The patient is 89 years old, who have cerebral hemorrhage. The hemorrhage expanded from left Thalamus to Putamen, which caused intracerebral hemorrhage.
According to CT scan, the brain has already mid-line shift. She has right hemiplegia and has difficulty to communicate due to the brain damage. She also has involuntary movement on her right side of her body, which is probably caused by midline shift.
She has a nasogastric tube for taking nutrition.
The hemorrhage is so huge that it is difficult to recover her consciousness and higher brain function. Her family choose DNAR.
Btw, She has high body temperature(around 38) when she come to this hospital. There is no certain source of infection and inflammatory reaction in L/D. Therefore, we consider this fever as central one due to cerebral hemorrhage.
We need to care about infection because she has some devices such as nasogastric tube and urethral balloons.