INR

UNFINISHED CASE: COME BACK LATER 

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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.  He is worried about a stroke

Vital Signs & Physical Exam:

• Vital signs are normal except for an irregular pulse of 112.
• Physical exam shows subtle left arm and left leg weakness, which the patient states he does not think was there prior to breakfast.  There is minimal left leg swelling

Initial Differential Diagnosis:

• CVA
• Sciatica
• DVT

Initial Diagnostic Testing:

• CBC and BMP are normal.  INR is 1.5
• Head CT shows the old stroke right-sided 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 other uncommon, but not rare condition should be high on your differential diagnosis?  Acute limb ischemia because his INR is subtherapeutic
2. What exam finding should you check for and what test should you order?  Cooler left leg and pulse deficit.  Arterial duplex
3. Want a 1-minute consult/tutorial on this case? See highlighted area below
4. Want to know what happened with this patient? had acute limb ischemia, treated with heparin followed by angioplasty.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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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