Case 4 History ---- The decedent was a 52-year-old man with a history of mental retardation due to anoxic brain injury at birth, paranoid schizophrenia, morbid obesity (BMI 41.8), hypertension, diabetes, non-ischemic cardiomyopathy with left ventricle dyskinesis (ejection fraction of 60% in Sept 2015), and GERD with chronic cough who was in his usual state of health until 9/1 when he presented to Saint Louis University ED for a fall and leg pain. He was evaluated and discharged to his residential care facility. The following day, he returned with left-sided flaccid paralysis, left-sided facial droop, and slurred speech. Head CT without contrast on 9/02 showed no acute hemorrhage. CT Angiogram revealed an evolving acute right pontine infarct and mild stenosis of the left internal carotid artery. Brain MRI from 9/3 showed a small ischemic stroke in the right basilar pons as well as encephalomalacia of the bilateral frontal cortex and the left parietal area in addition to chronic small vessel disease. The patient was discharged to a rehabilitation facility on 9/9. His mental status returned to baseline, slurred speech improved, and he was able to walk with assistance. On 9/21 he was found unresponsive and CPR was initiated but he remained in asystole and there was no return of spontaneous circulation. Examination at the Barnes-Jewish ED showed asystole with pale, cyanotic skin, Glasgow Coma Scale of 3, low end-tidal carbon dioxide measurements, and fixed symmetric non-reactive pupils. He was pronounced dead.
