Leg Numbness

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History of Present Illness:

• An 82-year-old male with a history a-fib on warfarin and a prior CVA that had caused left-sided weakness, presents to the ED with new left leg numbness that started while eating breakfast 1 hour ago.
• He states the leg feels swollen to him, but denies leg pain, weakness, headache, back pain, other complaints

Vital Signs & Physical Exam:

• Vital signs are normal except for.
• Physical exam shows subtle left arm and left leg weakness, which the patient states he does not think was there prior to breakfast

Initial Differential Diagnosis:

• CVA
• Sciatica
• DVT

Initial Diagnostic Testing:

• CBC and BMP are normal.  INR is only 1.7
• Head CT shows the old stroke, but no bleed
• Venous duplex is negative for DVT
• He is seen by the stroke team, which recommends aspirin but no tPA

QUESTIONS:

1. What other uncommon, but not rare condition should be high on your differential diagnosis?  
2. What exam finding should you check for and what test should you order?  
3. Want a 1-minute consult/tutorial on this case? 
4. Want to know what happened with this patient?

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ANSWERS:

1. What does the case image image show?  The image shows .
2. What should you do next?  Treat with.  Consult.
3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
4. Want to know what happened with this patient?  See case conclusion below tutorial page.

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CASE CONCLUSION:  Unilateral leg numbness or weakness with no arm involvement is rarely due to a stroke.  Consider sciatica or limb ischemia