Case from last month

[soorg]

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28 year old, mild asthmatic, otherwise healthy, to OR for a D&C, 15 week pregnancy. Other than being understandably emotional pre-op, nothing remarkable noted. To OR, rapid-seq induction, easy airway, easy maintenance, smooth emergence. Post-op, in PACU, can't move or feel anything on the entire right side of her body. No pressure, touch, pain, or motor function on the entire right side. No hypotension during case, no history of an neuro problems in patient/family. Thoughts?

 

[ssmallz]

What's the rest of her mental status? Is she responsive and appropriate? Protecting her airway? When you say entire right side of her body, does that include her face? How bout occular movement? Any double vision? VSS?

Check her lytes, get a CT scan, neuro consult, and when all that is negative it's time for psych to see her. I had a similar case like this as a Ca-3, we did a knee scope on an otherwise healthy mid 30s female. Uneventful case but when she woke up she had upper extremity weakness. Million dollar work up yielded nothing and she was diagnosed w/a psychosomatic disorder. Further history revealed some family history of violence with in the family that may have contributed to it.

 

[soorg]

Post-op elytes normal. She went for a CT scan of head/neck, MRA/MRI, hypercoagulable workup. All negative.

 

[cincincyreds]

At least scan for maybe an air embolus? Is that possible in this case? Amniotic fluid embolism if vitals not stable but much less likely? At least get an echo to check the heart for anything weird.

 

[Mman]

conversion disorder? She's obviously got some serious psychological strain going on and maybe waking up in PACU triggered it.


Did it resolve spontaneously?

 

[scudrunner]

conversion disorder? She's obviously got some serious psychological strain going on and maybe waking up in PACU triggered it.


Did it resolve spontaneously?

That was my thought.

Was this an elective abortion or the end of a miscarriage?

 

[SexPanther]

Conversion d/o is the 1st thing that comes to my mind also, but you've got to do the w/u as this is an absolute diagnosis of exclusion.

One thing to consider in the preggers population is venous sinus thrombosis - a MRV added to that work-up would be nice.

We've had 2 cases in the last year in which pregnant woman (maybe they were post-partum, can't remember) had symptoms of a CVA and were diagnosed as conversion d/o by the ED. Ending up having massive strokes - devastating and sad.

 

[DScully]

One thing to consider in the preggers population is venous sinus thrombosis - a MRV added to that work-up would be nice.

Would you see anything abnormal from plain MRI if it is venous sinus thrombosis? I would imagine that MRA would at least signal some minor abnormality...and then the next step could be MRV. Or do you have to get MRA/MRV at the same time despite a "normal" plain MRI?

 

[Idiopathic]

yeah, i think you have to have MRI/MRV (will probably need MRV for venous thrombosis). also consider PFO for etiology. Conversion disorder always dx of exclusion.

 

[urge]

28 year old, mild asthmatic, otherwise healthy, to OR for a D&C, 15 week pregnancy. Other than being understandably emotional pre-op, nothing remarkable noted. To OR, rapid-seq induction, easy airway, easy maintenance, smooth emergence. Post-op, in PACU, can't move or feel anything on the entire right side of her body. No pressure, touch, pain, or motor function on the entire right side. No hypotension during case, no history of an neuro problems in patient/family. Thoughts?

Put the twitch monitor on her right and crank it up all the way. There are some bad fakers out there.

Is her face the same? Eyes? Caloric?

DTR-hyper, hypo?

Call Neuro.... This is beyond the scope of anesthesia.

 

[Per4mer8]

Put the twitch monitor on her right and crank it up all the way. There are some bad fakers out there.

Is her face the same? Eyes? Caloric?

DTR-hyper, hypo?

Call Neuro.... This is beyond the scope of anesthesia.

Question?? Wouldn't she twitch by direct stim with or without stroke/embolism? (as long as paralytics are off).

I guess unless this test is designed to be painful and prove sensation is intact.... Sorry if this is a total n00b question, just wondering the thought process here.

 

[fakin' the funk]

28 year old, mild asthmatic, otherwise healthy, to OR for a D&C, 15 week pregnancy. Other than being understandably emotional pre-op, nothing remarkable noted. To OR, rapid-seq induction, easy airway, easy maintenance, smooth emergence. Post-op, in PACU, can't move or feel anything on the entire right side of her body. No pressure, touch, pain, or motor function on the entire right side. No hypotension during case, no history of an neuro problems in patient/family. Thoughts?

First, finish your neuro exam. From your story I do like conversion d/o here though.

-- Mental status - awake/lethargic/obtunded etc.
-- Cranial nerves - (I think this is where the money is) pupils, blink reflex, confrontation, facial droop, tongue protrusion, dysarthria
-- Strength - sounds like you covered
-- Sensory - sounds like you covered (consider some truly painful stimuli)
-- DTRs - whatever they are on that right side, it'd be interesting

 

[fakin' the funk]

Question?? Wouldn't she twitch by direct stim with or without stroke/embolism? (as long as paralytics are off).

I guess unless this test is designed to be painful and prove sensation is intact.... Sorry if this is a total n00b question, just wondering the thought process here.

This.

And you're right, applying tetany to any of the facial muscles in the scenario described would cause twitch.

 

[ssmallz]

Put the twitch monitor on her right and crank it up all the way. There are some bad fakers out there.

Did that w/my conversion d/o pt last year, no movement, we tried pinching her arm as well and no response. Conversion d/o isn't the same as faking

 

[Mman]

Did that w/my conversion d/o pt last year, no movement, we tried pinching her arm as well and no response. Conversion d/o isn't the same as faking

while it isn't the same as faking it, it also responds to physical examination differently than an actual CNS event because it is psychological and not physical.

 

[Idiopathic]

Did that w/my conversion d/o pt last year, no movement, we tried pinching her arm as well and no response. Conversion d/o isn't the same as faking

hold on. you put the twitcher on and it didnt twitch or she didnt react to it. id believe the latter but would have trouble believing the former.

 

[Noyac]

Versed!

 

[Idiopathic]

i feel like at some point you will have to give us the punch line

 

[ssmallz]

hold on. you put the twitcher on and it didnt twitch or she didnt react to it. id believe the latter but would have trouble believing the former.

Didn't react to it, she had a strong 4/4 twitch.....I guess I should have clarified

 

[ssmallz]

while it isn't the same as faking it, it also responds to physical examination differently than an actual CNS event because it is psychological and not physical.

Not necessarily. If the pt had a stroke they will still respond to the twitcher with strong tetanus and train of 4. If the pt has a conversion d/o she may not react to the pain even when the twitcher is cranked all the way up. That's exactly what happened to my patient. We ran every test under the sun, all negative, PE was consistent w/a stroke, she couldn't move her left arm and didn't respond at all to pain. In the end we found out she had some family violence issues going on that likely contributed to it. Psych diagnosed her w/a conversion d/o.

 

[lord_jeebus]

Did the patient seem at all concerned about her loss of sensory and motor function?

 

[Noyac]

Not necessarily. If the pt had a stroke they will still respond to the twitcher with strong tetanus and train of 4. If the pt has a conversion d/o she may not react to the pain even when the twitcher is cranked all the way up. That's exactly what happened to my patient. We ran every test under the sun, all negative, PE was consistent w/a stroke, she couldn't move her left arm and didn't respond at all to pain. In the end we found out she had some family violence issues going on that likely contributed to it. Psych diagnosed her w/a conversion d/o.

And then she got some Versed, right?

 

[soorg]

Crap-sorry for late reply. Was out for awhile...

Post-op echo was NL, no PFO, NL EF. No, she did not seem at all concerned about her post-op status. La belle indifference? For her, but I was def nervous!

The evening of her first post-op day she had regained about 25% function of motor and sensation. By post-op day 2 she had regained 100% and was sent home. Again, all tests, scans, hypercoag. w/u was all normal. Conversion disorder was the discharge diagnosis. It was just very stark to see something that you always read about to actually happen in real life. Psychiatry isn't all bs, and here is definite proof!

In addition, it was nice to have this diagnosis after the neuro NP told me that conversion disorder was "highly unlikely" after I suggested it to her in the PACU immediately post-op.

 

[BLADEMDA]

 

[BLADEMDA]

 

[Gern Blansten]

I have seen conversion disorder present like this a couple of times and that was my initial thought when I read the case.
Of interest and for completeness sake, hemiplegic migraine can mimic stroke as well. Not likely in this case, but often overlooked and something to always consider in the differential of unilateral paralysis patients when things aren't adding up correctly, especially in the young population.