Age: 18.0
Sex: M
Vaccine: HEPAB, MNQ, TDAP
Symptoms: Cough, Dysphagia, Dysstasia, Exercise tolerance decreased, Fall
Clinical narrative: Pt received immunizations (FLUMIST, HepA/B, Meningococcal, MMR, and Pneumococcal) on 7/1/09. He denied any local reaction. The pt was seen in medical on 8July09--the pt had fallen while running and injured his right knee. In reflection the pt remembered a feeling of weakness in both of his thighs. He was treated with naproxen and states that he felt ok on the 9th of July. The pt reported to medical on 20July09 with complaints of fever, sore throat, headache, cough and chest congestion for approximately 10 days. The pt remembers that several members of his platoon were sick with the same symptoms. The pt also complained of sharp, shooting pain in both of his legs and weakness in both of his arms. He denied having bowel or bladder incontinence at any time. The pt states that he experienced about 4 falls prior to this medical appt (he had intermittent numbness/weakness in his legs which seemed better after a night's sleep). The pt was released but he returned at 1030 stating that his legs were numb, his legs were weal (R>L). The pt was taken to a civilian ER. He had a CT scan of his head and spine (see below). The pt was discharged to full duty. On 21 July 09 the pt had difficulty walking--he fell and he required assistance to ambulate, he could not hold up his head--he felt a constant, throbbing, pressure in his neck and back, and he was having difficulty swallowing. The pt was seen by a civilian neurologist who performed an NCS (see results below). The pt was admitted to hospital with GBS. At his worst he needed assistance with getting out of bed, standing transferring; he had difficulty chewing and swallowing; and difficulty lifting his arms to feed himself. The pt received a 3 day course of IV IG .8mg/kg with improvement in his symptoms. After 4 days he was transferred to acute rehab. Prior to discharge the pt was able to swallow, he was able to walk short distances with support, his arms were weak. As of 8/27/09 the pt had no issues with swallowing or chewing. His fatigue was 60% better. He was able to feed himself and had adequate arm strength and movement to performs ADLs. He was unable to perform any pushups (prior 44), no pull ups (prior 4-5), no sit-ups (prior 88). Previously he could curl 25-30lbs and now he can curl 9 lbs for 10 reps. He fatigued within 2-3 minutes of performing on the arm bike. He was able to ambulate short distances without assistance otherwise he used a cane; he could walk on the treadmill for about 1/2 mile before he fatigued. According to the pt he had made no progress in the last 7-10 days. He is currently a pt on the "light care" unit at the hospital. 11/20/2009 ED and MR for 7/21-7/24/2009.Dx GBS  Patient with c/o's progressive extremity weakness and dysphagia. Neuro exam noted hyporeflexia. Tx: IVIG, LP,  evaluated for PT, OT and ST , dc'd to inpatient rehab for continuing care 12/10/09 Medical records received for DOS 07/24/09- 07/31/09 (Rehab Inpatient Unit) and  07/20/09-9/09/09 (PCP records) Following discharge on 07/31/09, Pt. reports fatigue improving; Physical therapy reports increased muscle strength and improved balance.