Lost for words

A 67-year-old right-handed woman with a history of a 3 cm mid left parietal lobe intra-cerebral hemorrhage (ICH) of uncertain etiology 5 years before was admitted to the inpatient neurology service after an acute episode of witnessed productive aphasia and inability to obey commands during an outpatient neurology assessment. The episode lasted 20 minutes and was not associated with other focal neurologic signs or change in level of consciousness. The reason for referral to the outpatient clinic was concern on the part of her family about her ability to function independently at home over the past several months. General history The patient is a high school educated, retired home care worker who lives alone with her son living close by. She has five grown children. Her hemorrhagic stroke 5 years ago was associated with transient right hemiplegia. She made a complete functional recovery, but her course was complicated by a post-stroke seizure disorder occurring 1 year after her stroke. She experienced a generalized tonic clonic seizure (preceded by right visual field aura and a feeling of apprehension) and required ICU admission. Her presentation was further complicated by post-ictal delirium. Her seizure disorder was initially treated with dilantin, but she was unable to tolerate a dose escalation and was therefore switched to valproic acid. There have been no recorded seizures for the past 4 years. Cognitive history indicates that she has noticed minor deficits of short-term memory and word finding since her stroke, but denied any functional deficits associated with her cognition. Her son has described a 3-year history of decreased attention to personal care, laundry, nutrition, and housekeeping. Her anticonvulsant levels have been lower than expected on several occasions suggesting medication non-compliance. After reviewing of her bank statements, her family suspects she may have gambled away her monthly food budget at a video lottery terminal. There is no history of depressive symptoms, but she has been less socially active and has not been calling out on the telephone in the past year. Past medical history includes atrial fibrillation, and mitral valve regurgitation confirmed on echocardiography. She has a history of hyperlipidemia and hypertension, a 20 pack-year history of smoking (quit 10 years ago) and does not consume alcohol. There are no other vascular risk factors. Medications include ECASA 81 mg daily, clonazepam 0.5 mg QHS, bisoprolol 10 mg daily, atorvastatin 20 mg daily, irbesartan 150 mg daily, valproic acid 250 mg twice daily.