Nervous System Chart: Subarachnoid Hemorrhage Medical Terminology Systems\" (201

Question

Nervous System Chart: Subarachnoid Hemorrhage Medical Terminology Systems" (2017). Gylys, Barbara and Wedding, Mary Ellen. FA Davis Discharge Summary Admission Date: July 5, 20xx Discharge Date: July 16, 20xx Admitting Diagnosis: Severe headaches associated with nausea and vomiting Discharge Diagnosis: Subarachnoid hemorrhage History of Present illness: Patient is a 61 year old woman who presents at this time complaining of an "extreme severe headache while swimming." She also complains of associated neck pain, occipital pain, nausea, and vomiting. A CT scan was obtained that showed blood in the cisterna subarachnoidalis consistent with subarachnoid hemorrhage. The patient also had mile acute hydrocephalus. Neurologically, the patient was found to be within normal limits. A cerebral MRI was performed, and no aneurysm was noted. Hospital Course: The patient was hospitalized on 7/5/xx, she had sudden worsening of her headache, associated with nausea and vomiting. Also, she was noted to have meningismus on examination. A lumba puncture was performed to R/O possible rebleed. At the time of the lumbar puncture, CSF in four tubes wa read as consistent with recurrent subarachnoid hemorrhage. A repeat MRI was performed without evidenc View as Text 1 2 v 3 4 5 8 9 Ul

Explanation / Answer

1) The patient felt the pain in the back of head (occipital region) and neck.

2) The imaging tests performed were CT and MRI brain. The CT brain showed blood in the cisterna subarachnoidalis consistent with subarachnoid haemorrhage. MRI brain showed normal results (no aneurysms).

3) The results of the lumbar puncture was consistent with sub arachnoid haemorrhage.

4) The repeat MRI showed no evidence.

5) The patient was instructed to avoid any kind of activity that would result in raised intracranial pressure. She was instructed to avoid all activities that are more rigirous than walking.

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