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I have a brief moment or two so I thought I'd throw out an amazing (I thought) case that I had a few weekends ago, working the overnight....
70ish male, retired MD, visiting from out of state. Was at the opera and during intermission developed sudden onset of unilateral leg paralysis. Was diaphoretic and didn't feel good. No CP, SOB, n/v. (15min PTA). Hx of very mild HTN, controlled with HCTZ. According to him and spouse pressure was never more than 130/80's at home. Has mild parkinsons.
On exam, patient mildly distressed, asking for tpa. VSS (nl bp, not tachycardic, pulse ox 100%). Exam significant only for complete paralysis of unilateral LE. Pulses intact, warm, perfused. EKG nl (not even flipped twaves, etc). Pt is rushed to head CT. In the meantime, labs sent.
When patient comes down, he has full recovery of his LE but is in excrutiating pain (8mg MSO4x2, 2mg Dilaudid got it under control). He is still wanting tpa. Exam is now completely normal, with no reason for the pain. Quick ultrasound of abdomen shows a normal aorta. Labs have come back and are nl except for a lactate of 6.5. BP in both arms are equal.
What do you want to do?
70ish male, retired MD, visiting from out of state. Was at the opera and during intermission developed sudden onset of unilateral leg paralysis. Was diaphoretic and didn't feel good. No CP, SOB, n/v. (15min PTA). Hx of very mild HTN, controlled with HCTZ. According to him and spouse pressure was never more than 130/80's at home. Has mild parkinsons.
On exam, patient mildly distressed, asking for tpa. VSS (nl bp, not tachycardic, pulse ox 100%). Exam significant only for complete paralysis of unilateral LE. Pulses intact, warm, perfused. EKG nl (not even flipped twaves, etc). Pt is rushed to head CT. In the meantime, labs sent.
When patient comes down, he has full recovery of his LE but is in excrutiating pain (8mg MSO4x2, 2mg Dilaudid got it under control). He is still wanting tpa. Exam is now completely normal, with no reason for the pain. Quick ultrasound of abdomen shows a normal aorta. Labs have come back and are nl except for a lactate of 6.5. BP in both arms are equal.
What do you want to do?