A 71-year-old woman is brought to the emergency department by her
daughter for evaluation of her mental status. The daughter says, "I visited
mom today for the first time in 6 months; her memory has worsened, her
bills are unpaid, and her house is unusually messy." The patient says, "I'm
perfectly healthy." Medical history is significant for hypertension diagnosed
more than 25 years ago, and two small strokes occurring 3 years and 7
months ago. The daughter gives you three empty medicine bottles from
her mother's home: metoprolol, hydrochlorothiazide, and aspirin. The
patient is 165 cm (5 ft 5 in) tall and weighs 59 kg (130 lb); BMI is 22 kg/m2 .
Vital signs are temperature 36.4°C (97.6°F), pulse 76/min, respirations
16/min, and blood pressure 196/112 mm Hg. Pulse oximetry on room air
shows an oxygen saturation of 93%. Muscle strength in her left hand is 1/5.
Strength in the right extremities is 4/5. The patient is oriented only to self;
she does not know the day of the week or today's date. She recalls 0 of 3
words at 5 minutes, and she is unable to name 2 objects, correctly draw
interlocking pentagons, or count backwards by serial sevens. Complete
blood count, renal function studies, liver function studies, and urinalysis are
all within the reference ranges. ECG shows no abnormalities.
Which of the following is the most likely underlying cause of the patient's
symptoms?
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