12 hours prior to admission, patient was seen lying down in bed repetitively reaching for the curtains beside

her bed using her right arm.

Decreased response when called, unable to recognize her relatives, with inappropriate response. She was also noted mumbling
incomprehensible words to herself. She would also repeatedly ask for food but would throw away her food when offered. No febrile episodes,
no convulsive movement of the extremities, no loss of consciousness.
She was unable to sleep throughout the night and was seen to be restless and irritable. Her relatives also noted that she kept her left arm on
a flexed position and cradledby her right upper extremity. She was unable to sit unsupported or stand up and ambulate with assistance
prompted consult at our institution.
Past Medical History:
Previous Illness:
(+) stroke (1998) left sided weakness
(+) MI (1963)
(+) hypertension (1998)- non compliant with meds
(+) PTB (s/p 3x anti kochs)
(+) goiter (1979)
Blood transfusions: Yes
Known allergies: None
Medications: None
Physical Examination on Admission:
Vital Signs: BP: 160/90 mmHg, PR: 72 bpm, RR: 19 cpm, Temp: 36.7C
General: Conscious, stretcher borne, not in cardiorespiratory distress, disoriented to person, time and place
Skin: Warm dry skin, good skin turgor, no pallor, with jaundice, with abrasion/ desquamation dorsum left forearm
Head: no scalp lesions
Eyes: Pink palpebral conjunctivae, anicteric sclerae, pupils 2-3 mm ERTL,
Nose: No alar flaring, nasal septum midline, no nasal discharge

Mouth: Moist lips and buccal mucosa, no oral lesions, tonsils not enlarged, nonhyperemic posterior pharyngeal walls, incomplete dentition
Neck: Supple neck, structures midline, thyroid not palpable, no cervical lymphadenopathy
Lungs: Symmetrical chest expansion, no retractions, no adventitious sounds
Cardiac: Adynamic precordium, apex beat at 5th LICS MCL, no heaves, lifts, thrills or murmur, S1>S2 at apex, S2>S1 at base
Abdomen: Soft, flabbly, no visible pulsation and peristalsis, (-) direct and rebound tenderness on all quadrants
Genitourinary: (-) CVA tenderness
Extremities: No edema, cyanosis, full and equal pulses, CRT <2secs
GCS 13 (E4V3M6), awake, conscious, coherent, not oriented to time, person and place, inappropriate responses, inappropriate smiling, unable to follow most commands,
unable to maintain eye contact with examiner, easily irritated
Cranial Nerves:
CNI no anosmia
CN II 2-3 mm ERTL
CN III, IV, VI EOM intact,
CN V can clench teeth, no sensory deficit
CN VII shallow L nasolabial fold, can smile and frown
CN VIII gross hearing intact
CN IX, X uvula midline
CN XI can shrug both shoulders against resistance
CN XII tongue protrusion midline
Motor: (+) limitation of movement on right upper and lower extremities. RUE 4 RLE 4 LUE 3 LLE 3
Cerebellum: unable to cooperate
Sensory: unable to cooperate
Reflexes: ++ DTRs left upper and lower extremities, +++ DTRs right upper and lower extremities (-) babinski
Meningeal: (-) nuchal rigidity, (-) Kernig sign, (-) Brudzinski sign