Altered Mental Status And Left Leg Dysfunction- Trauma

HISTORY: 28-year-old male with schizophrenia presented to the emergency department via EMS after his roommate found him slumped over a chair with fluid around his mouth and diffuse bruising. He denied any mechanical trauma or source of the bruises. Initially, he was alert and oriented to self only. He reported that, due to back pain the day prior, he had taken six-10 mg baclofen tablets and doxylamine. He reported numbness of the left leg below the knee and inability to move his left foot. He denied headache, vision change, neck pain, shooting pain in the lower extremity, right lower extremity weakness, or upper extremity weakness. He denied recreational drug use and EMS found no signs of self-harm or overdose. Later, he remembered fading consciousness after taking two tablets of a substance that he was unwilling to disclose. PHYSICAL EXAM: Upper extremities: ecchymosis and abrasions, no tenderness to palpation, pulses intact, full range of motion Pelvis: no pain with inward or posterior pressure on ASIS Right lower extremity: abrasions, pulses intact, full range of motion and strength Left lower extremity: tender (5 in) hematoma on lateral thigh, limited range of motion of knee and hip due to pain, 0/5 strength of ankle and toe dorsi and plantarflexion. Absent light touch sensation distal to the ankle, decreased light touch sensation of the thigh and calf, pulses intact DIFFERENTIAL DIAGNOSIS: 1. Sciatic neuropathy associated with rhabdomyolysis 2. Compartment syndrome 3. Lumbar plexopathy secondary to mass or ischemia 4. Mononeuropathy multiplex 5. Acute motor and sensory axonal neuropathy TEST AND RESULTS: Creatinine kinase: 37282 U/L Urine drug screen: positive for tricyclic antidepressants MRI lumbar spine: no significant abnormality MRI lumbar plexus: - Subcutaneous and muscular edema throughout - Findings suggestive of myonecrosis of quadratus femoris and obturator internus muscle bellies - Enhancement of left sciatic nerve and edema within quadratus femoris muscle belly FINAL/WORKING DIAGNOSIS: Left lower extremity weakness due to sciatic neuropathy associated with rhabdomyolysis and muscular edema TREATMENT AND OUTCOMES: 1. Aggressive IV fluid resuscitation 2. PT and OT 3. Gradual functional improvement and discharge to rehab facility 4. Podus boot for left foot drop 5. Outpatient neurology follow-up and EMG