block 9b. ab, 66m married right-handed from cavite chief complaint: generalized weakness
TRANSCRIPT
GUILLAIN-BARRE SYNDROME
Block 9B
General Data
AB, 66M Married right-handed from Cavite Chief complaint:
generalized weakness
History of Present Illness
1 month prior to admission Patient complained of severe intermittent low
back pain characterized as shooting in character, radiating to bilateral lower extremities.
(-) numbness(-) weakness(-) incontinence Sought consult at PGH Orthopedics Assessment: Spondylolisthesis L2-L3
2 weeks prior to admission Patient complained of ascending weakness of
bilateral lower extremities, allegedly with no sensory deficits. Still ambulatory but would walk with the aid of a cane.
1 week prior to admission Can no longer ambulate, wheelchair-bound,
weakness up to the thigh level. No associated dyspnea, dysphagia or sensory deficits. There was urinary retention, which eventually resolved.
4 days PTA Weakness of bilateral upper extremities with
no associated dyspnea or pysphagia. (+) anorexia.
Sought consult in PGH
Past Medical History
Not known hypertension or DM (-) PTB, BA, CVD (+) non-healing wound, right foot (2009) (-) Food and drug allergy No previous surgery or hospitalization
Family History
(+) HTN (+) DM (-) PTB, BA, CVD, HD
Personal and Social History
Occasional smoker Heavy alcoholic beverage drinker Copra farm owner Lives with children and wife
Physical and Neurological Examination
AB, 66/M
General Awake, stretcher-bound, not in cardiorespiratory distress
Vital Signs: BP: 140/90 HR: 96 RR: 20 T: afebrile
HEENT Pink conjunctivae, anicteric sclerae, (-)ANM/CLAD/NVE
Chest/Lungs Equal chest expansion, clear breath sounds, no rales/crackles/wheezes
CVS Adynamic precordium, distinct heart sounds, (-) murmur
Abdomen Flabby, soft, normoactive bowel sounds, (-) hepatosplenomegaly, (-) masses/tenderness
GU Essentially normal
Skin/Extremities
Pink nailbeds, CRT<2 sec,full and equal pulses, (-) edema/jaundice/cyanosis
Alert, opens eyes spontaneously, speaks in sentences, follows commands
Cranial Nerve Examination
I Not assessed
II 2-3 mm EBRTL
III, IV, VI EOMs intact
V Brisk corneals
VII No facial asymmetry
VIII Weber: Lateralizes to L, AD: BC> AC AS: AC>BC
IX Good gag reflex
X Uvula midline
XI Good shoulder shrug
XII Tongue midline
No sensory deficits Motor Exam:
R L R L
Shoulder abduction 3 3 Hip flexion 0 0
Shoulder adduction 3 3 Hip extension 0 0
Elbow flexion 4 4 Knee flexion 0 0
Elbow extension 4 4 Knee extension 0 0
Wrist flexion 4 4 Ankle plantarflexion
0 0
Wrist extension 4 4 Ankle dorsiflexion
0 0
Grip good good
DTRs: areflexia all extremities (-) clonus/ Babinski Supple neck (-) nystagmus
Laboratory test resultsAB, 66/M
Lab Test Result
CBC 2/18: Hgb 82 Hct 0.236 Plt 215 WBC 21.6 N 0.962 L 0.026 M 0.009 E 0.0032/23: Hgb 83 Hct 0.254 Plt 208 WBC 11.3 N 0.880 L 0.072 M 0.046 E 0.00
Blood Chem
BUN 7.19 Crea 67 UA 0.16 Alb 13 HDL 0.25 LDL 2.6 Trig 0.81 Chole 3.22 Mg 0.74 Na 126 K 4.4 Cl 74 HbA1c 5.7
ABG pH 7.461 pCO2 25.6 PO2 86.6 HCO3 18 .2 O2sat 97 BE -3.0
PT/PTT 12.5/15.4/0.66/1.47; 36.6/40.3
Urinalysis Dark yellow, turbid, 1.015, 7.0, (-) sugar, 1+ protein, 1-4 RBC, abundant WBC, few EC, 3+ bacteria, (-) MT/cast/crystal
Urine GS PMN 5-10, Gram (+) cocci in pairs> 25/OIF
AssessmentAB, 66/M
Guillain-Barre Syndrome Complicated UTI, resloving Sacral decubitus ulcer, grade 2 Multiple electrolyte imbalance, resolving Spondylolisthesis L2-L3 Dyslipidemia Anemia, multifactorial Sensorineural hearing loss, AS
MANAGEMENTAB, 66/M
Pharmacologic
Ceftriaxone 2g IV OD Metronidazole 500/cap q6 FeSO4 + FA Simvastatin 40 mg OD Celebrex PRN Lactulose 30 cc BID
Guillain Barre Syndrome
GBS
Acute inflammatory demyelinating or axonal polyneuropathy
Common cause of acute or subacute generalized paralysis
Mild respiratory or gastrointestinal infection precedes the neuropathic symptoms
Symptomatology
Paresthesias and numbness in toes and fingers
Symmetrical weakness, lower extremities before upper extremities
Pain or aching discomfort in muscles often hip, thigh and back
Variable sensory losses Hypo- or areflexia Cranial nerve palsies come later Autonomic function disturbances
Pathophysiology
Differential Diagnosis
Acute spinal cord injury Poliomyelitis Carcinomatous meningitis Botulism Polyneuropathy of critical illness
Diagnostics
Electrodiagnostic studies EMG- reduction in the amplitude of muscle action
potentials, slowed conduction velocity, and conduction block in motor nerves singly or in combination
Prolonged distal latencies and prolonged or absent F-reflexes
CSF examination Suggestive of demyelination without evidence of
active infection Spine MRI
Lumbosacral area enhancement of nerve roots with gadolinium
Therapeutics
Aimed primarily at immunomodulation Intravenous immunoglobulin (IVIG)
Adults: 2g/kg IV over 2-5 days Children: 0.4 g/kg/d IV for 5 d; 2 g/kg once or 1
g/kg/d over 2 d Plasmapheresis may decrease the severity
and shorten the duration of GBS Removal of 200-250 ml/kg of plasma in 4-6
treatments on alternate days or on sgort period if no coagulopathy
Potential complications; autonomic instability, hypercalcemia, bleeding
Non-pharmacologic
Consultation with neurologist, rehab ,medicine specialist, and intensivist if necessary
Occupational Therapy Physical therapy
passive movement and positioning of limbs to prevent pressure palsies and, later, mild resistance exercisesoccupational therapist
Prevention of decubitus ulcers