Case 3
CASE 3: DESCRIPTION
A 75-year-old right-handed woman with migraines, hx of stroke and dementia is brought in by ambulance to the emergency room after her daughter witnessed an episode of shaking and confusion. In the morning, she complained of her typical slowly worsening migraine headache. During breakfast, suddenly her eyes rolled up, she made a guttural sound, then her right arm stiffened and started shaking rhythmically followed by total body stiffness and jerking x 60 seconds with her eyes open and looking to the right. She bit her tongue and had bladder/bowel incontinence. Her daughter helped her onto the floor on her side. Afterwards, she was breathing heavily, tired and confused.
SHx: Retired, identifies as Filipino, no substance usage
Vitals: T 37, BP 120/80, HR 110, RR 20, O2 sat 98% RA
General: NAD
HEENT: lateral tongue laceration
Skin: no lesions
MS: drowsy, but easily arousable, able to state her name but was unable to state the date, her surroundings, why she was in the hospital, limited attention, frequently falling asleep during the exam, no complaints of headache (per daughter at baseline she is usually awake and she typically knows her whereabouts but not the date)
CN: VFFTC, PERRL, EOMI, intact frontalis strength and eye closure, flattened nasal labial fold on right and lower right facial droop, intact hearing, tongue midline and strong
Motor: anti-gravity in all limbs but right hemiparesis (new per daughter) most evident in the right upper extremity, right pronator drift, tone slightly low in the right limbs compared to the left, left full strength, normal bulk
Reflexes: 2+ throughout except right arm 3+, toes down
Sensation: intact to light touch in all extremities, + extinction to double simultaneous stimulation on the right face, arm, leg
Coordination: no obvious ataxia
Gait: By the time of the gait exam, she appears more alert. She is steady but she has decreased arm swing on the right