Clinical Reasoning: A 71-Year-Old Man With Horizontal Gaze Palsy, Anarthria, and Quadriparesis
Bibliographic record
Abstract
A 71-year-old right-handed male nonsmoker with type 2 diabetes, hypertension, and chronic lymphocytic leukemia (CLL) never requiring active treatment presented to the hospital with 1 week of subacute-onset nausea, vomiting, and unsteady gait.On examination, he was afebrile with blood pressure 155/82 mm Hg and heart rate 62 bpm.He had right hemiataxia with widebased gait.CT head and CT angiogram resulted in ischemic stroke diagnosis with no vascular abnormalities.Cardiac workup was unremarkable.He was managed with antiplatelet therapy and risk factor optimization.Following discharge, the patient's symptoms worsened, with intractable nausea, hyperemesis, weight loss, slurred speech, and loss of independent ambulation, resulting in hospital readmission 2 weeks later.Repeat imaging showed mild lesion expansion.Despite receiving antiplatelets, he progressively deteriorated, becoming nonverbal, communicating with gestures, and eventually becoming seemingly nonresponsive with no movement beyond eye opening.He required intubation, subsequent tracheostomy, and transfer to our center for further evaluation 3 months into his presentation.At this point, the patient remained afebrile and normotensive without meningismus.He was nonverbal with spontaneous eye opening and blinking.He could look up and down to written commands with preserved vertical saccades and tracking, but no horizontal eye movements.Pupillary and corneal reflexes were preserved with impaired cough.He had spasticity with no spontaneous limb movements or resistance to strength testing.Painful stimulation caused upper extremity extensor posturing and triple flexion in the lower extremities.Deep tendon reflexes were brisk with bilateral extensor plantar responses.On further history, we learned that the patient was born in India, emigrating to Canada 40 years ago.He had no preceding infectious or constitutional symptoms, recent travel, previous tuberculosis, or sick contacts. Question for Consideration:1. What is the expected localization of the patient's deficits on initial presentation and subsequently following transfer?
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.002 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.003 | 0.003 |
| Insufficient payload (model declined to judge) | 0.006 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".