Age: 58.0
Sex: F
Vaccine: FLU3
Symptoms: Splenomegaly, Tremor, Visual evoked potentials normal
Clinical narrative: 2130 hrs; 10-17-07; Low back pain, radiating down posterior thighs. Numbness/ tingling left foot; N/T bilateral hands with neck flexion. 10/22/07: PCP ordered Ultram, Flexeril and Dexamethasone PO. Post 48 hrs, N/T increased in right foot. Hosp Admission:10-26 to 10-30-07; Dx: Bell's Palsy. N/T progressive lower extremities; muscle weakness increased, hand tremors. PCP ordered Solu-medrol dose pk and PT. Weakness increased.  11/18/07:Severe pain, weakness and tremors; to ED then admitted to Medical Center 11-18-07; neurology floor. Spinal tap: protein 307. Multiple labs: MS vs neurosarcoidosis. Treated with 1000mg IV solumedrol x 6 days. GMI antibody & Visual Evoke Potential with EEG: ruled out MS. EMG lower extremities: Chronic Demyelinated Polyneuropathy; consistent with Guillain Barre' Syndrome.  Plasma phoresis to start 1/3/08 x 5. Possible IVIG administration after plasmaphoresis. Employee last day of work; 10/25/07.    1/8/08 Reviewed hospital medical records which reveal patient experienced numbness & weakness of right side of face since 10/26/07 with back & leg pain.  Admitted 10/26-10/30/2007.  Consults by Neuro, Neurosurgery & GYN done.   FINAL DX: right facial Bell's palsy; cervical & lumbar disk prolapse; left ovarian mass; DM; primary biliary cirrhosis; hx of sarcoidosis in remission.    1/25/08 Received hospital medical records for 11/19-11/26/2007.  Had developed URI symtoms s/p d/c from initial hospital.  Neuro exam revealed right side Bell's phenomenon & Bell's palsy, severe low back pain, diffuse asymmetric weakness of bilateral legs w/significant gait impairment, hyperreflexia & bilat Babinski.  Neurosurg, Neurology consults done.  LP done.  Tx w/IV steroids & did improve to be able to ambulate w/wheeled [[name]].  D/C to home on continued steroids w/outpatient PT & further neuro w/u to be done.   FINAL DX: probable multiple sclerosis. 3/14/08 Reviewed hospital outpatient plasmapheresis records & labs which reveal patient received tx 1/3-1/14/2008 x 5 doses.  With initial tx experienced severe muscle cramping & was seen in ER.  Dx w/muscle cramping s/p plasmapheresis, HTN, esophageal pathology, GBS & hx of Bell's palsy.  D/c to home w/meds.  3/21/08 Reviewed neuro office notes of 12/7/2007-3/19/2008. FINAL DX: Guillian Barre syndrome Initial vs of 12/7/07 reveals patient experienced LBP & leg pain, paresthesias & weakness of legs & arms, Bell's palsy, difficulty voiding.  Recently dx w/MS.  Using wheeled [[name]] for ambulation but had been walking 2 [[name]]/[[name]] prior to this illness.  Exam revealed right facial paresis & unable to completely close right eye; gait stiff & unstable.  Referred for plasmapheresis x 5 doses.  Improved to be able to ambulate w/quad cane; prednisone weaned; returning to PT.  On 3/19 vs, was greatly improved but w/pain in various joints.  Allowed to return to work part time & referred to rheumatologist. Per 60 [[name]] follow up: Facial paralysis continues; requires cane for ambulation; tires easily/ physical threapy continues for strengthing endurance and balance. Concerned over medical bills-unable to work since 10/17/07. States unable to comply with $250.00 fee for program. 1/15/2010 Continues to recover from Guillain Barre Syndrome, facial paralysis, muscle weakness and fatigue.