May I ask a "case study" type question for IM physicians?

[health123]

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Hello Everyone, I hope I found the right place to ask a question about a patient I recently saw. I'm an adult NP and usually do rounds in subacute and rehab facilities part time. I came across a new patient whose history was unfamiliar to me but was asked to look at. 67 y/ female has history of depression/anxiety, fibromyalgia, htn, hyperlipidemia, underwent gastric bypass approximately 8 years ago (lost 140 lbs) she's now at 143 lbs. Recently was admitted to hospital with complaints of severe abdominal pain....was found to have diverticulosis, stabilized and discharged to rehab. Her complaint was that she walked into the hospital, was given anesthesia and after that everything went downhill; she was unable to stand, extremely weak, etc. Now she's here in rehab doing rpt and is complaining of right sided upper and lower extremity weakness. I did extensive neuro check on her; hand grips were definitely unequal with weakness of right side.
However, I hate to stereotype but I've had quite a few patients with history of depression/anxiety who exaggerate their symptoms for "attention" per say, but I try to be as objective as possible. So, after I did the neuro check I talked to her some more and redid the neuro check to see if the neuro grip was similar to what she presented on the first try and what i noticed was she was able to squeeze harder this time but it was still weaker than the left. Anyway, I really didn't know what to do for her. The Doc was on vacation who came back the next day and took over her care. Wasn't able to follow to see what really happened to her. What were my differentials here? What was I looking at? Thanks everyone, and I appreciate the responses in advance.

 

[CptNemo]

Unilateral weakness? Stroke vs. malingering vs. conversion disorder vs. local injury. In either case, it would likely be too late to do anything acutely once she gets to rehab, other than reducing risk for future stroke or treating her psych comorbidities. Some neurologists are pretty good at distracting patients during the exam to weed out maligering/conversion d/o vs. true weakness. Also, it helps to analyze gait... sometimes patients forget to maintain the act while walking. -I'm getting cynical...

 

[McSap]

...vs malignancy (CNS mets or primary brain tumor) being another differential at that age.
She had anesthesia? (for a colonoscopy?)-> any periods of severe hypotension during this? (stroke)
Agree that the story of "extremely weak and unable to stand" (unless clearly describing unilateral weakness +/- other focal neuro symptoms) followed by isolated R sided weakness sounds a bit atypical and suspect for a functional problem. A thorough physical exam is really the key in these types of patients. By extensive neuro check - everything else was normal except grip power? ie cranial nerves, pronator drift (not many patients know how to fake this), tone, reflexes, sensation, gait. At that age and her risk factors id get some imaging regardless.