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I'm having trouble making sense of the exam of a patient, and was wondering if anyone else on this forum could provide any insights.
This is an 80+ year old man who underwent an elective surgery for severe aortic stenosis, and they noticed he wasn't completely "with it" after the procedure performed under general anesthesia. While off all sedation, 24 hours after his urgery, he would not follow commands, but moved his head from side to side spontaneously, would open his eyes on his own and had spontaneous roving eye movements. Also, various examiners noted he seemed to have trouble moving the left arm and the right leg, but at other times he moved both legs strongly and equally, although he wouldn't withdraw to pain in the right leg (despite moving it on his own just seconds earlier). There was no hypoxic-ischemic event during the surgery. He also had an unusual coarse tremoring of the right arm at this point. Eventually, he was extubated and "woke up"; per his family, he's back to his baseline now, about a week later, although he seems to have trouble following complex commands and has a degree of perseveration, I think. The right arm tremoring has disappeared.
He's diffusely arreflexic, although I believe that's related to his diabetes. What's odd about his exam now is that he has almost full strength in his left deltoid, biceps and triceps, but 0/5 in the finger flexors, finger extensors, wrist flexors and extensors and interossei; the only intrinsic hand movement he has on the left is trace opponens of the thumb. It's very hard to tell how weak he is in his right leg, as he complains of pain and says he can't move it because it's "weak"; again, it has been noted to move pretty well on other occasions spontaneously. Sensory exam is unreliable since it's inconsistent.
Everyone's concern is for a stroke; he does have a history of atrial fibrillation but he's not considered a candidate for anticoagulation for many reasons. We can't get an MRI because of a pacemaker. Two head CTs have been negative.
It almost looks like a peripheral process, given the degree and distribution of the weakness in the left hand, but I can't localize it to any particular nerve, root, or plexus lesion. His history would be inconsistent with a peripheral process as well. It just seems very localized for a stroke. Also, I'm not sure how the right leg weakness (if it truly is real) fits into it.
Any thoughts?
This is an 80+ year old man who underwent an elective surgery for severe aortic stenosis, and they noticed he wasn't completely "with it" after the procedure performed under general anesthesia. While off all sedation, 24 hours after his urgery, he would not follow commands, but moved his head from side to side spontaneously, would open his eyes on his own and had spontaneous roving eye movements. Also, various examiners noted he seemed to have trouble moving the left arm and the right leg, but at other times he moved both legs strongly and equally, although he wouldn't withdraw to pain in the right leg (despite moving it on his own just seconds earlier). There was no hypoxic-ischemic event during the surgery. He also had an unusual coarse tremoring of the right arm at this point. Eventually, he was extubated and "woke up"; per his family, he's back to his baseline now, about a week later, although he seems to have trouble following complex commands and has a degree of perseveration, I think. The right arm tremoring has disappeared.
He's diffusely arreflexic, although I believe that's related to his diabetes. What's odd about his exam now is that he has almost full strength in his left deltoid, biceps and triceps, but 0/5 in the finger flexors, finger extensors, wrist flexors and extensors and interossei; the only intrinsic hand movement he has on the left is trace opponens of the thumb. It's very hard to tell how weak he is in his right leg, as he complains of pain and says he can't move it because it's "weak"; again, it has been noted to move pretty well on other occasions spontaneously. Sensory exam is unreliable since it's inconsistent.
Everyone's concern is for a stroke; he does have a history of atrial fibrillation but he's not considered a candidate for anticoagulation for many reasons. We can't get an MRI because of a pacemaker. Two head CTs have been negative.
It almost looks like a peripheral process, given the degree and distribution of the weakness in the left hand, but I can't localize it to any particular nerve, root, or plexus lesion. His history would be inconsistent with a peripheral process as well. It just seems very localized for a stroke. Also, I'm not sure how the right leg weakness (if it truly is real) fits into it.
Any thoughts?