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A 71-year-old Caucasian man was brought to the emergency department (ED) for left-sided weakness and confusion. According to his wife, he was found on the floor in his bathroom at home with a paralyzed left arm and leg and slurred speech. This was 6 hours before he came to the ED. The patient has a history of non–insulin-dependent diabetes, hypertension, and hyperlipidemia. On arrival to the ED, he was confused and was noted to have left hemiparesis and left facial droop with aphasia. The vital signs revealed a blood pressure of 119/60 mm Hg, pulse of 119 beats per minute (bpm), respiratory rate of (RR) 33 breaths/min, and arterial oxygen saturation (Sao2) of 85%. He was intubated and ventilated after appropriate sedation and chemical paralysis. A noncontrast computed tomography (CT) scan of the head was performed, which showed a dense right middle cerebral artery sign and no evidence of acute intracranial hemorrhage. The electrocardiogram revealed atrial fibrillation. The radiograph of the chest revealed appropriate endotracheal tube position and a right lower lobe infiltrate.

On his arrival in the neurologic intensive care unit (ICU), his vital signs showed a temperature of 36.4°C (97.5°F), pulse of 132 bpm (sinus), respirations (ventilated) at 14 breaths/min, blood pressure of 113/47 mm Hg, and oxygen saturation of 100%. On physical examination, he appeared acutely ill and cachectic. The carotid pulses were equal, and there were no bruits. A pulmonary examination demonstrated right lower lobe crackles. The heart sounds were normal. The limbs were well perfused, and the abdomen revealed diminished bowel sounds with a soft and nondistended abdomen. A musculoskeletal examination showed moderate diffuse muscle wasting. The neurologic examinations were not informative because of deep sedation. The results of laboratory tests are shown in Table 51-1.

According to his wife, he retired a year ago from his previous occupation as a taxicab driver for 40 years. He had been smoking 1 pack of cigarettes per day on average for 35 years and drank alcohol occasionally. For the last 5 months, his appetite has been decreased and he has been eating small portions at 2 to 3 meals per day. He lost 15 lb (6.8 kg) during the past 5 months and his most recently measured weight was 115 lb (52 kg). His height was 5 feet and 8 inches (172 cm).

Table 51-1.Laboratory Values on Admission

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