Go Back to the House, MD

A 72-year-old man presented to the emergency department with dysarthria and a left facial droop. He was in his usual state of health prior to the day of presentation. His social worker described him as being at his baseline on the morning of presentation, only to find him immobile with a facial droop, dysarthria, and incontinence several hours later. His medical history included hypertension, hyperlipidemia, and aspiration pneumonia complicated by delirium. Medications included lisinopril, furosemide, aspirin, carvedilol, and atorvastatin. No allergies were known. His family history was unclear. He was previously undomiciled but more recently lodged in state-sponsored housing with other previously homeless individuals. His substance use history was unknown. The initial examination, conducted by a neurology resident in the emergency department, revealed a disheveled patient with insect bites on his appendages. He answered simple questions but seemed inattentive (e.g., calling out for water). The cranial nerve examination revealed complete, non-supranuclear ophthalmoparesis OU but was otherwise normal, including reactive pupils and visual fields which were full to finger counting. His face appeared symmetric. The motor examination was limited but revealed symmetric anti-gravity movement throughout. Light touch was intact throughout. Reflexes, coordination, and gait were not assessed. Aspiration pneumonia was identified and he was started on antibiotics and IV thiamine. After admission, systolic blood pressures increased to the 200s. The neurology attending examination revealed preserved ability to follow commands despite an inability to open eyes. Blink to threat was absent. Pupils reacted from 3.5-3 on hospital day 2 but were fixed by hospital day 3 at 4.5mm. Eyes were conjugate with complete ophthalmoplegia and absent vestibulo-ocular reflexes in all directions. Corneal reflexes were very weak and cough was absent. No movement was noted proximally, though he could weakly squeeze hands and wiggle toes symmetrically. Tone was low. Reflexes were absent.