General Data DS 65 year old Female Right- handed

Chief Complaint “Numbness of the left hand”

History of Present Illness One hour PTA, –(+) inward movement and numbness of the left hand – (-) blurring of vision, palpitations, tremors, nausea, vomiting, dizziness, sweating – (+) disorientation and confusion – (+) stiff? – Rapid and incoherent speech

History of Present Illness At the ER, – Two episodes of generalized tonic- clonic seizures lasting 1- 2 minutes stiffening and jerking of the upper and lower extremities head tilted to the right eyes rolling upward tongue biting

History of Present Illness At the ACSU – throbbing headache located on the top of her head,(6/10) – (+) generalized weakness – (-) urinary incontinence, blurring of vision, nausea or vomiting – (-) memory of what happened

Review of Systems General: (-) fever, weight loss HEENT: (-) tinnitus, colds Respiratory: (-) difficulty of breathing, coughing Cardiovascular: (-) chest pains, orthopnea, PND Gastrointestinal: (-) change in bowel movements

Review of Systems Genitourinary: (-) dysuria, frequency Endocrine: (-) heat or cold intolerance, excess thirst, excess sweat Musculoskeletal/ Dermatologic: (+) dermatoses/ trophic skin changes

Past Medical History Illnesses – Seizure secondary to CVD infarct January 2010 –Angina 2007 –Hypertension –Diabetes mellitus type (-) Trauma (-) History of febrile seizures

Past Medical History Surgeries: None Hospitalization: January 2010 Allergies: None

Past Medical History Ob- gyne – G3P3(3003) –LMP 55 years old –(+) OCP use for 6 months – (-) hormone replacement therapy – (+) preeclampsia: third pregnancy – (+) blood transfusion: third pregnancy

Medications Compliant with: 1) Lantus 40 mg SQ OD 2)Aspirin 75 mg OD 3)ISMN (Imdur) 60 mg durule 4)Bisoprolol 10 mg OD 5)Peridopril 8 mg OD 6)Atorvastatin 20 mg/ tab OD 7) Dipyridamole 200 mg/ tab OD

Family Medical History Diabetes Hypertension Breast Cancer Stroke Cardiovascular disease

Personal and Social History Married with three children Occupation: nurse Occasional drinker Non- smoker

Physical Examination

Awake, not in cardiorespiratory distress Height: 165 cm Weight: 80 kg BMI = 34 BP = 160/70 HR = 73 RR = 14 T = 36.5 O C

Physical Examination HEENT –Anicteric sclerae; pink palpebral conjunctiva –No nasal congestion – (-) CLAD, (-) TPC, Non- distended neck veins Respiratory –Symmetric chest expansion –Clear breath sounds

Physical Examination Cardiovascular – Adynamic precordium –Apex beat at 5 th ICS LMCL –Regular rhythm, normal rate –Distinct S1 and S2 –(-) Murmurs Abdominal –Flabby, soft abdomen –Normoactive bowel sounds –No tenderness

Physical Examination Extremities –Full and equal pulses (2+) –(-) edema –Good skin turgor Skin –Normal hair and scalp, nails –Trophic skin changes/ dermatoses –No pallor or jaundice

Physical Examination Neuro examination at the ER: – Awake, still confused and disoriented, able to follow some verbal commands; GCS 14 – Primary gaze: midline dysconjugate gaze, initially oscillopsia on extreme gaze. – CN II- pupils are equally reactive to light 3 mm; CN III, IV, VI- EOMs full and equal; CN V brisk corneal reflex; CN VII no asymmetry or weakness; CNXIII intact; CN IX- X (-) dysarthria, dysphagia; CN XI no weakness; CN XII tongue midline.

Physical Examination Neuro examination at the ER: – Motor 5/5 on all extremities except for the left upper extremity 4/5. Minimal spasticity on the left. Left arm can lift 30˚. –Sensory intact. –Supple neck –(-) Babinski reflex – (-) hyper, hyporeflexia

Physical Examination Neurologic : MMSE: 28/ 30; GCS 15 –Cranial Nerves I – Not done II – Pupils 3mm, equally reactive to light; visual fields full to confrontation III, IV, VI – Full EOM’s V – Corneal reflex not done, sensory- intact bilaterally in all three divisions for sharp, dull, touch stimuli; motor- temporal and masseter strength intact VII – No facial weakness and asymmetry VIII – Gross hearing intact IX, X – (+) gag reflex

Neurologic : Cranial Nerves (cont.) XI- (+) shoulder shrug, head turn, 5/5 XII – tongue at midline

Physical Examination Neurologic –Motor o (-) muscle, involuntary movements o 5/5 on all extremities except for left upper extremity (4/5) o Drift on the upper left extremity o DTRs: ++ on bilateral brachioradialis, ankle; (-) Babinski –Somatic o Reactive to touch/pain on all extremities. Temperature sensation intact bilaterally and symmetrically. Position sense intact bilaterally and symmetrically intact except for left upper extremity – Cerebellar o No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel along shin intact bilaterally) – Supple neck, (-) Brudzinski, Kernig

Differential Diagnoses

Syncope Rule InRule Out Loss of consciousness-No precipitating factors -LOC and GTC movements < seconds - Loss of postural tone -Rare tongue biting and headache

Transient Ischemic Attack

Acute Psychosis

Neoplastic Rule InRule Out -Family history of cancer-No focal neurologic deficit -No chronic headache which worsens over time -No weight loss, nausea, vomiting, irritability

Infection Rule InRule Out -No fever, nausea, vomiting, irritability -Supple neck, (-) Kernig and Brudzinski

Stroke Rule InRule Out -Headache, confusion, lapse of consciousness -(+) hypertension, diabetes mellitus -No neurologic deficit -No stroke sequelae

Hypoglycemia Rule InRule Out - Good compliance - Does not skip meals

Migraine Rule InRule Out -Talkativenes -Altered consciousness and headache -Unilateral weakness -Prolonged unilateral headache -Duration of headache can last for hours -Seizure?