A 63-year-old man with a past medical history of Parkinson's dementia presented to the emergency department after a fall from his scooter. Patient described worsening weakness and inability to perform activities of daily living over the last seven years, recently requiring a scooter to aid in movement. In the emergency department, head imaging showed no signs of cerebral hemorrhage and patient was stable. He was, however, noted to have dysarthria, dysphagia, and weakness of the orbicularis oculi muscles. Additionally, physical exam found upper and lower motor neuron signs including flaccid paralysis and tongue fasciculations (Video), findings which are inconsistent with Parkinson's dementia. Further analysis revealed pseudobulbar symptoms, sudden emotional outbursts, stiffness of the lower extremities, and general muscle spasms. Suspicions arose about patient's prior diagnosis, and a new presumptive diagnosis of amyotrophic lateral sclerosis (ALS) was made. The rest of the patient's hospital course was unremarkable and on day three post-admission, the patient was discharged. Given ALS is a clinical diagnosis of exclusion supported by appropriate neurological imaging studies, the diagnosis was further supported by outpatient electromyography. Regular follow-up with a neurologist was established and patient is currently receiving appropriate care for ALS. This case highlights the importance of conducting a thorough physical examination on every patient regardless of initial presentation.