You are asked to see a 64-year-old woman in the Yale Emergency Department in January because of fever and headache. She claimed to feel well until 3 days prior to admission when she began to develop fever. Two days before admission she developed a headache that began to increase in intensity, and the fever continued so she came to the Emergency Department. She denied any trauma, cough, visual or hearing problems. She was never hospitalized for any medical illness. PE reveals a thin woman in moderate distress wanting all lights off in the room. T 101.6, P112, R 26, BP 140/84. SKIN – no rash or petechiae. LN – none palpable. HEENT – nuchal rigidity was noted; sinuses nontender; oropharynx red but without exudate; conj normal; Fundi reveal sharp discs without retinal exudates; TMs are red without effusion. CHEST – clear. COR – RRR with 1/6 SEM at base. ABD – soft, nontender without organomegaly. G/R – normal; heme negative. NEURO – somnolent but oriented; motor, sensory, cerebellar and CN exams are normal; Kernig’s and Brudzinski signs were negative. Fifteen minutes after the initial evaluation, the patient develops a grand mal seizure.

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