A 64-year-old man arrives to the urgent care center with his wife. He has a complaint of two days of intermittent dizziness. He has vomited 3 times in the past 2 days but does not have a stomachaches or fever. When questioned in more detail, the patient describes intermittent right arm and right leg tingling for the past two to three days. His wife says that he does not demonstrate any unusual behavior, but she adds that his speech has been occasionally slurred for the past couple of days. He has not had any loss of consciousness, shortness of breath, chest pain, fevers, headaches, or diarrhea. He has not had any bladder problems, skin problems, or rashes.
The patient has a history of hypertension and mild asthma, and he does not generally get routine medical checkups. He has occasional heartburn for which he takes an over-the-counter medication as needed. He has been a smoker for 40 years (one pack a day for the past 25 years). He had several broken toes 13 years ago due to a fall while riding a motorcycle and he has some persistent discomfort of his foot as well as trouble walking since then. He does not take any prescription medications or vitamins.
The patient is well-nourished but he appears unsettled and afraid to walk due to his dizziness. He is cooperative and able to answer questions and provide a history of his symptoms and his overall health. Blood pressure is 170/95. His skin appears normal. His throat appears normal. His heart rate and rhythm are normal. His pulses are slightly decreased, but palpable. His breathing is clear and normal. There is no abdominal tenderness. He has a hoarse voice and occasional hiccups.
On neurological exam, the patient is alert and oriented x3 with no tremors or involuntary movements of his arms or legs, and normal strength in all four extremities. He has ataxia and dysmetria of his left upper and lower extremities. He has normal sensation to touch on the right arm and right leg, decreased pain and temperature sensation of the right arm and right leg, and normal sensation to all modalities on the left arm and left leg.
His reflexes are slightly diminished on the right arm and right leg without positive Babinski, and reflexes are normal on the left arm and left leg. He has mild ptosis (droopy eyelid) of the left side; normal and equal pupils; bilateral nystagmus; and decreased sensation on the lower left side of the face. Sensation of the forehead is equal on both sides. Although he tries to walk, he is unable to do so without supporting himself by holding on to a chair.
CBC and electrolyte tests were normal. A brain CT scan showed diffuse small vessel disease, with no acute lesions. He was sent home and referred to a neurologist, who ordered a brain MRI, which showed a left sided subacute lateral medullary infarction.
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