Case+2+-+Extremity+Pain,+Paralysis,+and+Numbness

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This is a bit of gimme I know but hopefully something to learn in there.

I’m in morning report today, which is synonymous with ‘signout.’ We as a team of providers including nurses, clinical officers, and a few MDs listen to the nurses report from the individual wards from overnight, with an opportunity to discuss patient care. Typically this is an opportunity for the most sick patients to be brought to our communal attention.

Per the ward nurse “EG is a 80 y/o female day # 3 of admission with continued complaint of RLE pain. Not being relieved by amitriptyline. Overnight patient noticed to have heavy breathing. Patient appears to be in respiratory distress. Admitting diagnosis of peripheral neuropathy. History of HTN. Pulse 140, irregular. BP 90 / 60, afebrile.”

To fill out the history: 80 y/o female with history of HTN who presented with three days of severe pain, numbness of right lower extremity. Unable to ambulate and was carried into ward by family. HTN has not been medicated for several years. Admission examination noting only ‘numbness’ of right lower extremity, with diagnosis of peripheral neuropathy and placed on amitriptyline. Hospital day # 2 brief note with no improvement, addition of ibuprofen. It is now hospital day #3.

At bedside, elderly patient appearing in extremis, with observable tachypnea, eye rolling, and appropriate but slow conversation. P 140 irregular, BP 90 / 60, RR 40, O2 sat 95% Neck: + JVD Pulm: CTAB, no crackles or wheezing CV: tachycardic and irregularly irregular, nl S1 and S2, no m/r/g Abd: soft, nd, nttp Ext: right lower extremity appearing mottled with toes deep purple color. Cold to touch compared to LLE, with absence of dorsalis pedis pulse on RLE. No edema of RLE. Patient completely unable to move RLE from hip flexion to toe flexion.

As the clinical officer on ward rounds that day remained skeptical of my suggested diagnosis, the ultrasound was brought to bedside and the following seen: