Neurology Clerkships
Case 4  
Author: Eric Kraus, MD
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This is a 83 year-old woman who presents to the ER by medics from her nursing home. She was watching TV when she had sudden onset of HA, increased confusion, and right leg weakness. No vision change, aphasia, or vertigo. At baseline she has trouble walking and moderate dementia. No previous similar events. Over the last 1 hour she has worsened slightly. Coumadin recently increased for a nontherapeutic INR.

1. HTN
2. ASCVD s/p MI 1999
3. DVT right leg 3 months ago
4. Hysterectomy 1974
5. CHF
6. Alzheimer's dementia

1. Lisinopril 20mg qd
2. Coumadin 5mg qd
3. Furosemide 20mg bid
4. KCl 10meq qd
5. Quinine hs prn
6. Aricept 10mg qd
7. MVI

Allergies: NKDA

Family History: Positive for ASCVD and diabetes mellitus. Father died of an MI at 72. Mother died of breast cancer at 79.

Social History: No smoking. No alcohol. Lives in nursing home. Widowed. No children.

BP 190/98   HR 92 (regular)   T 37.2°C
General: Agitated elderly female. Carotid auscultation normal.
Mental Status: Does not follow all complex commands. Fluent. Oriented to place and self only.
HEENT: PERRLA. EOMI. Visual fields full. Face normal. OP benign. Tongue midline.
Motor (Power/Tone/Bulk): Left 4+/5 consistent with age. Right arm 4+/5. Right leg 2/5.
Sensory: Reduced light touch in the right leg.
Reflexes: 1/4 at the biceps, triceps bilaterally. Right knee and ankle 3/4. Left knee and ankle 2/4. Right toe upgoing, left toe downgoing to plantar stimulation.
Coordination: FNF normal. Can't test right HKS.
Gait: Can't test.
Abnormal Movements: None
Other Organ: 2/6 systolic murmur heard at the ULSB without radiation. The right calf is swollen. JVD 8cm. Lungs reveal bibasilar fine crackles.

Abnormal. Normal rate of 82. Sinus rhythm. Q-waves in II, III and AVF indicative of an old inferior MI.

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