A 58-year-old man with a history of hyperlipidemia presents to his primary care provider with increased fatigue for the past 3 months. He works 10 or more hours a day as a truck driver but he recently began falling asleep immediately in his recliner upon returning home in the evenings because he feels “exhausted.” He notes he is sleeping 2 to 4 hours more per day than normal.

The patient has not felt like riding his horses or maintaining his 70-acre farm, which is out of the ordinary for him. In addition to the fatigue, he also acknowledges new-onset left lower extremity weakness, paresthesia, and abnormal gait over the last 2 weeks. He describes his gait as “dragging my left leg” and “veering toward the left” upon ambulation. He also reports malaise, which has been so significant that he decided to take an at-home COVID test 2 months prior. The COVID-19 test was negative.

He denies any recent lifestyle modifications that could account for these changes. He denies changes in cognition, headaches, alterations in appetite, unexpected weight loss, fecal or urinary incontinence, or seizure-like activity. He denies taking any medications. His social history includes the use of smokeless tobacco as a teen until the age of 33 years and he has a positive family history of maternal vascular dementia.

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His vital signs are normal (Table 1). Physical examination reveals a White male who is alert and oriented x 4. He is well-developed and well-nourished.

Table 1. Vital Signs

Temperature98 °F
Blood pressure132/83 mm Hg
Pulse69 beats per min
Respiratory rate16 breaths per min
Oxygen saturation96%

Cardiovascular examination reveals normal heart rate and rhythm without murmurs, rubs, or gallops heard. Lungs are clear to auscultation bilaterally. Normal bowel sounds are heard in all 4 quadrants. No pain or tenderness is noted on abdominal examination. Neurologic examination reveals cranial nerves II through XII are grossly intact. He has 3/5 strength in the proximal left upper and lower extremities and 4/5 strength in the distal left upper and lower extremities. He has full strength in his right upper and lower extremities. Symmetric sensation is present in all extremities. Reflexes are normal with slightly brisk patellar reflexes on the left. A complete blood cell count, comprehensive metabolic panel, coagulation panel, and COVID-19 polymerase chain reaction (PCR) test are obtained, which are within normal limits.

The patient reported to the emergency department 1 year ago following a syncopal episode during chiropractic care. At that time, his cardiac workup was negative. Head computed tomography (CT) scan revealed no evidence of acute intracranial pathology. Head and neck CT angiograms were unremarkable.

The patient was scheduled for magnetic resonance imaging (MRI) of his brain and cervical and lumbar spine 1 month after the initial clinic visit. However, he began having more pronounced left-sided weakness, ataxia, frequent urinary urge incontinence, and an episode of bowel incontinence. An urgent MRI was ordered (Figure).

Figure. Magnetic resonance imaging of the brain. Credit: A. Faith Bartello, PA-C.


Glioblastoma multiforme (GBM) tumors are aggressive and fast-growing stage IV brain tumors. Glioblastoma multiforme is a subtype of gliomas, which are tumors affecting the glial cells of the brain and spinal cord. Glioblastoma multiforme is considered the most prevalent malignant, primary brain tumor and is one of the deadliest cancers.1 These tumors are most commonly found in White men and the incidence increases with age with the highest incidence found among those aged 75 to 84 years.2,3