Age: 81.0
Sex: M
Vaccine: FLU3
Symptoms: Loss of personal independence in daily activities, Mobility decreased, Nerve conduction studies abnormal, Pain, Pain in extremity
Clinical narrative: Guillain-Barre Syndrome Adverse Event from a flu shot for Patient. Enclosed you will find your form completed with HandOuts describing some of the questions. This syndrome has completely changed my husbands quality of life from a man who was very active, working in the yard, going to local games, attending church, visiting children and grandchildren and traveling and camping in the RV. Since this happened to him, he is unable to do very much at all except see doctors, do Physical Therapy, take medication throughout the day, and sleep a lot. Thank you in advance for wanting to know more about this syndrome and maybe there could be more explanation from doctors concerning this syndrome and recommending the flu shot or other vaccinations. If you need additional information and I can help in any way, please let me know. Patient is seen in return for GBS. He was doing better with his strength until 3 weeks ago when he had a sinus infection and a sty on the right eye. This has set him back some. He is using antibiotic eye drops for the sty. He is able to walk around the house, sometimes without a cane. He has fallen twice since his last visit, tripping on steps and then over the wheel of his wheelchair. He continues to have home PT/OT/SLP. When he sleeps at night and having a lot of vivid dreams and hallucinations. He takes Gabapentin and Tylenol PM at night. Medication and medical history lists reviewed and updated. Patient was screened for COVID 19. The patient responded no to fever, cough, travel outside of the country in the last 2 months, or exposure to someone with symptoms. Patient Follow-Up. Patient is seen after a 2.5 month absence has remained stable to improved from his GBS--he is better able to turn over in bed and to keep his trunk stable. He continues to have some falls, somewhat when he tripped over a wheel of a wheelchair but he has now gone a week without incident. "We all feel like he's come a long way." His NCS demonstrated a mixed sensorimotor axonal/demyelinating polyneuropathy with denervation on EMG in the UE and LE. No significant injury. He is receiving HHS PT and ST and OT and was recently identified as having some persistent aspiration issues and they are working on dietary manipulation at this point with ST. His pain levels occur aroune 3-4 AM from the thighs down which has been helped by higher dose of the Neurontin 300 mg QID. He uses PRN Tylenol. His pain appears to gradually be improving as well. Medication list reviewed and revised. Patient was screened for COVID 19. The patient responded no to fever, cough, travel outside of the country in the last 2 months, or exposure to someone with symptoms. There have been no new medical illnesses or new medications added. PATIENT FOLLOW UP Patient is seen in return for GBS. He is able to walk with a walker around the house and next week should graduate to a cane. He has been having sharp shooting pains in his legs throughout the day and night. This has kept him awake. He was on Gabapentin 200 mg TID, but was recently increased to 600 mg by his PCP. He has not had any falls since his last visit. Medication and medical history lists reviewed and updated. The NCV of the lower extremities showed sensiomotor polyneuropathy. PATIENT FOLLOW-UP VISIT Patient is seen in return for his difficulties with GBS diagnosed in October 29, 2019 with rapidly ascending quadriparesis with intubation for which he received 6 PLEX treatments and IVIG 0.4 gm/kg daily x 5 with minimal improvement. He was then transferred to hospital where he made slow progress, but remained non ambulatory. He was discharged 12/19 to other where he is currently an IP with discharge scheduled for tomorrow to other for additional rehab. He is ambulatory with a walker a distance of 155 feet. He continues to have issues with a stage 3 sacral decubitus requiring Wound Care. He combines both PO intake and PEG feedings to maintain protein supplies. He denies trouble swallowing--some choking on water. He denies difficulties with his UE but cannot raise his arms right < left. He denies pain. Medication list reviewed and revised. There have been no new medical illnesses or new medications added.