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Poster 221: Rehabilitation Considerations in a Patient With Klippel-Feil Syndrome: A Case Report
S202
Abstracts / PM R 9 (2017) S131-S290
Poster 218: Musculocutaneous Neuropathy Due to PICC Line Insertion: A Case Report Maria Janakos, MD (University of Louisville Physical Medicine, Louisville, KY, United States), David Haustein, MD, Preeti Panchang, MD Disclosures: Maria Janakos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with uncontrolled diabetes mellitus developed a diabetic foot ulcer and osteomyelitis requiring intravenous antibiotics. He underwent sonographically guided PICC line placement using a 5-French catheter with radiographic confirmation of the tip at the cavoatrial junction. The patient recalls terrible pain and extensive ecchymoses of his right arm and lateral thorax in the days following the procedure as well as weakness with right elbow flexion and paresthesias over the lateral forearm. He was seen 2 months later by a physiatrist at the VA hospital and found to have weak right elbow flexion and diminished sensation in the right lateral antebrachium; otherwise normal strength and sensation throughout the bilateral upper limbs. An abbreviated electrodiagnostic study was performed that day for further evaluation. Setting: VA hospital. Results: A limited EMG of the right upper limb demonstrated a right musculocutaneous neuropathy at least proximal to the fascicles to the biceps characterized by at least partial axonal loss. Also noted was an underlying peripheral polyneuropathy characterized by sensorimotor axonal loss and demyelination. Discussion: Given its deep location, musculocutanous nerve injuries are rare but have been reported in athletes performing repetitive overhead activities as well as a complication of direct trauma, shoulder dislocations, and surgery. Symptoms include arm pain, weakness with elbow flexion and/or supination as well as sensory loss over the lateral aspect of the forearm. Differential diagnoses include brachial plexopathies and cervical stenosis. Spontaneous recovery is possible but may take months to years. Conclusions: A musculocutaneous nerve injury is an unusual complication of upper extremity vascular access; given the close proximity of nerve and vascular structures in the limbs, close monitoring for neuropathy symptoms during and after the procedure is warranted. Level of Evidence: Level V Poster 219: Male Infertility Treatment Leading to Cerebellar Cerebrovascular Accident: A Case Report Hanzla Quraishi, MD (Marianjoy Rehab Hosp) Disclosures: Hanzla Quraishi: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 47-year-old man with a past medical history of asthma, hypertension, and male infertility presented with a complaint of acute vertigo for 6 days. He stated that it came on suddenly with concurrent nausea, emesis and diplopia. Brain MRI was positive for acute right posterior inferior cerebellar artery occlusion and right vertebral occlusion. He subsequently underwent a midline suboccipital craniectomy with durotomy and resection of infarcted brain. The patient was seen by neurology and it was determined that his cerebrovascular accident was secondary to hCG injections for male infertility. Prior to presenting, the patient had no history of atherosclerotic disease or hypercoagulable state predisposing patient to stroke. Setting: Acute Rehabilitation Hospital. Results: The patient completed a course of comprehensive inpatient rehabilitation including physical, occupational, and speech therapies. Discussion: There is a known link between spinal cord injury and stroke with infertility, specifically in the male population. This case appears to be the first known event of male hCG treatments directly leading to cerebrovascular accident. Prior cases of hormone therapy
leading to stroke involved either female hormonal therapy or testosterone treatment. In the younger rehabilitation population, fertility and the ability to bear children are a distinct concern of many patients. Given this, there is merit to educating patients about risks of fertility therapy as well as monitoring patients actively undergoing fertility treatment. Comorbidities in the rehabilitation population may further predispose patients to adverse outcomes regardless of gender. Conclusions: Treatment of male infertility can be associated with increased risk of stroke, even in the absence of testosterone therapy, specifically with hCG or Clomiphene. Given the biopsychosocial profile of rehabilitative medicine, fertility concerns can often be of paramount importance in this population. Accordingly, it is the responsibility of the physician to educate patients in regards to risks and benefits of potential therapy regardless of gender. Level of Evidence: Level V Poster 220: The Psychosocial Impact of Rehabilitation Services as Highlighted by the Care of a Patient with Multiple Epiphyseal Dysplasia: A Case Report Charles P. Scott, MD (New York Presbyterian Hosp), Nasim Chowdhury, MD Disclosures: Charles Scott: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient was diagnosed with MED at age 7 after 2 years of progressive gait impairment. Her father, paternal uncle, and paternal grandmother were previously diagnosed with MED; her father and uncle had each undergone bilateral hip replacements. Neither she, nor her family, has yet undergone genetic testing; all diagnoses were made clinically with plain film radiographs. She described feeling increasingly socially isolated as a teenager, largely due to her inability to participate in activities such as athletics and casual play, given chronic joint pain and severe fatigue within several minutes of activity onset. With progressive gait impairments causing her to limp, she began physical therapy as a young adult, allowing her to remain independent and to participate in academic, professional, and social pursuits. After graduating from college, she completed a 26month engagement with the Peace Corps in the developing world, remaining ambulatory with use of a cane. Due to progressive disease and functional deficits, she underwent bilateral hip replacement at age 29. Post-operatively, rehabilitation focused on retraining gait mechanics and increasing independence with household tasks. Setting: In-patient rehabilitation unit of a tertiary care hospital. Results: The patient made rapid progress with ambulation and functional tasks, and returned to full-time work 45 days after surgery. Discussion: Rehabilitation medicine played an integral role throughout the care of this patient by helping to maintain mobility and range of motion and through introduction of specific interventions such as teaching the use of a cane and retraining gait mechanics. Conclusions: MED patients face a variety of physical limitations that may have a marked impact on psychosocial functioning. Rehabilitation strategies play an integral role in management of MED and can help patients overcome significant physical barriers to social and professional integration. Level of Evidence: Level V Poster 221: Rehabilitation Considerations in a Patient With Klippel-Feil Syndrome: A Case Report Grace L. Maloney, MD (Marianjoy Rehab Hosp, Naperville, IL, United States), Anjum Sayyad, MD Disclosures: Grace Maloney: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with Klippel-Feil syndrome, morbid obesity (BMI 47.8), type II diabetes, and asthma
Abstracts / PM R 9 (2017) S131-S290 presented for rehabilitation following prolonged hospital stay for respiratory failure. The patient required tracheostomy placement. Setting: Acute inpatient rehabilitation. Results: His stay was complicated by multiple episodes of tracheal dislodgment related to body habitus and sizing. Emergent transfers occurred in each instance. Characteristic morphologic differences in this patient with Klippel-Feil syndrome included craniofacial and spinal deformities with congenital absence of left nostril, scoliosis, and a short neck. These congenital deformities required consideration during episodes of respiratory compromise. He had multiple facial reconstruction surgeries as a child. The trach was replaced multiple times and placement maintained using a size 6.0 XLT distal flexible trach. Discussion: Klippel-Feil syndrome is characterized by congenital fusion of cervical vertebrae. This anomaly is associated with limited neck extension and rotation. Klippel-Feil syndrome has association with other phenotypic characteristics including scoliosis, short neck, low hairline, Sprengel’s deformity, cardiac abnormalities, and facial anomalies. Respiratory failure in these patients may be multifactorial. Anomalies may lead to the inefficacy of typical approaches during an event of respiratory compromise. Developmentally non-patent nares limit use of a nasal cannula for oxygen supplementation. Limited neck extension leads to difficult visualization of the larynx during traditional intubation. Conclusions: In the rehabilitation setting, Klippel-Feil syndrome presents a challenge to approaches relying on typical anatomy for positioning, therapy, and procedures. Vertebral anomalies with cervical fusion and limited rotation and extension are characteristic, however other patient specific and associated anomalies must be considered for proper management during acute events. Those with Klippel-Feil syndrome and respiratory failure are a unique group benefitting from a targeted approach to rehabilitation when scoliosis, obesity, and deconditioning are major factors contributing to functional decline. Level of Evidence: Level V Poster 222: A Rare Case of a Massive Bilateral Pulmonary Embolism After Routine Knee Arthroscopy: A Case Report Samuel S. Murala (Montefiore Medical Center/Albert Einstein, Bronx, NY, USA), Francis J. Lopez, MD Disclosures: Samuel Murala: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 53-year-old woman with no significant medical or surgical history underwent routine arthroscopic surgery to repair a meniscal tear in her left knee. A day after the procedure she developed severe shortness of breath and presented to the emergency department (ED). In the ED she was found to be tachycardic, hypoxic and hypotensive and subsequently diagnosed as having a massive pulmonary embolism (PE) and was admitted to Intensive Care Unit and ultimately underwent catheter directed thrombolysis. Once she was hemodynamically and medically stable, she was transferred to the acute inpatient rehabilitation unit for functional optimization with oral anti-coagulation. Setting: Acute Inpatient Rehabilitation Unit. Results: Lung spiral CT scan revealed large clot burden extending from the distal right and left main pulmonary arteries bilaterally to segmental and subsegmental branches, occlusive and nonocclusive along with elevated troponins. Her hypercoagulability workup was negative for all thrombophilic syndromes including antiphospholipid, anti-cardiolipin syndromes as well as lupus. Discussion: Pulmonary embolism following arthroscopic surgery is a very rare complication. One study placed the incidence of such events at just 2.8 cases per 10,000. However, there remains limited data describing the rarity this event. Conclusions: Though pulmonary embolism after arthroscopic surgery is an extremely rare event, it is extremely important for physiatrists and primary care practitioners to be cognizant of this serious and potentially fatal complication. Level of Evidence: Level V
S203
Poster 223: Management of Man with Recurrent Intradural Extramedullary Metastasis from Breast Cancer Causing Progressive Lower Extremity Weakness and Paresthesias: A Case Report Yodit Tefera (New York Presbyterian Hospital Columbia and Cornell), Akinpelumi Beckley, MD, Wade O. Johnson, DO Disclosures: Yodit Tefera: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old man with Stage IV HER2/NEU breast cancer presented to a tertiary care facility with bilateral lower extremity weakness which began approximately 4 weeks prior with acute progression prompting presentation. He was initially diagnosed with breast cancer in 2004 and received treatment including chemotherapy, radiation, and Tamoxifen therapy. In June 2015, he developed weakness in his lower extremities and ambulatory difficulties. Found to have a metastatic lesion warranting T8 corpectomy and thoracic laminectomy to be followed by radiation and chemotherapy. The patient presented 15 months later with left lower limb weakness and paresthesia. He had a progressive loss of proprioception, sensation and ambulation over the course of 3 weeks. CT myelogram and MRI completed demonstrated a recurrence of his metastatic disease from T6-T10 and intradural lesions present at S1-S2. He underwent revision thoracic decompression and tumor resection. Post-surgery the patient continued to have lower extremity weakness, paresthesias, numbness, and incontinence necessitating acute rehabilitation and adjuvant therapy. Setting: Tertiary care hospital. Results: The neurological manifestations the patient presented with are characteristic of acute spinal cord compression. Neuropathic pain was a predominant complaint from the patient during hospital course. Discussion: Breast cancer in men is rare, representing 1% of total breast cancer cases worldwide. Spinal cord injury in the setting of breast cancer in males is even more rare and review of this case also brings attention to the natural progression and symptoms of thoracic myelopathy. Conclusions: It is important to recognize neurological changes in patients with history of malignancy in order to diagnose and treat metastatic disease. Rehabilitation is important in the management of these patients with acquired spinal cord injury. Level of Evidence: Level V Poster 224: An Unusual Case of Pulmonary Embolism in a Stroke Patient: A Case Report Ashley Simone Maybin, MD (Vanderbilt Univ Med Ctr) Disclosures: Ashley Simone Maybin: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 56-year-old African American man with a past medical history of hypertension and hyperlipidemia was admitted to inpatient rehabilitation for impaired mobility, self-care, and gait dysfunction status post-acute infarct in his left middle cerebral artery and posterior cerebral artery distribution. He was diagnosed with aphasia and right hemiparesis. He was progressing with his rehabilitation when suddenly he showed signs of abdominal discomfort. He was not able to communicate details but gestured. The patient had no nausea or emesis and vital signs were stable. Due to this acute change in pain, the patient was transferred for further evaluation. Setting: Inpatient Rehabilitation. Results: Patient was evaluated in the Emergency Department 1 hour after his initial symptoms. Focused physical examination was notable for upper abdominal pain radiating down toward his umbilical region. His exam was also positive for guarding. CT of his abdomen and pelvis revealed no evidence of acute intra-abdominal pathology, however there was an incidental finding of a pulmonary embolus in his right lower lobe. Radiology
Abstracts / PM R 9 (2017) S131-S290
Poster 218: Musculocutaneous Neuropathy Due to PICC Line Insertion: A Case Report Maria Janakos, MD (University of Louisville Physical Medicine, Louisville, KY, United States), David Haustein, MD, Preeti Panchang, MD Disclosures: Maria Janakos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with uncontrolled diabetes mellitus developed a diabetic foot ulcer and osteomyelitis requiring intravenous antibiotics. He underwent sonographically guided PICC line placement using a 5-French catheter with radiographic confirmation of the tip at the cavoatrial junction. The patient recalls terrible pain and extensive ecchymoses of his right arm and lateral thorax in the days following the procedure as well as weakness with right elbow flexion and paresthesias over the lateral forearm. He was seen 2 months later by a physiatrist at the VA hospital and found to have weak right elbow flexion and diminished sensation in the right lateral antebrachium; otherwise normal strength and sensation throughout the bilateral upper limbs. An abbreviated electrodiagnostic study was performed that day for further evaluation. Setting: VA hospital. Results: A limited EMG of the right upper limb demonstrated a right musculocutaneous neuropathy at least proximal to the fascicles to the biceps characterized by at least partial axonal loss. Also noted was an underlying peripheral polyneuropathy characterized by sensorimotor axonal loss and demyelination. Discussion: Given its deep location, musculocutanous nerve injuries are rare but have been reported in athletes performing repetitive overhead activities as well as a complication of direct trauma, shoulder dislocations, and surgery. Symptoms include arm pain, weakness with elbow flexion and/or supination as well as sensory loss over the lateral aspect of the forearm. Differential diagnoses include brachial plexopathies and cervical stenosis. Spontaneous recovery is possible but may take months to years. Conclusions: A musculocutaneous nerve injury is an unusual complication of upper extremity vascular access; given the close proximity of nerve and vascular structures in the limbs, close monitoring for neuropathy symptoms during and after the procedure is warranted. Level of Evidence: Level V Poster 219: Male Infertility Treatment Leading to Cerebellar Cerebrovascular Accident: A Case Report Hanzla Quraishi, MD (Marianjoy Rehab Hosp) Disclosures: Hanzla Quraishi: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 47-year-old man with a past medical history of asthma, hypertension, and male infertility presented with a complaint of acute vertigo for 6 days. He stated that it came on suddenly with concurrent nausea, emesis and diplopia. Brain MRI was positive for acute right posterior inferior cerebellar artery occlusion and right vertebral occlusion. He subsequently underwent a midline suboccipital craniectomy with durotomy and resection of infarcted brain. The patient was seen by neurology and it was determined that his cerebrovascular accident was secondary to hCG injections for male infertility. Prior to presenting, the patient had no history of atherosclerotic disease or hypercoagulable state predisposing patient to stroke. Setting: Acute Rehabilitation Hospital. Results: The patient completed a course of comprehensive inpatient rehabilitation including physical, occupational, and speech therapies. Discussion: There is a known link between spinal cord injury and stroke with infertility, specifically in the male population. This case appears to be the first known event of male hCG treatments directly leading to cerebrovascular accident. Prior cases of hormone therapy
leading to stroke involved either female hormonal therapy or testosterone treatment. In the younger rehabilitation population, fertility and the ability to bear children are a distinct concern of many patients. Given this, there is merit to educating patients about risks of fertility therapy as well as monitoring patients actively undergoing fertility treatment. Comorbidities in the rehabilitation population may further predispose patients to adverse outcomes regardless of gender. Conclusions: Treatment of male infertility can be associated with increased risk of stroke, even in the absence of testosterone therapy, specifically with hCG or Clomiphene. Given the biopsychosocial profile of rehabilitative medicine, fertility concerns can often be of paramount importance in this population. Accordingly, it is the responsibility of the physician to educate patients in regards to risks and benefits of potential therapy regardless of gender. Level of Evidence: Level V Poster 220: The Psychosocial Impact of Rehabilitation Services as Highlighted by the Care of a Patient with Multiple Epiphyseal Dysplasia: A Case Report Charles P. Scott, MD (New York Presbyterian Hosp), Nasim Chowdhury, MD Disclosures: Charles Scott: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient was diagnosed with MED at age 7 after 2 years of progressive gait impairment. Her father, paternal uncle, and paternal grandmother were previously diagnosed with MED; her father and uncle had each undergone bilateral hip replacements. Neither she, nor her family, has yet undergone genetic testing; all diagnoses were made clinically with plain film radiographs. She described feeling increasingly socially isolated as a teenager, largely due to her inability to participate in activities such as athletics and casual play, given chronic joint pain and severe fatigue within several minutes of activity onset. With progressive gait impairments causing her to limp, she began physical therapy as a young adult, allowing her to remain independent and to participate in academic, professional, and social pursuits. After graduating from college, she completed a 26month engagement with the Peace Corps in the developing world, remaining ambulatory with use of a cane. Due to progressive disease and functional deficits, she underwent bilateral hip replacement at age 29. Post-operatively, rehabilitation focused on retraining gait mechanics and increasing independence with household tasks. Setting: In-patient rehabilitation unit of a tertiary care hospital. Results: The patient made rapid progress with ambulation and functional tasks, and returned to full-time work 45 days after surgery. Discussion: Rehabilitation medicine played an integral role throughout the care of this patient by helping to maintain mobility and range of motion and through introduction of specific interventions such as teaching the use of a cane and retraining gait mechanics. Conclusions: MED patients face a variety of physical limitations that may have a marked impact on psychosocial functioning. Rehabilitation strategies play an integral role in management of MED and can help patients overcome significant physical barriers to social and professional integration. Level of Evidence: Level V Poster 221: Rehabilitation Considerations in a Patient With Klippel-Feil Syndrome: A Case Report Grace L. Maloney, MD (Marianjoy Rehab Hosp, Naperville, IL, United States), Anjum Sayyad, MD Disclosures: Grace Maloney: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with Klippel-Feil syndrome, morbid obesity (BMI 47.8), type II diabetes, and asthma
Abstracts / PM R 9 (2017) S131-S290 presented for rehabilitation following prolonged hospital stay for respiratory failure. The patient required tracheostomy placement. Setting: Acute inpatient rehabilitation. Results: His stay was complicated by multiple episodes of tracheal dislodgment related to body habitus and sizing. Emergent transfers occurred in each instance. Characteristic morphologic differences in this patient with Klippel-Feil syndrome included craniofacial and spinal deformities with congenital absence of left nostril, scoliosis, and a short neck. These congenital deformities required consideration during episodes of respiratory compromise. He had multiple facial reconstruction surgeries as a child. The trach was replaced multiple times and placement maintained using a size 6.0 XLT distal flexible trach. Discussion: Klippel-Feil syndrome is characterized by congenital fusion of cervical vertebrae. This anomaly is associated with limited neck extension and rotation. Klippel-Feil syndrome has association with other phenotypic characteristics including scoliosis, short neck, low hairline, Sprengel’s deformity, cardiac abnormalities, and facial anomalies. Respiratory failure in these patients may be multifactorial. Anomalies may lead to the inefficacy of typical approaches during an event of respiratory compromise. Developmentally non-patent nares limit use of a nasal cannula for oxygen supplementation. Limited neck extension leads to difficult visualization of the larynx during traditional intubation. Conclusions: In the rehabilitation setting, Klippel-Feil syndrome presents a challenge to approaches relying on typical anatomy for positioning, therapy, and procedures. Vertebral anomalies with cervical fusion and limited rotation and extension are characteristic, however other patient specific and associated anomalies must be considered for proper management during acute events. Those with Klippel-Feil syndrome and respiratory failure are a unique group benefitting from a targeted approach to rehabilitation when scoliosis, obesity, and deconditioning are major factors contributing to functional decline. Level of Evidence: Level V Poster 222: A Rare Case of a Massive Bilateral Pulmonary Embolism After Routine Knee Arthroscopy: A Case Report Samuel S. Murala (Montefiore Medical Center/Albert Einstein, Bronx, NY, USA), Francis J. Lopez, MD Disclosures: Samuel Murala: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 53-year-old woman with no significant medical or surgical history underwent routine arthroscopic surgery to repair a meniscal tear in her left knee. A day after the procedure she developed severe shortness of breath and presented to the emergency department (ED). In the ED she was found to be tachycardic, hypoxic and hypotensive and subsequently diagnosed as having a massive pulmonary embolism (PE) and was admitted to Intensive Care Unit and ultimately underwent catheter directed thrombolysis. Once she was hemodynamically and medically stable, she was transferred to the acute inpatient rehabilitation unit for functional optimization with oral anti-coagulation. Setting: Acute Inpatient Rehabilitation Unit. Results: Lung spiral CT scan revealed large clot burden extending from the distal right and left main pulmonary arteries bilaterally to segmental and subsegmental branches, occlusive and nonocclusive along with elevated troponins. Her hypercoagulability workup was negative for all thrombophilic syndromes including antiphospholipid, anti-cardiolipin syndromes as well as lupus. Discussion: Pulmonary embolism following arthroscopic surgery is a very rare complication. One study placed the incidence of such events at just 2.8 cases per 10,000. However, there remains limited data describing the rarity this event. Conclusions: Though pulmonary embolism after arthroscopic surgery is an extremely rare event, it is extremely important for physiatrists and primary care practitioners to be cognizant of this serious and potentially fatal complication. Level of Evidence: Level V
S203
Poster 223: Management of Man with Recurrent Intradural Extramedullary Metastasis from Breast Cancer Causing Progressive Lower Extremity Weakness and Paresthesias: A Case Report Yodit Tefera (New York Presbyterian Hospital Columbia and Cornell), Akinpelumi Beckley, MD, Wade O. Johnson, DO Disclosures: Yodit Tefera: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old man with Stage IV HER2/NEU breast cancer presented to a tertiary care facility with bilateral lower extremity weakness which began approximately 4 weeks prior with acute progression prompting presentation. He was initially diagnosed with breast cancer in 2004 and received treatment including chemotherapy, radiation, and Tamoxifen therapy. In June 2015, he developed weakness in his lower extremities and ambulatory difficulties. Found to have a metastatic lesion warranting T8 corpectomy and thoracic laminectomy to be followed by radiation and chemotherapy. The patient presented 15 months later with left lower limb weakness and paresthesia. He had a progressive loss of proprioception, sensation and ambulation over the course of 3 weeks. CT myelogram and MRI completed demonstrated a recurrence of his metastatic disease from T6-T10 and intradural lesions present at S1-S2. He underwent revision thoracic decompression and tumor resection. Post-surgery the patient continued to have lower extremity weakness, paresthesias, numbness, and incontinence necessitating acute rehabilitation and adjuvant therapy. Setting: Tertiary care hospital. Results: The neurological manifestations the patient presented with are characteristic of acute spinal cord compression. Neuropathic pain was a predominant complaint from the patient during hospital course. Discussion: Breast cancer in men is rare, representing 1% of total breast cancer cases worldwide. Spinal cord injury in the setting of breast cancer in males is even more rare and review of this case also brings attention to the natural progression and symptoms of thoracic myelopathy. Conclusions: It is important to recognize neurological changes in patients with history of malignancy in order to diagnose and treat metastatic disease. Rehabilitation is important in the management of these patients with acquired spinal cord injury. Level of Evidence: Level V Poster 224: An Unusual Case of Pulmonary Embolism in a Stroke Patient: A Case Report Ashley Simone Maybin, MD (Vanderbilt Univ Med Ctr) Disclosures: Ashley Simone Maybin: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 56-year-old African American man with a past medical history of hypertension and hyperlipidemia was admitted to inpatient rehabilitation for impaired mobility, self-care, and gait dysfunction status post-acute infarct in his left middle cerebral artery and posterior cerebral artery distribution. He was diagnosed with aphasia and right hemiparesis. He was progressing with his rehabilitation when suddenly he showed signs of abdominal discomfort. He was not able to communicate details but gestured. The patient had no nausea or emesis and vital signs were stable. Due to this acute change in pain, the patient was transferred for further evaluation. Setting: Inpatient Rehabilitation. Results: Patient was evaluated in the Emergency Department 1 hour after his initial symptoms. Focused physical examination was notable for upper abdominal pain radiating down toward his umbilical region. His exam was also positive for guarding. CT of his abdomen and pelvis revealed no evidence of acute intra-abdominal pathology, however there was an incidental finding of a pulmonary embolus in his right lower lobe. Radiology