allergies: penicillins / meperidine attending: chief complaint: altered mental status major surgical or invasive procedure: none history of present illness: the patient is a 67 year old man with a history of dementia, depression, hypertension, and left cea 3 weeks ago now presenting with an episode of shaking witnessed by sister and worrisome for a seizure. as per the sister, on the day of admission to the osh, the patient was complaining of abdominal pain and went to bed early. she checked on him later in the night and thought him to be restless in the bed, moving about and unable to sleep. she checked on him again about an hour later and found him nude in the now-urine soaked bed. his clothes were also soaked in urine and on the floor next to the bed. of note, the patient is incontinent of urine and stool (less often) at baseline. as per the sister, he only had one eye open and kept saying "turn it on" and "i want that barrel over there" while pointing to a chair in the corner. a few moments later, he started grimacing, became very stiff, then started shaking all four extremities in a rhythmic fashion with clenched fists. at that point, the sister called for an ambulance and the patient was brought to the osh. at the osh, he was loaded with phenytoin, ativan, ceftriaxone and transferred to for further management. in our ed, the patient was febrile to 102.8, hypertensive to 214/136 and minimally responsive to painful stimuli. he was started on a nitro drip for blood pressure control and transferred to the micu. there an lp was performed which showed 0 wbc, 0 rbc, 15% polys, 45% lymphs, 40% monos. he was started on vanco and acyclovir. he was subsequently transferred to the neurology service for further management. past medical history: niddm diet controlled cad htn hypercholesterolemia aaa throat ca s/p resection/xrt seizure disorder depression parkinson's dz social history: worked as a security guard, lives with nephew and sister. walks unaided. hcp (nephew) . current smoker, 1 pack per day hx for "many years" etoh dependency, stopped 25 years ago no drug use family history: mother: intracranial bleed 72 yr old physical exam: vitals: t=99.0 bp=114/60 p=98 r=18 sao2=98% general: well nourished, in no acute distress neck: supple, carotid bruit on right lungs: decreased breath sounds at the bases cv: rr, 2/6 systolic murmur abdomen: non-tender, non-distended, bowel sounds present ext: warm, no edema; good pulses neurologic examination: mental status: awake and alert, cooperative with exam, normal affect oriented to person, place, month but not president attention: can say months of year forward and backward in 50 sec language: fluent, no dysarthria, no paraphasic errors, naming intact fund of knowledge normal registration: items, recall items at 3 minutes with prompting no apraxia, no neglect intact cranial nerves: visual fields are full to confrontation. pupils equally round and reactive to light, 4 to 2 mm bilaterally. extraocular movements intact, no nystagmus. facial sensation and mild right facial droop. hearing intact to finger rub bilaterally. tongue midline, no fasciculations. sternocleidomastoid and trapezius normal bilaterally. motor: normal bulk and tone bilaterally no tremor. d t b wf we fif ip gl q h af ae tf te right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 mild right pronator drift sensation was intact to light touch, pin prick, temperature (cold), vibration, and proprioception reflexes: b t br pa pl right 2 2 2 2+ 1 left 2 2 2 2+ 1 grasp reflex absent plantar reflex was withdrawal fnf slower on right, rapid alternating movements slowed on right pertinent results: cbc: 13.3>36.6<172 inr: 1.2 chem: 140/2.9 99/29 19/0.7 133 ast:23 alt:13 ak:104 tb:1.1 c/m/p: 9.4/1.5/2.4 cxr : bibasilar densities head mri : (from omr) severely limited examination due to motion artifact. bilateral white matter and cortical hyperintensities in the posterior frontal and parietal regions with a more prominent area in the left posterior temporal region. these are suspicious for infarction occuring after . however, these areas appear normal on the diffusion weighted images and thus do not represent acute infarction. 11:50pm cerebrospinal fluid (csf) protein-77* glucose-138 11:50pm cerebrospinal fluid (csf) wbc-0 rbc-0 polys-15 lymphs-45 monos-40 brief hospital course: the patient was managed on the neurology service for his possible seizure activity in the setting of a recent stroke. he underwent an eeg on that showed abnormally slowed background rhythms. he had a carotid ultrasound performed which showed no significant stenosis as well on . over the course of his 3 day admission his neuro exam changed slightly in that the weakness in his lower extremity improved slightly but his memory impairments remained. he was discharged on day 4 in stable condition. medications on admission: protonix 40 qd asa 81 qd donepezil 15 qd lopressor 25 colase quetiapine 200 qd aricept 10 qd nardil 30/45 discharge medications: 1. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 2. atorvastatin calcium 10 mg tablet sig: one (1) tablet po hs (at bedtime). disp:*30 tablet(s)* refills:*2* 3. donepezil hydrochloride 10 mg tablet sig: one (1) tablet po hs (at bedtime). 4. lisinopril 20 mg tablet sig: two (2) tablet po qd (once a day). disp:*60 tablet(s)* refills:*2* 5. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 5 days. disp:*5 tablet(s)* refills:*0* 6. metronidazole 500 mg tablet sig: one (1) tablet po tid (3 times a day) for 5 days. disp:*15 tablet(s)* refills:*0* 7. phenytoin sodium extended 100 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 8. metoprolol tartrate 50 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 9. clopidogrel bisulfate 75 mg tablet sig: one (1) tablet po qd (once a day). disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: 1. subacute stroke 2. seizure discharge condition: stable, steady on feet. discharge instructions: please return to nearest er if symptoms of shaking, headache, or visual disturbance occur. please take medications as prescribed. followup instructions: provider: study where: cc clinical center radiology phone: date/time: 10:00 please follow-up with your primary care physician, . in weeks as needed. md, Procedure: Arteriography of other intra-abdominal arteries Arteriography of other specified sites Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other convulsions Depressive disorder, not elsewhere classified Pneumonitis due to inhalation of food or vomitus Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Iatrogenic cerebrovascular infarction or hemorrhage Dementia with lewy bodies Dementia in conditions classified elsewhere with behavioral disturbance