Date:
Patient:
Reason for Visit: Follow-up for Subarachnoid Hemorrhage (SAH)
History of Present Illness:
Date of symptom onset (e.g., sudden severe headache, also known as “thunderclap headache”)
Associated symptoms (nausea, vomiting, neck stiffness, altered consciousness)
Witnessed loss of consciousness (if applicable)
Risk factors for SAH (hypertension, smoking, family history)
Physical Exam:
Vital signs (blood pressure control, heart rate, respiratory rate)
Neurological examination:
Mental status (alertness, orientation)
Cranial nerve function
Motor and sensory function
Meningismus (nuchal rigidity)
Imaging:
Mention the type of imaging performed to diagnose SAH (CT scan of the head typically)
Describe the location and extent of bleeding on imaging
Angiography:
If performed, mention the type of angiography (cerebral angiography or CTA) and any findings related to aneurysm or vascular malformation.
Labs:
Electrolytes (serum sodium imbalance can worsen outcome)
Complete blood count (CBC)
Diagnosis:
Confirmed SAH based on imaging
Include laterality (e.g., left SAH) if known
Management:
Summarize the current treatment plan:
Blood pressure control (critical to prevent re-bleeding)
Nimodipine (calcium channel blocker to prevent vasospasm)
Pain management
Seizure prophylaxis (if indicated)
Management of hydrocephalus (if present)
Intervention:
Document any performed interventions:
Surgical clipping of aneurysm (if surgically accessible)
Endovascular coiling (minimally invasive procedure to block aneurysm)
Consultation:
Document any consultations with specialists (neurosurgery, neurocritical care)
Plan:
Outline the plan for the next day(s):
Monitoring of vital signs and neurological status
Continued blood pressure control
Pain management
Repeat imaging (if indicated)
Rehabilitation planning (physical and occupational therapy)
Discharge planning (once stable)
Prognosis:
Briefly discuss the prognosis based on severity of bleed, initial clinical presentation, and response to treatment.
Mention potential complications of SAH (seizures, vasospasm, hydrocephalus)
Additional Information:
Document Glasgow Coma Scale (GCS) score on admission and current score.
Note any modifiable risk factors addressed (e.g., smoking cessation)
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of subarachnoid hemorrhage.