2. Case Report
A 65-year-old right hand dominant, African American male presented to the ED via emergency medical service. He had just finished smoking crack cocaine when he developed left arm pain that he described as “cramping”. He reported that the pain was so intense that he became weak causing him to fall onto the ground. The pain made him feel like “jumping out of the window.” He denied any head injury and he had no loss of consciousness (LOC). The patient had no chest, shortness of breath, or dyspnea on exertion. He denied any neck, back, or abdominal pain.
The patient’s past medical history included diabetes, hypertension, hepatitis C, sick sinus syndrome, paroxysmal atrial fibrillation, hyperlipidemia, deep vein thrombosis, chronic kidney disease, hilar mediastinal adenopathy, diastolic heart failure, valvular heart disease, and cardiac arrhythmia of nonsustained ventricular tachycardia with a permanent pacemaker. The patient admitted to intermittent cocaine abuse. His medications include atorvastatin, furosemide, isosorbide mononitrate, acetaminophen with codeine, apixaban, hydralazine, metformin, albuterol sulfate, amlodipine, and tamsulosin.
Vital signs were essentially within normal limits with the exception of a blood pressure of 142/83 mmHg.
The patient had a strong left radial pulse and brisk capillary refill of the left hand with no tenderness or deformity. The patient was noted to have left arm weakness and what looked like choreiform or clumsy left arm movements. His left leg was also noted to be weak. There was no numbness. Interestingly, light touch to any part of the left arm produced significant discomfort to the point where he did not want anything touching the left arm. He was noted to have decreased rapid alternating movements on the left upper extremity as well as mild difficulty with fine motor control. His left arm and left leg motor strength was 4/5. His cranial nerves II to XII were grossly intact. There were no visual fields cuts noted. Extraocular motility was intact. The grimace was symmetric. There was no evidence of double simultaneous extinction.
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There were no pulsatile abdominal masses on exam and the bilateral radial pulses were equal. The patient was unable to tell the exact time of onset of his symptoms. The patient’s left arm pain improved with morphine 4 mg intravenously.
The electrocardiogram (ECG) showed sinus tachycardia with first degree atria-ventricular block, as well as ST and T wave abnormality suggestive of lateral ischemia [Figure 1]. This is however unchanged compared to his ECG from two years previously [Figure 2]. His cardiac enzyme was negative.
A computed tomography (CT) scan of the head without contrast showed an acute 2.2 cm intraparenchymal hemorrhage with vasogenic edema in the posterior right parietal lobe [see Figure 3]. X-rays of the upper extremity were unremarkable. The chest X-ray showed normal cardiac silhouette and pulmonary vasculature.
Laboratory data showed a creatinine of 1.34 mg/dL. The urine drug screen showed cocaine.
The patient was placed on a continuous nicardipine infusion to maintain a systolic blood pressure of 140 mm Hg as per neurosurgical consultation. He was transferred to a neurointensive care unit. His left arm pain resolved after 24 hours. The carotid ultrasound showed no hemodynamically significant carotid stenosis and antegrade flow was present in the bilateral vertebral arteries. A CT angiography of the head and neck did not show any aneurysms. His serial cardiac enzymes remained negative throughout his hospitalization. A cardiac catheterization was not performed as the patient had it done one year previously showing angiographically normal coronaries. A cardiology consult was obtained and the patient was found to have no evidence of acute coronary syndrome (ACS) or ischemia. He was subsequently discharged to a rehabilitation facility.
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