A 71-year-old woman with a 4-month history of recurrent headaches refractory to treatment presented to her primary care physician's office with persistent headaches, generalized weakness, and a droopy left eyelid. During initial hospital assessment, she endorsed a 20-pound weight loss. She denied any fever, neck stiffness, or photophobia. Her medical history was significant for type II diabetes mellitus and hypertension (both well-controlled and off medications). On examination, the patient was alert and oriented to person, place, and time. Her speech was dysarthric and she had difficulty with word-finding and following 2-step commands. Pupils were 3 mm and equally reactive to light. She had complete ptosis of the left eyelid, and her left eye was down and out at rest. The left eye was able to abduct and look down, but unable to adduct. The right eye was able to abduct and look down, but unable to go past midline when adducting. Upward gaze was limited in both eyes. Eyelid closure was weak bilaterally, but weaker on the left. Facial sensation to light touch was decreased in the V2 distribution bilaterally, and the patient also exhibited mild left facial droop. Hearing was intact. Shoulder shrug was intact. No palate or tongue weakness/asymmetry was noted. Strength in upper and lower limbs was 5/5 throughout. Deep tendon reflexes were 2+ and symmetric throughout. Toes were downgoing bilaterally. Sensation to light touch, pinprick, and temperature was intact on the right side, but diminished in the left arm and leg throughout and did not fit with a peripheral nerve distribution. Truncal ataxia was noted when sitting up and walking. She had an unsteady, wide-based gait, and her balance did not worsen with eyes closed.