Age: 18.0
Sex: M
Vaccine: HEPAB, IPV
Symptoms: Fall, Fatigue, Full blood count, Gait disturbance, Grip strength decreased
Clinical narrative: This 19 yo patient reported onset of a stomach ache with 5-6 hours of crampy abdominal pain mid May 2009 w/o any associated symptoms (fever, diarrhea, n/v). On 20 May 2009 he reported sudden onset of "wobbly legs" as he ran to the car. He ignored but began to perceive numbness and tingling with increasing weakness first in left foot then right progressing up to mid thighs over the next 2 weeks (ascending pattern). He reported for PRT weigh in on 26 May 2009 completing bike qualifications instead of running since legs were unstable resulting in a fall x1 (legs just gave out-buckled with no strength). 01 June 2009 he reported to medical with bilateral lower leg/feet paresthesia, weakness and now to left arm (left elbow down ulnar nerve patter to 4-5th digits and index finger). He writes right handed but does all other activities with left hand. Providers documented a normal exam with no perceived weakness or reflex asymmetry. Lab studies showed normal ESR and chemistry. Thyroid panel ordered but no results available. He was released with routine neurology referral for 18 June 2009. Meanwhile, he presented for routing TWINRIX vaccination on 3 June 2009. On 10 June 2009 while preparing for scheduled leave to home, he was walking with a friend when his legs again gave out as he bent over resulting in a fall (no injury). His friend was unable to lift as SM legs would not hold him. He sat for approximately 20 minutes before being able to stand on own, balanced for 2-3 min then walked with friend supporting. He obtained a walking cane day and continued to use for next 2 weeks. (June 11-23, 2009) his parents drove him to ER on 13 June 2009 after SM fell a third time walking down bleachers with legs again giving out. Pt complained of increasing paresthesia to include entire legs (included feet slapping and difficulty picking up feet R>L, inability to jump) and bilateral upper extremity paresthesia (elbows to fingertips), weakness (bilateral arms and legs), mild sensation loss to lower abdomen (points to suprapubic region with no loss bowel/bladder or genitalia paresthesia), and sensation of "claustrophobia" as if he couldn't inflate lungs (but denied any breathing difficulties). He reported he could hold a pen and other light objects, but was unable to write his name and had weak grips bilaterally (problems buttoning, holding objects > 5 lbs, etc). ED provider reported positive reflexes, normal CT of head, and LP showing cytoalbuminologic dissociation (CSF lymphocytes 49, protein 75, RBC 148 otherwise wnl). Lab studies included normal UA, ESR/CRP, CBC with neutrophils 38.7 (40-80) and lymph 48 (15-45), and chem nl with sodium 146?136 (134-143), AST 53 (39), lactate dehydrogenase 325 (135-225). He was sent home to f/u with neurology. He returned to ED 14 June 2009 with severe headache post LP. He declined blood patch and was treated with IV fluids. His headache took approximately 5-6 days to resolve without reoccurrence. Neurology workup 18 June 2009 included EMG/NCS with findings consistent with acquired demyelinating polyneuropathy. He was hospitalized for 48 hours with Guillain Barre Syndrome remaining stable with gradual improvement of symptoms (not treated with IVIG). His breathing had returned to normal with paresthesia unchanged. He returned being followed by neurophysiologist on 26 June 2009 reporting continued proximal and distal upper and lower extremity weakness with increased strength. He reported he was able to hold a basketball but still unable to lift overhead to throw. He no longer walked with cane. His paresthesia was also easing. He was placed into physical and occupational therapy with LIMBU x6 months (see notes 6/18/2009 & 9/2/2009). As of 15 September 2009, his only complaint is of persistent sense of fatigue. He denied any paresthesia, weakness, loss of grips, foot slapping or headaches. He has resumed normal ADL.  9/22/09 VHC medical records DOS 6/18/09 to 9/17/09 Assessment: Guillain-Barre Syndrome. Patient presents with crampy abdominal pain, bilateral Upper/Lower extremity weakness/numbness since May '09. Fatigue, headache, neck and back pain, difficulty walking. Decreased anteroflexion neck. Muscle atrophy, muscles flaccid. Abnormal unsteady gait with wide base. Deep tendon reflexes absent - patellar, Ankle jerk, Bi, Br, Tr. Steppage gait.