Lydia is a 31 year-old woman brought to the clinic confusion and 'talking a lot'.

Lydia was well until 2 days ago. Unable to answer questions appropriately. Minimally cooperative during the exam. Finally admitted she had a headache. Family had not noticed nausea, vomiting, diarrhea, dyspnea or cough. Treated for malaria one year ago. She has 5 children.

©wwwKarlGrobl.com

Physical exam

• Vital signs: Afebrile (37.5°C), Pulse = 90, BP = 110/70, Resp = 22
• Thin woman, oriented as to person only.
• PERLA, but there appears to be a bilateral sixth nerve palsy.
• Neck is supple, oropharynx, clear, pale mucus membranes and conjunctivae.
• Chest is clear and there are no abnormal heart sounds.
• Deep tendon reflexes are 2+ and gait is normal.
• Blood smear is negative for malaria parasties.

An LP is performed, she was admitted and empirically started on quinine.