letters until 20/25
Acuity
No pinhole test done due to unavailable materials
Interpretation: She can see
II: Optic
only at 20 feet what a
Direct and Consensual pupillary reflex – Pupils: 3mm;
normal person can read in
Pupils Equally Round and React to Light and
25 feet
Accommodation

Swinging Light Test – Active pupil restriction

Fundoscopy: not available in the setting

6 fields of gaze test: Abnormal medial movement of Left
CN III: Not intact
eye
Medial Rectus Palsy of the
III: Oculomotor CN IV: Intact. Able to move eyes inferolaterally
Left Eye
IV: Trochlear CNVI: Intact. Able to abduct eyes laterally.
VI: Abducens
CN IV: Intact
CN VI: Intact

Able to overcome jaw resistance

Motor division: intact

Able to identify soft or blunt

Blunt: intact
V: Trigeminal INTACT
Sharp: intact

Corneal reflex: positive both eyes

Sensory division: Intact

Motor: no facial asymmetry, presence of nasolabial folds on

both sides
 Upon wrinkling: no asymmetry, presence of wrinkles
on both sides
 Puffing of cheeks: no asymmetry, no weakness
VII: Facial INTACT
 Closing of eyes tightly: no weakness

Sensory
Intact: can identify stimulants
Screen hearing: normal (both)
VIII: Vestibulocochlear Intact. Able to hear medical students and converses with INTACT
 them.

Weber Test: After placing a vibrating 128 Hz tuning fork on

the middle of EC’s head
- No reaction

Rinne Test: Air conduction is greater than bone conduction

on both ears.
- Rinne: AC>BC (both)

IX: Glossopharyngeal
X: Vagus
XI: Spinal Accessory
XII: Hypoglossal
Positive Gag Reflex, symmetrical movement of the uvula. INTACT
Able to swallow. INTACT
Can shrug shoulders and can turn head from left to right with
little resistance.
 Trapezius muscle (shrugging): no weakness INTACT
 SCM: no weakness, able to twist head on resistance
 No atrophy on both shoulders
Tongue is symmetrical with no atrophy and fasciculations.
Able to stick tongue out fully and move from left to right with INACT
resistance.

III. SOMATIC MOTOR SYSTEM

C1 Able to flex neck T1 Able to abduct and adduct fingers

C2 Able to extend neck L1 Able to flex hips

Able to perform lateral flexion of the Able to adduct and medially rotate hips
C3 L2
neck

C4 Able to shrug shoulder L3 Able to extend leg/knee

C5 Able to abduct shoulder L4 Able to dorsiflex

C6 Able to flex elbow and extend wrist L5 Able to extend big toe

C7 Able to extend elbow and flex wrist S1, S2 Able to plantar flex

C8 Able to flex fingers and extend thumb

Motor Exam Upper Extremities: Lower Extremities:

● Deltoid test: 5/5 ● Hip flexion and extension: 5/5
● Pronator test: normal ● Leg adduction: 5/5
● Forearm flexion: 5/5 ● Leg abduction: 5/5
● Arm extension: 5/5 ● Knee extension: 5/5
● Wrist flexion and extension: 5/5 ● Knee flexion: 5/5
● Grip: 5/5 ● Ankle dorsiflexion: 5/5
● Intrinsic hand muscle: Normal (with ● Toe resistance: 5/5
resistance)
● Thumb opposition: normal

Deep Reflex Interpretation

Tendon Plantar reflex: Negative Babinski;
Reflexes positive flexion of toes except for big toe

Jaw Jerk Reflex: Normal; slight closure of jaw 2+

Biceps Reflex: Normal 2+

Brachioradialis reflex: Normal 2+

Triceps Reflex: Normal 2+

Finger flexor reflex: negative 2+

Knee/Patellar Reflex: Normal both knees 2+ 2+

Ankle Reflex: No reflex 0

IV. SOMATIC SENSORY FUNCTIONS

SENSORY Light touch:

EXAM ● Able to distinguish light touch on left and right hands, feet, and the trunk

Pain:
● Right side: sharp interpreted as blunt
● Left side: sharp identified as sharp

Temperature:
● Cold sensation intact (no ice; neuro hammer was used)
● Hot interpreted as hot

Vibration
● Intact vibration sense

2-point discrimination
● Normal palmar
● Normal dorsum

Joint position
● Intact joint proprioception

Graphesthesia
● Able to distinguish 3/5 letters

Stereognosis
● Able to identify 5/5 objects

Romberg Test - cannot be elicited since non-ambulatory; proceed to heel-and-shin test

V. CEREBRAL FUNCTIONS
1. Working Memory

 Serial 7s - 100-7 = 83
 Digit Span: First try: 8, 2, 4, 8
 Spelling Backwards: WORLD —> W, U, A, D
Interpretation: EC was not able to correctly do the Serial, she was not able to remember the numbers given to her,
and she was not able to spell the word ‘WORLD’ backwards
2. Judgement
When asked what she would do if she found a lost wallet - She replied “give back to owner”
3. Fund of Knowledge
Past Presidents
1. Pnoy
2. Corazon
3. Erap
4. Binay
5. Marcos
6. Gloria
Interpretation: EC was able to enumerate past presidents of the Philippines except for Binay who is a Vice President

4. Task Organization
Luria’s Three Step Test: unremarkable
Interpretation: Intact Motor sequencing for the frontal lobe

5. Set Generation
Within 1 minute: (~30 seconds only)
1. Orange
2. Apple
3. Paho (Mango)
4. Saging (Banana)
5. Bayabas (Guava)
6. Peras (Pear)

Interpretation: Her categoral abilities were intact and unremarkable

6. Abstract Reasoning
Proverb: “Aanhin mo and damo kung patay na ang kabayo?”
Answer: anhon mo pa ang bulig kung patay na ang tao

7. Orientation and Memory

Oriented to time, place, and date
8. Three-word recall Test
Can identify objects: ballpen, notebook, paper
- First try: ballpen, paper, notebook
Interpretation: EC was able to remember the objects although not in order

9. Remote Memory
Long term:
  Birthday of husband: Feb 19, 1966
 Wedding anniversary: 2000

Short term
 Dinner last night: Chicken
 Breakfast this morning: egg
Interpretation: EC was able to answer significant personal events and was able to remember her breakfast and
dinner to test for short term memory

10. Judgement and Spatial Relationship

EC was able to point out the similarities of an Apple and Orange
Similarities: apple vs. orange - “pareho bilog”

11. Test for Agnosia

EC was able to identify the objects presented to her

12. Test for Dyscalculia and Alcalculia

Unassessed

13. Test for Left-Right Orientation

EC was able to identify her Left hand from her Right hand

Interpretation: Hence: Left-right orientation was unremarkable

14. Receptive Language

EC was able to maintain attention by listening to the medical students and was able to follow the simple commands
instructed to her.
15. Visual Recognition
EC was able to identify the colors presented to her correctly

 No hallucinations
 No visual agnosia, dysnomia
Interpretation: EC
MSE: UNREMARKABLE

Coordination  Finger to nose: Normal

(Cerebellar) o (patient able to move finger directly from nose to examiner’s finger)
 Finger-to-toe: Normal
o (patient able to move toe directly towards examiner’s finger)
 Finger to finger: Normal
o (patient able to move finger directly towards opposite finger)
 Finger tapping: Normal
 Rapid alternating movement:
 Truncal stability
 Heel to toe - cannot be elicited
 Heel-knee-shin - L leg upon sliding is shaky; abnormal

Meningeal  Kernig Sign: negative

 Signs  Brudzinski’s sign: negative
 Nuchal rigidity: no resistance

FINDINGS

PERTINENT POSITIVES

4 years PTC  Hypertension

5 hours PTC  Generalized weakness on her entire body

 Numbness of both hands and feet
 Lost balance
 Dizziness
 Doubling of vision followed
 Vomited approximately 2 cups of vomitus
 Ringing sound
 Headache which she describes as throbbing localized on her the left temporal side with a
pain rating scale of 10 out of 10.

At the time of  Pain on her neck which she describes as ‘gapalanghugot’ that persisted for hours and an
admission  Onset of weakness on her lower extremities was noted.

PERTINENT NEGATIVES

 history of binge drinking

 Tobacco use
 Drug use
 Use of contraception
 Facial droop
 Dysarthria

PAST MEDICAL HISTORY

15 years with maintenance meds:

Losartan - unrecalled dosage
Amlodipine - unrecalled dosage
Hypertensive With good compliance

FAMILY HISTORY

Father and Siblings

Hypertensive

PERSONAL, SOCIAL, AND ENVIRONMENTAL HISTORY

Laundry Service
Non-smoker
Non-alcoholic drinker

PHYSICAL EXAM

CN I: 20/25
CN III: Medial Palsy
Heel to Shin Test – Shaky

NEUROLOGIC EXAM

CNIII not intact – Medial palsy of Left Eye

Heel to Shin test – Abnormal finding of unstable and shaky movement of leg

DIAGNOSIS
Clinical Hemorrhagic vs Ischemic Stroke: Vertebrobasilar Artery
Impression: involvement
Definition: In hemorrhagic stroke, bleeding occurs directly into the brain parenchyma. The usual
mechanism is thought to be leakage from small intracerebral arteries damaged by chronic
hypertension.
Risk Factors  Advanced age
 Hypertension (up to 60% of cases)
 Previous history of stroke
 Alcohol abuse
 Use of illicit drugs (e.g., cocaine, other sympathomimetic drugs)

HEMORRHAGIC STROKE: Cerebellar or brainstem involvement

Clinical Findings Found in Our Patient
Gait or limb ataxia (+)
Vertigo or tinnitus (+)
Nausea and vomiting (+)
Hemiparesis or quadriparesis (+)
Hemisensory loss or sensory loss of all 4 limbs -
Eye movement abnormalities resulting in diplopia or
nystagmus (+)

Oropharyngeal weakness or dysphagia -

Crossed signs (ipsilateral face and contralateral body) -
History
Weakness or paresis that may affect a single extremity,
(+)
one half of the body, or all 4 extremities
Facial droop -
Monocular or binocular blindness -
Blurred vision or visual field deficits (+)
Dysarthria and trouble understanding speech -
Vertigo or ataxia (+)
Aphasia

ISCHEMIC STROKE: SUBARACHNOID HEMORRHAGE

Clinical Findings Found in Our Patient
 Sudden onset of severe headache (+)
Signs of meningismus with nuchal rigidity (+)
Photophobia and pain with eye movements -
Nausea and vomiting (+)
Syncope - Prolonged or atypical -

Different types of Stroke

Ischemic stroke Intracerebral hemorrhage Subarachnoid hemorrhage

Epidemiology  Most common cause  10% of all strokes  5% of all strokes

 85% of all strokes
 Embolism  Ruptured cerebral artery or  Ruptured berry
 Thrombus microaneurysm aneurysm
Etiology  Small vessel occlusion  Trauma  Arteriovenous
 Systemic  Reperfusion injury after malformation
hypoperfusion ischemic stroke  Trauma

 Age >65  Age >65  Hypertension

 Hypertension  Hypertension  Tobacco use
 Diabetes mellitus  Vasculitis  Family history
Risk factors  Atrial fibrillation  Malignancy
 Carotid artery stenosis  Ischemic stroke

 Sudden onset of focal  Headache, confusion, nausea  Rapid onset of

neurologic deficits
Clinical  (left gaze preference,
right hemiparesis,
features
muscle grading UE
4/5, LE 3/5)
 Sudden onset of focal severe headache
neurologic deficits  Meningeal signs
 Sudden onset of
focal neurologic
deficits

 Noncontract head CT  Noncontrast head CT  Noncontrast head

to rule out hemorrhage  MRI CT
 MRI  CTA/ MRA  CTA
 CTA/MRA (if a  Lumbar puncture 
Diagnosis candidate for
thrombectomy or to
localize the affected
vessel)

 tPA (if within <4.5 hrs  Reversal of coagulopathy  Reversal of

of onset of symptoms)  BP management coagulopathy
 intra-arterial  Surgical intervention if there  Blood pressure
Treatment thrombolysis are signs management
 thrombectomy of herniation or increased ICP  Prevention of
 aspirin or clopidogrel vasospasm
for secondary  Surgical clipping
prevention

DIFFERENTIAL DIAGNOSES
Differential: MENINGITIS
Definition: Infections of the central nervous system (CNS) can be divided into 2 broad categories: those primarily
 involving the meninges (meningitis; see the image below) and those primarily confined to the
parenchyma (encephalitis).
Etiology Causes of meningitis include bacteria, viruses, fungi, parasites, and drugs (
 Fever
 Headache
 Neck stiffness.
 Nausea
 Vomiting
History  Photalgia (photophobia)
*Green – Found in
Patient  Sleepiness
 Confusion
 Irritability
 Delirium
 Coma

 Focal neurologic signs

 Signs of meningeal irritation
Physical
 Systemic and extracranial findings
Findings
 Level of consciousness

ABSENT:
 Nuchal Rigidity
Special Test  Brudzinski’s Sign
 Kernig’s Sign

Diagnostic
 Early identification and treatment of patients with acute bacterial meningitis
 Assessing whether a treatable CNS infection is present in those with suspected subacute or
chronic meningitis
 Identifying the causative organism
Diagnosis
Blood studies:
 Complete blood count (CBC) with differential
 Serum electrolytes
 Serum glucose (which is compared with the CSF glucose)
 Blood urea nitrogen (BUN) or creatinine and liver profile

Differential: TRANSIENT ISCHEMIC ATTACK

Definition: a transient episode of neurologic dysfunction caused by focal brain, spinal cord or retinal ischemia
without acute infarction." 
Etiology  Atherosclerosis of extracranial carotid and vertebral or intracranial arteries
 Embolic sources
 Arterial dissection
 Arteritis
 Sympathomimetic drugs
 Mass lesions
 Hypercoagulable states
History  Recent surgery (eg, carotid or cardiac)
*Green – Found in  Previous strokes or TIAs
Patient
 Seizures
 Systemic or central nervous system (CNS) infections
 Use of illicit drugs
 Complete medication regimen, including all over-the-counter medications
 Comorbidities related to metabolic disorders, especially diabetes
 Known coagulopathy or family history of early clotting or thrombotic events
  History of arteritis
 Noninfectious necrotizing vasculitis, irradiation, and local trauma
 Thromboembolic risk factors
 Other known cardiovascular disease
 History of migraine

Physical  Cardioembolic events are significant causes of TIAs.

Findings  irregular rhythm or other unusual rhythms and rates, murmurs, or rubs that might suggest
valvular disease, atrial-septal defects, or ventricular aneurysm (a source of mural thrombi).
 Check for splinter hemorrhages in the nail beds.
Diagnosis  Ruling out metabolic or drug-induced causes of symptoms consistent with a transient ischemic
attack (TIA) is important.
 A fingerstick blood glucose test
 Obtain a 12-lead electrocardiogram (ECG) with rhythm strip,
 Brain imaging is recommended within 24 hours of symptom onset.
 The cerebral vasculature should be imaged on an urgent basis, preferably at the same time as
the brain.
 Electroencephalography (EEG) may be indicated to evaluate for seizure activity. 
 Lumbar puncture (LP) may be indicated if subarachnoid hemorrhage, central nervous system
(CNS) infection, or demyelinating disease is to be excluded

Differential: SUBDURAL HEMATOMA

Definition: A subdural hematoma (SDH) is a collection of blood below the inner layer of the dura but external to
the brain and arachnoid membrane. Subdural hematoma is the most common type of traumatic
intracranial mass lesion.
Etiology Causes of acute subdural hematoma include the following:
 Head trauma
 Coagulopathy or medical anticoagulation (e.g., warfarin [Coumadin], heparin, hemophilia, liver
disease, thrombocytopenia)
 Nontraumatic intracranial hemorrhage due to cerebral aneurysm, arteriovenous malformation,
or tumor (meningioma or dural metastases)
 Postsurgical (craniotomy, CSF shunting)
 Intracranial hypotension (eg, after lumbar puncture, lumbar CSF leak, lumboperitoneal shunt,
spinal epidural anesthesia [12]
 Child abuse or shaken baby syndrome (in the pediatric age group)
 Spontaneous or unknown (rare)
Causes of chronic subdural hematoma include the following:
 Head trauma (may be relatively mild, e.g., in older individuals with cerebral atrophy)
 Acute subdural hematoma, with or without surgical intervention
 Spontaneous or idiopathic

Risk factors for chronic subdural hematoma include the following:

 Chronic alcoholism
 Epilepsy
 Coagulopathy
 Arachnoid cysts
 Anticoagulant therapy (including aspirin)
 Cardiovascular disease (eg, hypertension, arteriosclerosis)
 Thrombocytopenia
 Diabetes mellitus

History Headache and confusion appear to be the most common presenting features, occurring in as many
*Green – Found in as 90% and 56% of cases, respectively. In 75% of cases, the headache had at least one of the
Patient
following characteristics:
 Sudden onset
 Severe pain
  Accompanying nausea and vomiting
 Exacerbation by coughing, straining, or exercise

Physical Clinical presentation for chronic subdural hematoma is often insidious, with symptoms that include the
Findings following:
 Decreased level of consciousness
 Headache
 Difficulty with gait or balance
 Cognitive dysfunction or memory loss
 Personality change
 Motor deficit (e.g., hemiparesis)
 Aphasia

Chronic subdural hematoma

Neurologic examination for chronic subdural hematoma
 Mental status changes
 Papilledema
 Hyperreflexia or reflex asymmetry
 Hemianopsia
 Hemiparesis
 Third or sixth cranial nerve dysfunction

Diagnosis  An emergent computed tomography (CT) scan of the head needs to be performed when an
acute subdural hematoma is suspected.
 A worsening of the Glasgow Coma Scale by 2 or more points should prompt repeat imaging in
salvageable patients.
 A cervical spine radiograph series is important in evaluating the possibility of concomitant
cervical spine fracture.
 Initial blood tests include the following:
o Complete blood count
o Hemoglobin or hematocrit
o Coagulation profile
o Basic metabolic panel
o Type and screen/cross-match

Sources:

1) Auer RN, Sutherland GR. Primary intracerebral hemorrhage: pathophysiology. Can J Neurol Sci. 2005 Dec. 32
Suppl 2:S3-12. 
2) Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet. 2008 May 10. 371(9624):1612-23. 
3) Ginsberg L, Kidd D. Chronic and recurrent meningitis. Pract Neurol. 2008 Dec. 8(6):348-61. [Medline].
4) Guideline] Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the
management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American
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