Neurology Clerkships
Case 2  
Author: Eric Kraus, MD
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This is a 67 year-old woman who presents to the ER by medics. She was found on her living room floor by her son. Up to 24 hours may have elapsed since the acute event. The patient can't give a history because of aphasia. She is clearly weaker on her right side. Her son says that she hasn't been feeling well for 3-4 days due to mild dyspnea and fatigue.

1. HTN
2. ASCVD s/p MI 1999
4. Anxiety

1. Lisinopril 20mg qd
2. ASA 81mg qd
3. Metoprolol 100mg qd
4. Pravastatin 10mg qd
5. Paxil 10mg qd

Allergies: NKDA

Family History: Positive for ASCVD and diabetes mellitus. Father died of a stroke at 82. Mother died of colon cancer at 79.

Social History: Quit smoking 1999 (25 pack years). Rare alcohol. Widowed. Lives alone. Son checks on her daily.

BP 180/102   HR 108 (irregularly irregular)   T 37.5°C
General: Agitated elderly female. Carotid auscultation normal.
Mental Status: Sedated. Global aphasia (receptive and nonfluent). She can stick out her tongue to mimic, but can't hold up fingers to command.
HEENT: PERRLA. EOMs can't test. She may have a right homonymous hemianopsia to confrontation. Right facial droop sparing the forehead. OP benign.
Motor (Power/Tone/Bulk): Left grossly normal but she can't follow commands. Right side flaccid with 1-2/5 strength to pain stimulus.
Sensory: Can't test. Feels pain on the right.
Reflexes: 1/4 at the left biceps, triceps, knee, and ankle. 0/4 at the left brachioradialis. 2/4 at the right biceps, knee, and ankle. 1/4 at the right brachioradialis and triceps. Right toe upgoing, left toe downgoing to plantar stimulation.
Coordination: Can't test.
Gait: Can't test.
Abnormal Movements: None
Other Organs: 2/6 midsystolic murmur heard at the apex consistent with MR.

EKG: Abnormal. Tachycardia with a rate of 102. Atrial fibrillation. Q-waves in II, III and AVF indicative of an old inferior MI.

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