A 64-Year-Old Man Unable to Lift His Arm or Walk

Winston Tan, MD; Nicole Ganon, PA; Ashton Ritter, MMS

Disclosures

May 21, 2019

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 64-year-old right-handed man presents to the emergency department with left-sided arm and leg weakness. He reports that over the past 4 weeks, he has had episodes of feeling "off balance" when walking but denies any falls or syncopal episodes. Over the past week, he has developed weakness and numbness in his left side, with increased difficulty when walking. The weakness worsened to the point where he could not comfortably walk or lift his left arm.

He does not report headaches, visual changes, confusion, facial weakness, or incontinence. He denies any falls or loss of consciousness. He has no pain. He has no recent history of fever, immunocompromised state, or neck stiffness. He has no history of convulsions or seizures. His history does not include stroke, myocardial infarction, or blood clots. He does not take any blood thinners but is on aspirin (81 mg by mouth daily). His past medical history includes well-controlled hypertension, sleep apnea, migraine, and depression. He is a current smoker, with a 30–pack-year history.

He has a history of stage I non-small cell lung adenocarcinoma diagnosed 5 years ago, for which he had a right upper lung lobectomy. The tumor was EGFR negative, anaplastic lymphoma kinase (ALK) negative, ROS1 negative, and PD-L1 positive. He did not have any chemotherapy or radiation adjuvantly and has been following up with PET and CT annually, with no evidence of disease on the most recent PET scan 5 months before evaluation.

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