Age: 39.0
Sex: F
Vaccine: FLUC4
Symptoms: Alanine aminotransferase normal, Anticoagulant therapy, Aspartate aminotransferase normal, Ataxia, Blood alkaline phosphatase normal
Clinical narrative: Flu vaccine (unknown which one) outside our system ~2 weeks prior to admission/onset of symptoms. Daily hospital progress note of 12/3 as follows:  HOSPITAL MEDICINE DAILY PROGRESS NOTE  LOS: 1 day    Chief Complaint: Uncontrolled shakes of her legs     Subjective       Patient states no change of her leg shaking with the first dose of IVIG.  She did not have any rash, shortness of breath or other reactions with IVIG.  Patient states that since COVID last year she noticed some shakiness of her legs going down stairs but never had any falls or difficulty with activities.  She states she is very physically active and does HIT training as well as yoga without difficulty.  She states she only noticed problems in the last 3 days with the only new medication being losartan started in September 2022 for hypertension as well as flu vaccine performed about 2 weeks ago.  Patient denies any numbness, tingling, back pain, headache, family history of muscular dystrophy.  There is ulcerative colitis in her mother, patient did have reactive arthritis post strep infection in the past.  Patient denies any rash, no difficulty with swallowing or speaking at the end of the day, she denies any shortness of breath.  She denies any history of headaches, no diplopia.     Current Facility-Administered Medications:  ?  [START ON 12/4/2022] diphenhydrAMINE (BENADRYL) injection 25 mg, 25 mg, intravenous, Daily, 25 mg at 12/03/22 1044 **AND** [START ON 12/4/2022] acetaminophen (TYLENOL) tablet 650 mg, 650 mg, oral, Daily ?  cyanocobalamin injection 1,000 mcg, 1,000 mcg, intramuscular, Daily, 1,000 mcg at 12/03/22 1052 ?  [START ON 12/5/2022] cyanocobalamin tablet 1,000 mcg, 1,000 mcg, oral, Daily,  ?  enoxaparin (LOVENOX) syringe 40 mg, 40 mg, subcutaneous, Daily at 1400, 40 mg at 12/02/22 2008 ?  immune globulin (human) (GAMMAGARD) infusion 20 g, 0.4 g/kg, intravenous, Daily at 1000, Last Rate: 109 mL/hr at 12/03/22 1200, Rate Change at 12/03/22 1200 ?  losartan (COZAAR) tablet 100 mg, 100 mg, oral, Nightly 100 mg at 12/02/22 2007 ?  Insert peripheral IV, , , Once **AND** Maintain IV access, , , Until discontinued **AND** Saline lock IV, , , Once **AND** sodium chloride flush 3 mL, 3 mL, intravenous, PRN,  ?  acetaminophen (TYLENOL) tablet 325-650 mg, 325-650 mg, oral, q4h PRN 650 mg at 12/03/22 0709 ?  magnesium hydroxide (MILK OF MAGNESIA) 400 mg/5 mL oral suspension 30 mL, 30 mL, oral, Daily PRN       Objective        VITAL SIGNS: Temp:  [36.4 °C (97.5 °F)-36.8 °C (98.2 °F)] 36.8 °C (98.2 °F) Heart Rate:  [79-101] 79 Resp:  [18-19] 19 SpO2:  [90 %-100 %] 98 % BP: (110-150)/(75-122) 134/99 Wt Readings from Last 3 Encounters: 12/02/22 54.4 kg (119 lb 14.9 oz) 10/24/22 53.4 kg (117 lb 12.8 oz) 10/06/22 52.2 kg (115 lb)   Intake/Output last 3 shifts: I/O last 3 completed shifts: In: 651.6 [P.O.:450; IV Piggyback:201.6] Out: 1000 [Urine:1000] Intake/Output this shift:   Intake/Output Summary (Last 24 hours) at 12/3/2022 1221 Last data filed at 12/3/2022 0333 Gross per 24 hour Intake 651.58 ml Output 1000 ml Net -348.42 ml     PHYSICAL EXAM:  General: lying in bed in no acute distress. HEENT: anicteric, mucous membrane moist, neck is supple without lymphadenopathy Chest: clear to auscultate bilaterally, no wheezes or crackles Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops Abdomen: normooactive bowel sounds, abdomen is soft, nontender, non distended, no hepatosplenomegaly. Extremities: 2+ radial and dorsalis pedis pulses, no pedal edema Skin: no rash Mental Status: Alert and oriented x3, evaluation of language shows normal fluency, comprehension and repetition.  Normal attention on digit forward testing  Cranial nerves: Visual fields intact in all quadrants, extraocular movements intact, patient has facial symmetry Motor: No pronator drift, normal finger tap, normal foot tap, 5/5 strength bilateral finger extensors, 5 out of 5 strength on hip flexion, hip extension, knee flexion extension, external rotation and internal rotation of hip and ankle dorsiflexion and plantarflexion bilateral.  Patient did have notable shaking of both legs when activating muscles of the hip or thigh.  This did not occur with strength testing on the distal lower extremity. Coordination: Normal finger-nose-finger Gait: Not assessed.   RESULTS AND DECISION MAKING: Results from last 4 days Lab Units 12/03/22 0625 12/02/22 1003 WBC AUTO 10*3/uL 5.7 4.9 HEMOGLOBIN g/dL 13.1 12.8 HEMATOCRIT % 39.2 38.2 PLATELETS AUTO 10*3/uL 298 314   Results from last 4 days Lab Units 12/03/22 0625 12/02/22 1003 SODIUM mmol/L 136 139 POTASSIUM MMOL/L 4.2 3.9 CHLORIDE mmol/L 107 108* CO2 mmol/L 20* 22 BUN mg/dL 11 10 CREATININE mg/dL 0.98 1.02 CALCIUM mg/dL 8.9 8.6 TOTAL PROTEIN g/dL 7.2 6.9 BILIRUBIN TOTAL mg/dL 0.58 0.45 ALK PHOS U/L 37 36* ALT U/L 13 14 AST U/L 16 17 GLUCOSE mg/dL 89 91               No results found for: TROPHS, TROPHS1HR, HSDELTA1, TROPHS2HR, HSDELTA2  Results from last 4 days Lab Units 12/02/22 1003 CK TOTAL U/L 73               Results from last 4 days Lab Units 12/02/22 1003 CRP mg/L 3.0   Results from last 4 days Lab Units 12/02/22 1003 SED RATE mm/hr 4   Lab Results Component Value Date   VITAMINB12 384 12/02/2022   Results from last 4 days Lab Units 12/02/22 1003 TSH uIU/ml 1.552      No results found for: OCCULTBLD Lab Results Component Value Date   PTH 18.6 10/24/2022   CALCIUM 8.9 12/03/2022   PHOS 2.7 12/02/2022   Lab Results Component Value Date   HCGQUAL Negative 12/03/2022     I have reviewed all the lab results.   CULTURES: Microbiology Results (last 21 days)      Procedure Component Value - Date/Time   CSF culture w/stain  (Normal) Collected: 12/02/22 1607   Lab Status: Preliminary result Specimen: Cerebrospinal Fluid from Lumbar Puncture Updated: 12/03/22 0802     CSF Culture No Growth 12 hours     Gram Stain Result Few WBC per oil immersion field       No organisms seen       --      Comment: Fluid concentrated by cytocentrifugation for direct smear.          IMAGING: FL lumbar puncture diagnostic Narrative: EXAM:  Fluoroscopically guided lumbar puncture 12/02/2022   INDICATION:   muscle weakness in limbs   PROCEDURE: The risks, benefits, indications, and alternatives to fluoroscopically guided lumbar puncture were discussed with the patient who understands and has given verbal and written consent to proceed.   The patient was placed in the prone position on the fluoroscopic table. Appropriate site for lumbar puncture was selected with fluoroscopy. The skin overlying the lower back was prepped and draped in usual aseptic manner. Local anesthesia was obtained with 1% lidocaine. A 22-gauge spinal needle was advanced into the thecal sac at the L3-4 level utilizing fluoroscopic guidance. A permanent image was acquired for documentation. Clear CSF was obtained. A total of 17 cc of CSF was collected in 3 separate tubes. The needle was removed, the skin was cleaned and a sterile bandage was applied to the puncture site. The procedure was tolerated well with no apparent immediate complication.   An opening pressure was not measured.   Fluoroscopy time: 0.1 minutes 1 permanent image was recorded. Impression: IMPRESSION:  Uncomplicated fluoroscopically guided lumbar puncture. MR brain with and without contrast Narrative: EXAM: MR BRAIN W AND WO CONTRAST   DATE: 12/2/2022 1:07 PM   INDICATION: Bilateral lower extremity weakness and ataxia, with possible focal numbness and possible developing involvement of the upper extremities now..   COMPARISON: None available.    Technique: Multiplanar magnetic resonance images of the brain were obtained prior to and following the administration of 10 mL of Prohance intravenous contrast. 0 mL were discarded.   Findings: The ventricles and other CSF spaces are nondilated. Few T2/FLAIR hyperintensities in the periventricular and subcortical white matter, commensurate with age. Areas of potential FLAIR signal abnormality in the posterior fossa (right pons and bilateral brachium pontis) are not substantiated on alternate FLAIR sequences and favored to be artifactual. No pathological intracranial enhancement. The major intracranial flow voids are preserved.   Small right lacrimal gland cyst. Normal globes and orbital soft tissues. The paranasal sinuses and mastoid air cells are well aerated.  Impression: IMPRESSION: No acute intracranial abnormality. No evidence of demyelination, infection, inflammation, or mass. MR spine screening with and without contrast Narrative: EXAM: MR SPINE SCREENING W AND WO CONTRAST   DATE: 12/2/2022   INDICATION:  muscle weakness in limbs   COMPARISON: None available.    TECHNIQUE: Multiplanar magnetic resonance images of the cervical, thoracic, and lumbar spine were obtained prior to and following the administration of 10 mL Prohance intravenous contrast. 0 mL of contrast was discarded.   FINDINGS: There are 7 cervical, 12 thoracic, and 5 lumbar type vertebral bodies. Mild reversal of the cervical lordosis, which may be positional and centered at C3-4. Preserved lumbar lordosis and thoracic kyphosis. No compression deformity or other spinal fracture. No pathologic marrow enhancement.    The paraspinal soft tissues are without acute abnormality.    Normal cord caliber and signal intensisty. Normal positioning of the conus. Normal appearance of the cauda equina. No pathological intrathecal enhancement.    No high grade spinal canal stenosis. Spondylotic changes in the cervical spine including facet arthropathy; no significant spinal canal or foraminal stenosis. No significant thoracic or lumbar spondylosis. Impression: IMPRESSION: No acute abnormality in the spine or cord; no significant stenosis or pathologic enhancement/myelitis changes.          Assessment/Plan        Principal Problem:   Leg weakness   40-year-old female with essential hypertension presents with 3-day onset of difficulty ambulation and lower extremity tremors.  She was admitted for further evaluation and neurological work-up.  She underwent LP and MRI imaging of the brain and spine with no abnormality found on imaging.  LP within normal limits.  Neurology was consulted with initial diagnosis of possible ataxia Guillain-Barré variant.  It was recommended that patient start IVIG   1.  Lower extremity weakness: Possible ataxia Guillain-Barré variant per neurology evaluation.  I had extensive discussion with neurologist regarding this case.  Objective measures including MRI of the brain and spine, lumbar puncture, CSF results, metabolic testing, inflammatory markers, respiratory pathogen panel were all essentially normal.  However since patient had acute change of her lower extremities with neurologist findings of intact strength except big toe dorsiflexion and plantarflexion, decree sensation to monofilament and pinprick at the soles of the feet, impaired heel-to-toe and heel shin walk there is a possibility this is ataxic Guillain-Barré variant. -Continue IVIG per neurology recommendations -Per neurology may consider trial of Solu-Medrol -IM cobalamin 1000 mcg x 3 doses   2.  Essential hypertension: Recently started on losartan: Patient has intermittent hypertension, diastolic pressure is elevated.  We will continue losartan while hospitalized with consideration of switching to olmesartan versus olmesartan amlodipine combination if persistent hypertension.    DVT Prophylaxis: Lovenox Social: Spouse of radiologist.  I spoke with Dr. and reviewed the working diagnosis so far as well as potential intervention with IVIG plus corticosteroids.  Functional Baseline: Independent with all activities prior to hospital stay Disposition: Needs further monitoring for change in neuro status