General Data

1. General Data • DS • 65 year old • Female • Right- handed

2. Chief Complaint • “Numbness of the left hand”

3. 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

4. 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

5. 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

6. 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

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

8. Past Medical History • Illnesses • Seizure secondary to CVD infarct January 2010 • Angina 2007 • Hypertension • Diabetes mellitus type 2 2000 • (-) Trauma • (-) History of febrile seizures

9. Past Medical History • Surgeries: None • Hospitalization: January 2010 • Allergies: None

10. 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

11. Medications • Compliant with: • Lantus 40 mg SQ OD • Aspirin 75 mg OD • ISMN (Imdur) 60 mg durule • Bisoprolol 10 mg OD • Peridopril 8 mg OD • Atorvastatin 20 mg/ tab OD • Dipyridamole 200 mg/ tab OD

12. Family Medical History • Diabetes • Hypertension • Breast Cancer • Stroke • Cardiovascular disease

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

14. Physical Examination

15. Physical Examination • Awake, not in cardiorespiratory distress • Height: 165 cm • Weight: 80 kg • BMI = 34 • BP = 160/70 • HR = 73 • RR = 14 • T = 36.5OC

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

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

18. 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

19. 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.

20. 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

21. 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

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

23. Physical Examination • Neurologic • Motor • (-) muscle, involuntary movements • 5/5 on all extremities except for left upper extremity (4/5) • Drift on the upper left extremity • DTRs: ++ on bilateral brachioradialis, ankle; (-) Babinski • Somatic • 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 • No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel along shin intact bilaterally) • Supple neck, (-) Brudzinski, Kernig

24. Differential Diagnoses

25. Syncope

26. Transient Ischemic Attack

27. Acute Psychosis

28. Neoplastic

29. Infection

30. Stroke

31. Hypoglycemia

32. Migraine