A man in his 80s presents to the emergency department with new left leg numbness that started while he was eating breakfast an hour ago. The patient has a history of atrial fibrillation, for which he takes warfarin, and a prior cerebrovascular accident (CVA) with persistent left-sided weakness. He states the leg feels swollen and a little weaker than it had been, but he denies any pain or other complaints. He is worried about a stroke and thinks he may have missed a dose of warfarin.

Vital Signs and Physical Examination

The patient’s vital signs are normal except for an irregular pulse rate of 112 beats per minute (normal range 60-100 bpm). Physical examination shows mild left leg weakness, which the patient states is worse than at baseline, and minimal left leg swelling. No weakness is noted in the arms. A head computed tomography (CT), venous duplex, and blood work are ordered. The CT confirms the previous right-sided stroke but no new bleed, and the venous duplex is negative for deep vein thrombosis. Laboratory results are within normal range except prothrombin with an international normalized ratio of 1.7. He is seen by the stroke team, which recommends aspirin but not tissue plasminogen activator (tPA) based on the patient’s INR.

Can you diagnose this condition? What additional test should you perform to confirm the diagnosis?

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