HEMORRHAGIC STROKE

This is a case of an 86 year old female, known hypertensive, and dyslipidemic for more than 20
years with poor compliance to her maintenance medications came in due to sudden loss of
consciousness.  Condition started 10 hours prior wherein patient was noted to have sudden
onset of R sided weakness and aphasia with no history of trauma and illicit drug use.  This was
associated with 3 episodes of vomiting previously ingested food.  She was immediately brought
to Balamban District Hospital, wherein she was noted to be unconscious hence intubated and
was then transferred in this institution for further work up.  Patient was received at Er with a
GCS of 4 with no spontaneous eye opening and flaccid extremities. BP was elevated at 200/100,
HR 90’s, o2 sat at 97% intubated. 

Stat CT scan was done which showed  parenchymal collection of hemorrhage at the left basal ganglia
extending to the thalamus and periventricular region measuring approximately 39 cc in volume, with
surrounding edema. The left lateral and third ventricles are compressed. The septum pellucidum is
deviated to the right by about 0.6 cm. Large amount of intraventricular hemorrhage is noted with
moderate to severe dilation of the ventricles. Minimal subarachnoid hemorrhage within the right parieto
temporal lobe sulci. 

Hypertension is the most common cause of intracerebral hemorrhage.  Common sites include basal
ganglia especially the putamen, thalamus, cerebellum and pons

With a GCS score of 4, age of 86, intracerebral volume of 39cc with intraventricular hemorrhage, this
gives a score of 5 in ICH score with 100% mortality.

CBC showed leukocytosis of 15 with predominance of segmenters at 85.  Bleeding parameters

elevated. Protime at 13.3 with 99% and prolonged INR of 1.9.  FBS was elevated at 192 with
normal HBA1c.  Lipid panel was unremarkable.  ECG showed Sinus rhythm with isolated
premature atrial contraction. CXR showed. 

Early specific management of hemorrhagic stroke include BP control by treating SBP>180 and or
acute lowering of SBP <140mmhg within 7 days in no surgical patient (small to moderate sized).
Immediate surgical candidates include supratentorial hematoma >30cc , cerebellar hemorrhage
>3cm with neurologic deterioration or brainstem compression and hydrocephalus from
ventricular obstruction, bleed from structural lesions, clinically deteriorating young patients,
ventricular drainage for intraventricular hemorrhage with moderate to severe hydrocephalus,
GCS 5 and above.  Increased Intracerebral Pressure is controlled by head elevation 30-45
degrees, osmotic therapy with mannitol.  

Nicardipine drip was started to decrease SBP with target of less than 140.  Patient was then
started with Mannitol, Citicholine and PPI. Patient was referred to Neuro service for Stat
Ventriculostomy and ICU admission for closer monitoring.  However, family refused surgical
intervention and opted to allow natural death.

Patient succumbed on the 30 hour of hospital admission. 

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5. CAP 
This is a case of BB 45 year old female with no known comorbidities admitted due to a 5 day hx
of productive cough with yellowish sputum and fever Tmax 40C.   Pt was noted to be febrile,
tachypneic and slightly tachycardic upon presentation at ER.  Pertinent PE include crackles on
right lower lung and wheeze.  CBC taken showed leukocytosis with neutrophilic predominance.
Chest Xray showed hazy infiltrates at right lower lung.  Patient was treated as a case of
Community Acquired Pneumonia Moderate risk on the basis of fever, tachypnea, tachycardia
and chest xray findings.

According to CAP CPG Guidelines, initial antibiotic treatment for moderate-risk CAP include a
combination of an IV non-antipseudomonal β-lactam with extended macrolide or respiratory
fluoroquinolone.  As for the patient, he was started with 2 gen Cephalosporin Cefuroxime to
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cover common respiratory pathogens such as, S. pneumoniae, H. influenzae, M. catarrhalis and
group A beta-haemolytic streptococci and Azithromycin to cover the atypical organisms such as
Legionella, and Mycoplasma organisms.  Supportive treatment such as mucolytics and
antipyretics were given.

In the interim, patient was afebrile for 72 hours with no evidence of tachypnea, tachycardia,
hypotension, desaturations and changes in sensorium.  Patient was clinically improving and was
hemodynamically stable. IV antibiotics were stepped down to oral.  The patient was deemed fit
for discharge on the 4 hospital day and was advised to complete oral antibiotics for 7 days. 
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Older guidelines recommended routine follow-up chest x-rays after 6 weeks presumably to
screen for malignancy after an acute infiltrate has cleared.  However recent guidelines don’t
recommend unless patient has persistent symptoms or those at higher risk of underlying
malignancy (especially smokers and those aged >50 years).  Influenza and Pneumococcal
vaccination are recommended especially in older adults as well as smoking cessation.

UTI
KS is a 43-year-old male, known diabetic admitted for 3 days fever, dysuria and increased urinary
frequency. Patient sought consult with AP as outpatient and was treated as cystitis hence started on Co
amoxiclav. Patient was advised urine culture. Upon ff up with AP, urine culture showed E. coli ESBL (+)
resistant to both SMX-TMP and ciprofloxacin hence was advised admission.

ESBL + E coli (ESBL-EC)) are resistant to multiple antimicrobial agents.  They hydrolyze beta-lactam
antibiotics, including third-generation cephalosporins. They are resistant to SMX/TMP, fluoroquinolones,
 

and aminoglycosides.  Carbapenems are generally considered the drug of choice.  

Patient was admitted as a direct to room with stable vital signs and unremarkable physical findings. As
for the patient, he completed a full course of Ertapenem for 7 days.  Repeat urinalysis showed marked
improvement with resolution of pyuria and bacteruria. Patient’s general health condition improved with
no evidence of fever and urinary symptoms. Vital signs were stable, hence discharged.  

Urinary tract infections in men are uncommon and increase with age. They are often associated with
structural or functional abnormality. Therefore, any man presenting with UTI should be evaluated for
structural abnormalities of the urinary tract, with the UTI treated as a complicated UTI until proven
otherwise.  However, no imaging was done.  Also, STD should be worked up for patients presenting with
history of multiple sexual partners, urethral discharge, urogenital pain and rash on genitalia.

CAP 
This is a case of BB 45 year old female with no known comorbidities admitted due to a 5 day hx of
productive cough with yellowish sputum and fever Tmax 40C.   Pt was noted to be febrile, tachypneic
and slightly tachycardic upon presentation at ER.  Pertinent PE include crackles on right lower lung and
wheeze.  CBC taken showed leukocytosis with neutrophilic predominance.   Chest Xray showed hazy
infiltrates at right lower lung.  Patient was treated as a case of Community Acquired Pneumonia
Moderate risk on the basis of fever, tachypnea, tachycardia and chest xray findings.

According to CAP CPG Guidelines, initial antibiotic treatment for moderate-risk CAP include a
combination of an IV non-antipseudomonal β-lactam with extended macrolide or respiratory
fluoroquinolone.  As for the patient, he was started with 2 gen Cephalosporin Cefuroxime to cover
nd

common respiratory pathogens such as, S. pneumoniae, H. influenzae, M. catarrhalis and group A beta-
haemolytic streptococci and Azithromycin to cover the atypical organisms such as  Legionella,
and Mycoplasma organisms.  Supportive treatment such as mucolytics and antipyretics were given.

In the interim, patient was afebrile for 72 hours with no evidence of tachypnea, tachycardia,
hypotension, desaturations and changes in sensorium.  Patient was clinically improving and was
hemodynamically stable. IV antibiotics were stepped down to oral.  The patient was deemed fit for
discharge on the 4 hospital day and was advised to complete oral antibiotics for 7 days. 
th

Older guidelines recommended routine follow-up chest x-rays after 6 weeks presumably to screen for
malignancy after an acute infiltrate has cleared.  However recent guidelines don’t recommend unless
patient has persistent symptoms or those at higher risk of underlying malignancy (especially smokers
and those aged >50 years).  Influenza and Pneumococcal vaccination are recommended especially in
older adults as well as smoking cessation.