A 62-year-old Man with Acute Dizziness, Nausea and Vomiting

The patient was a 62-year-old man presenting to the emergency department 6 hours after the onset of dizziness, nausea and vomiting. The patient complained of numbness of the right side of her body and reported swallowing problems. The initial examination showed the patient was alert and stable. The left side of her face was sweating while the right side was completely dry. The neurological examination revealed the patient was alert, and the right pupil was about 2 mm smaller than the left eye pupil, and both pupils responded to light. A paresis was observed in the right side of the face, tongue and uvula. Uvula was slightly deviated to the right. Other signs included hoarseness and swallowing impairment. The muscle strength of all four limbs was 5/5. Babinski reflex was downward on both sides. The patient could not sit by herself, and leaned to the right. The patient had a history of primary coronary intervention (PCI) and stent placement four years ago. She had smoked a pack of cigarettes for 40 years. She used nitrocontin, pearl, lisinopril, carvedilol and furosemide. Laboratory tests were normal. The first CT scan in the emergency department was normal. As a brain stem infarction was suspected, MRI was performed and revealed an infarct (Figure 1). The patient received neurology consultation and was discharged with stable vital signs and the daily order of aspirin and atorvastatin after five days. The patient was asked to have weekly follow-up visits.