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Old 06-11-2010, 02:26 AM   #1
Linuss
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Right sided weakness but not a stroke


I had an odd patient yesterday and it had me stumped.


We were called to a clinic for a 39yo exhibiting signs of right sided weakness. I get there and start my assessment.

He claimed it's been going on for about 3 days, same 'severity' all three days but finally decided to get it checked. Also states he has noticed some short term memory loss (not noticed by me as I gave him some words to remember, which he did better then I could have and I'm healthy!) No medical history aside from a broken arm when he was a teenager. Not on any medications, has not been out of the country recently, and hasn't gone swimming. No recent trauma / falls to speak of. No fatigue felt. Family history (aunt) of MS.


I had him squeeze both my hands at once and the right side was noticeably weaker. I then had him push down / pull up on the feet, and again, right side was way weaker. Arm drift was negative (able to hold both arms out the same). I had him smile, show teeth, and stick out tongue and all was normal.

Complains of no tingling, but slightly diminished sensation in the right extremities. The diminished feeling starts just below the clavicals which made me think that it probably wasn't CNS in origin, probably just PNS which means possibly peripheral neuroapthy? But caused by what?

BGL of 117. Normal temp. Eyes PERL.


Did a 12 lead and saw NSR with no ectopy.



Anyone have anything like this?

If I missed something that can help more, let me know and I'll see if I can get it up.


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Old 06-11-2010, 02:53 AM   #2
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Meh, let me correct my title. I guess I can't completely rule out it being a stroke, so "right sided weakness, but doesn't present as a classic stroke"
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Old 06-11-2010, 03:26 AM   #3
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I've got a frequent flier who presents with severe one-sided weakness that looks a lot like a stroke. Diagnosed with conversion disorder.

Could also be a spinal injury, despite his lack of memory. Drinker? Sleepwalker? Emotional issues?

MS symptoms can also be one-sided. Could be his first attack.

Brain tumor, possibly. Headaches recently? Other neuro issues?

Could also be fatigue, depending on what he's been doing.
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Old 06-11-2010, 05:22 AM   #4
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^^^

I'd say a pinched/shocked nerve, but that's usually one extremity or area. So that's out.

I'd say MAYBE something ischemic going on (TIA, etc), some neck/cervical problem yet unknown, or a tumor.

I don't know about anyone else, but the moment my mom told me Ted Kennedy had a seizure at the Capitol, I told her he had a brain tumor. Something out of the blue and neuro, I point to metabolic, stroke or tumor. If it's not acute, I lean more to metabolic or tumor, and this doesn't seem metobolic.
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Old 06-11-2010, 05:54 AM   #5
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The DDxs based on just the information provided are pretty extensive. From off the top of my head (including the fact that neuro was about a month and a half ago now, so a lot of the specifics are in long term storage until board review)

CVA/TIA
Conversion (albeit this one is completely inapporate to DDx prehospitally)
Some sort of central motor neuron disorder.
Some sort of spinal cord insult.

What would be helpful is knowing which muscles were actually affected and which dermatones are. In musculoskeletal disorder, there are specific patterns seen, such as distal arm/proximal leg weakness (inclusion body myositis) or limb-girdle (Duchenne's, polymyositis, dematomyositis). Muscle innervation grossly follows deep tendon reflex nerves and there's a quick and dirty way to remember this:

1,2: Achillies (sacral 1, 2)
3,4: Patellar (lumbar 3, 4)
5,6: Biceps (cervical 5, 6)
7,8, Triceps (cervical 7, 8)

Remembering DTRs is as simple as 1,2 3,4 5,6 7,8

As far as being CNS, just because something stops at a specific area doesn't mean it can't be CNS. First off, CNS includes the spinal cord, second off, the motor and sensory homunculus (homunculi?) follow a similar pattern in terms of what is located where and are right next two each other, except on different gyri (hills).

Also, loss of fine touch, sharp touch, or both? Different types of sensation (for example, pain/temp follows a different pathway than fine touch/vibration/conscious proprioception) have different pathways all the way up to the cortex. You don't need something sharp enough to easily cause injury. Anything somewhat "sharp" would do. Sure, a hypodermic needle would "work" (although I wouldn't suggest it), something as simple as the pointy tip of the handle of a Taylor style reflex hammer (stereotypical style in the US) would work for this purpose.
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Last edited by JPINFV; 06-11-2010 at 05:59 AM.
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Old 06-11-2010, 08:00 AM   #6
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Quote:
Originally Posted by Linuss View Post
I had an odd patient yesterday and it had me stumped.


We were called to a clinic for a 39yo exhibiting signs of right sided weakness. I get there and start my assessment.

He claimed it's been going on for about 3 days, same 'severity' all three days but finally decided to get it checked. Also states he has noticed some short term memory loss (not noticed by me as I gave him some words to remember, which he did better then I could have and I'm healthy!) No medical history aside from a broken arm when he was a teenager. Not on any medications, has not been out of the country recently, and hasn't gone swimming. No recent trauma / falls to speak of. No fatigue felt. Family history (aunt) of MS.


I had him squeeze both my hands at once and the right side was noticeably weaker. I then had him push down / pull up on the feet, and again, right side was way weaker. Arm drift was negative (able to hold both arms out the same). I had him smile, show teeth, and stick out tongue and all was normal.

Complains of no tingling, but slightly diminished sensation in the right extremities. The diminished feeling starts just below the clavicals which made me think that it probably wasn't CNS in origin, probably just PNS which means possibly peripheral neuroapthy? But caused by what?

BGL of 117. Normal temp. Eyes PERL.


Did a 12 lead and saw NSR with no ectopy.



Anyone have anything like this?

If I missed something that can help more, let me know and I'll see if I can get it up.
Sounds like MS. No way to tell without further diagnostics.
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Old 06-11-2010, 11:31 AM   #7
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Sounds supratentorial.

Have him grip your paired fingers, then you start shaking them rapidly about an inch or so back and forth and tell him firmly "harder, harder harder". You can elicit a firmer grip that way, often to equal, or you can observe the grip suddenly stop altogether (not shaken off but goes limp); these are signs that it likely, not certainly but likely, is voluntary.

I had the "luxury" being able to watch patient's gait to AND FROM me, and getting onto the exam table or down/up to a chair. After an encounter, sometimes the pt suddenly "regained" normal gait and stance once the appointment was over.

When it comes to falling or selectively regaining strength and proprioception, usually the fear of falling wins. If someone DOES fall, observe for how they assist their "rescuer", or, how they either catch themselves or hit the floor. (Cold stuff, but sometimes you cannot get them, so observe while it goes down). A stroke will not allow guarding, and the pt usually has inadequate coordinaton and strength to help their "catcher".

Last edited by mycrofft; 06-11-2010 at 11:35 AM.
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Old 06-11-2010, 11:38 AM   #8
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PS: A history I took on a similar case...

Weakness? yes
Pain? yes
Visual disturbance? yes
PAresthesia? yes
Hemiplegia? yes
Hemiopia? yes
Sense of vibration? yes
Loud noises frighten you? yes
Has this happened before? yes
What did you do?
I took my Dilaudid and went back to bed.
Oy veh.
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Old 06-11-2010, 12:52 PM   #9
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tia
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Old 06-11-2010, 02:29 PM   #10
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As a field provider I'd advise you to treat it as a "non-acute" (i.e. onset >6hrs) CVA and transport to a stroke center. Narrowing a "weakness" call down to a specific diagnosis often requires time, resources and education most EMS providers (myself included) don't have. See if you can follow up and learn what to look for next time.
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