You are called to see a 35 y/o male for a stroke. He came into screening clinic with weakness and tingling/numbness of his left arm since he awoke. The night before, he had a couple of cocktails and fell asleep with his wife's head on his shoulder. When he went to work the next morning as a draftsman, he was unable to hold tools with his left hand and had persistent parasthesias over the back of his forearm onto his hand.General exam:V.S. afebrile, normotensiveWN,WD AA male in NAS: exam WNL except:Neurological exam:Neurological exam:Intact in detail except --Moderate left triceps weakness with left biceps and pronator normal. -Absent movement in left brachioradialis, wrist and finger extensors but normal wrist and finger flexor strength with hand held in extension. -Small area of decreased superficial sensation over dorsal/radial aspect of left forearm on to dorsal surface of left hand involving thumb and digits II & III.-Decreased left triceps jerk and absent left brachioradialis reflex.

Called to fracture clinic to see a 58 y/o MD with multiple recent fractures who was observed to have 2 tonic-clonic convulsions which began with turning of head and eyes to left. A friend states that the patient drinks heavily, has gone for "the cure" several times and had last drink the night before. The fractures occurred when he fell arising from the toilet at 4:00 a.m. No previous seizures or acute alcohol withdrawal known.

General exam:V.S. afebrile; HR 120: RR 24: BP 170/90Disheveled, dirty white male in NAD with fractures of right arm, left shoulder and left ankle, Tongue lacerationNeurological exam:Neurological exam:HIF:HIF: Mildly tremulous; alert but oriented x 2 1/2 (wrong year) Coordination:Coordination: mildly clumsy with all extremitiesCranial Nerves:Cranial Nerves: Jerky EOMs with mild left ptosis and unsustained horizontal nystagmus on lateral gaze to either side, Sensory:Sensory: Stocking impairment in superficial sensationMotor:Motor: No focal or asymmetric weakness or other sensory abnormalities.Reflexes:Reflexes: (+) such, snout, jaw and Hoffman reflexes. Toes downgoing. Normoactive DTRs except absent ankle jerks

Called to EW to see a 55 y/o psychologist who complained of acute onset of severe bifrontal headache awakening him from sleep followed in a couple of hours by drooping of his right eyelid. Past medical history remarkable only for migraine. Current headache is “worst ever.”General Exam:V/S: BP 128/80 RR 16 HR 72 afebrileWNWD white male in moderate distress from headache.Head: diffusely tender to percussionNeck: suppleNeurological exam:Neurological exam:HIF:HIF: Lethargic, OX3; memory 1/3 @ 5'; speech - normal; repetitions and naming intact. Serial 7's correct; right - left orientation intact.Cranial Nerves:Cranial Nerves: Virtually unable to move right eye with fixed, dilated pupil and ptosis. Mildly decreased abduction of left eyeReflexes:Reflexes: Mildly increased DTRs on right with right extensor plantar.

LP:LP: OP-220 WBC=22 (83% poly) RBC-890 GLU=57 Prot=94 supernatant: benzidine (+)SXR: mildly enlarged sella turcica

A 44 y/o alcohol abuser with one week history of headache, anorexia and gait unsteadiness. Brought to EW by "friend" because he was very lethargic and somewhat confused. No history of head trauma; last drink was shortly before admission. Past history remarkable for GI bleed due to gastritis, old pulmonary TB and hepatosplenomegaly.

General Exam at midnight:V/S: 37° C, BP 140/90, HR 88, RR 20, unlaboredDirty, disheveled WD white male in NAD: no jaundiceHead: nontender; no evidence of traumaNeck: suppleNeurological exam:Neurological exam:HIF:HIF: OXl, lethargic but arousable to loud voice Follows 1-step commands; impersistent, easily distracted Speech often inappropriate but fluent and understandableGait:Gait: tended to circumduct right legCranial Nerves:Cranial Nerves: Fundi-benign; VFs apparently full, EOMs full without nystagmus; right pupil 2mm and reactive - left 4mm and reactiveSensory:Sensory: Responded to pain everywhereMotor:Motor: Moved all extremities appropriately to pain with good strengthReflexes:Reflexes: DTRs 2-3+ symmetric with toes downgoing Asterixis presentCT scanner down for repairs: LP showed OP=225, prot 90, glucose 75, neg stains and cells

At 6:00 am called because patient was found unresponsive to voice or touch with fixed, dilated right pupil – responds only to deep pain with minimal grimace and general agitation/increased respiration