Clinical Reasoning: A 70-Year-Old Man With Right Arm and Leg Shaking

A 70-year-old man with a medical history significant for abdominal aortic aneurysm and provoked deep vein thrombus (DVT) (no longer on anticoagulation) presented with seizure-like activity. His wife found him on the floor with shaking of his right arm and right leg. The shaking occurred intermittently and lasted for seconds to minutes without loss of consciousness. He subsequently became more lethargic and was taken to the hospital approximately 10 hours after symptom onset. His vital signs, including oxygen saturation and blood pressure, were normal. His tone was increased in all 4 extremities, worse on the right. He was able to move his left arm and leg against gravity. His right arm was forcibly flexed at the elbow and his right leg was fixed in an extended position; neither could be moved by passive range of motion. He had no facial numbness or weakness. The patient had no speech output but was able to nod yes and no appropriately to some questions. He was hyperreflexic in his knees and ankles with upgoing toes bilaterally.

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