Presenting Signs and Symptoms DS, a 55-year-old female, arrived by ambulance to the emergency room on Friday afternoon of October 7, 2011. Patient arrived to Sunrise Hospital complaining of a one-day history of headache with severe intensity that started the night before and became increasingly painful, prompting her to call 911. DS was experiencing difficulty breathing at rest, and altered mental status. In the emergency room, CT scan was done and revealed a large amount of subarachnoid hemorrhage (SAH) in the sylvian fissures and blood in the fourth and third ventricles.
DS started suffering from rapid deterioration of mental state and emergency room physician elected to intubate. She was immediately evaluated by a neurosurgeon and he successfully placed a right frontal twist drill for external ventricular drain placement due to the subarachnoid hemorrhage. Pulmonologist was also consulted and aided on the ventilated patient after procedure. Her temperature had been as low as 94.8°F, and she was put on a bear hugger. She was given Propofol titrated to sedation and started on antibiotics. DS was transferred to Neuro ICU on mechanical ventilation and, so far, is currently stable.
History and Physical DS has past medical history of emphysema, migraine headaches, and osteoporosis. Her past surgical history includes breast augmentation. DS drinks alcohol on occasion, but denies smoking and recreational drug use. Home medications include ProAir HFA Inhalation and Symbicort Inhalation. The patient is allergic to Flagyl and Sulfa antibiotics.
The admitting physical exams for DS are as follow: Vital signs: blood pressure173/108, heart rate 48, respiratory rate16, temperature at 96°F axillary and oxygen saturation 100% on mechanical vent. Appearance: she appeared ill and pale and on moderate distress. EENT: Right pupil 3mm and dilated. Left pupil 3mm and dilated. Patient was encephalopathic with generalized weakness. Oriented to person only. Pharynx was normal. Neck: normal inspection, neck supple. Cardiovascular system: normal heart rate and rhythm, heart sounds normal, EKG rhythm strip lead II rate at 54, sinus bradycardia, regular rhythm, non specific ST segment/T-wave abnormalities. Respiratory: patient on mechanical vent assist control, rate 16/minute, 100% FiO2, tidal volume at 500ml; no respiratory distress, breath sounds normal, ET tube size 7fr, 4.9cm above the carina, in proper placement per radiology. Abdomen: soft and non-tender, no organomegaly. Skin: warm and dry, pallor. Extremities: no lower extremity edema. Neurologic: The patient is disoriented to time and place. Alertness is decreased as evidenced by patient not opening eyes in response to pain. There was evidence of cranial nerve deficit as evidenced by EOM palsy on the left and difficulty swallowing. No motor or sensory deficit noted. Patient is not moving her left eye laterally. She has difficulty swallowing and a weak gag reflex.