Age: 71.0
Sex: M
Vaccine: FLU3, VARZOS
Symptoms: Mobility decreased, Muscular weakness, Neurological examination abnormal, Nuclear magnetic resonance imaging spinal cord abnormal, Paraesthesia
Clinical narrative: DATE OF ADMISSION:   01/15/2013 HISTORY AND PHYSICAL ADMITTING DIAGNOSIS(ES):   Generalized weakness. HISTORY OF PRESENT ILLNESS:   This is a 72-year-old male admitted after having been seen in the emergency department where he presented with a 48-hour history of progressive weakness.   The weakness has been relatively rapidly progressive.  It started with some numbness and tingling in his hands and feet, progressed to weakness such that he was unable to reach above his head to place dishes in his cupboard above while standing at the kitchen sink.  That was yesterday.   Today, he was unable to walk unassisted.   He fell, was unable to get up by himself and unable to use his arms and hands in any meaningful way.   The relatively rapid progression prompted his evaluation in the emergency department where he was seen with the findings of symmetrical primarily proximal muscle weakness but some degree of distal weakness was noted as well.  He noted no pain in the muscles and no cranial nerve or cognitive dysfunction was noted.  He had significant weakness throughout, although he is able to hold his head upright.   He is unable to ambulate or sit forward without assistance.  He notes some numbness and tingling, although no frank pain and in any of the muscle groups appreciated.   He has not had any previous history of similar problems.  He is usually a reasonably vigorous physically active person.  It is notable he had an influenza immunization about 4 weeks ago at which time he also had a shingles shot as well. PAST MEDICAL HISTORY:   His past medical history is remarkable for a recent hospitalization at which time he presented with GI bleeding felt to be secondary to ischemic colitis.  He was felt to have a thrombotic aspect to that course and was started on a combination of aspirin and Plavix, which was started 4 days prior to this admission.  His last dose of Plavix was yesterday.  He has a history of paroxysmal atrial fibrillation and has been on Multaq for the past several months.   Prior to that, he was on amiodarone and that was discontinued because of various side affects in favor of the current treatment, which is been well tolerated and has been effective in maintaining his normal sinus rhythm.  He is followed by cardiology elsewhere, as well as electrophysiology.  In addition, he is past medical history is remarkable for the absence of a history of a myocardial infarction, angina pectoris or congestive heart failure, or TIA.   He has not had a history of hypertension and diabetes. He had a previous echocardiogram in March 2012 done by Dr. showing evidence of dilatation of the left atrium with normal left ventricular systolic function. FAMILY MEDICAL HISTORY:   Remarkable for generally longevity.   He does have 1 brother who also has atrial fibrillation and possibly his mother has atrial fib as well. SOCIAL HISTORY:   Shows he is retired.   He is an ex-smoker, having quit in the 1960s.  Does not use alcoholic beverage on a regular basis. REVIEW OF SYSTEMS:   Remarkable for those symptoms noted in the history present illness.  Otherwise, he has been feeling well with a generally negative system review including the absence of headache, visual disturbance, difficulty swallowing, nausea, vomiting, diarrhea, constipation, shortness breath, cough, chest pain, sore throat, swollen glands, difficulty with hearing or vision, skin nodules or rashes, or cognitive or memory deficits at this time.  He has not had any further GI bleeding after being discharged from the hospital last week. MEDICATIONS:   As listed in the medication reconciliation that include primarily: Plavix 75 mg daily. Multaq 400 mg b.i.d. PHYSICAL EXAMINATION:   GENERAL:  Shows he is awake, alert, oriented, and conversant, in no acute distress.  He is lying in bed, able to answer questions without difficulty. VITAL SIGNS:  Generally unremarkable and are as noted. HEAD AND NECK:  Otherwise not remarkable.  Carotid upstrokes are full.  No bruit is appreciated.  The cranial nerves are intact. LUNGS:  Clear to auscultation.  No dullness to percussion. HEART:  Normal S1, S2.  The rhythm is regular.  No gallop rhythm is appreciated. ABDOMEN:  Soft, nontender with active bowel sounds.  Liver and spleen not enlarged.  No masses palpated.  Femoral pulses full. EXTREMITIES:  No edema or deformity.  The peripheral pulses are present.  The feet are somewhat cool. NEUROLOGIC:  Shows profound and diffuse weakness, proximal greater than distal in both arms and legs.  He is unable to raise any extremity against gravity.  He has intact sensation, however, throughout and diminished reflexes are noted throughout as well. LABORATORY DATA:   Laboratory is pending at this time. IMPRESSION:   This man presents with signs and symptoms of a progressive bilateral symmetrical polyneuropathy.  It is notable that his CK level is normal.   This most likely represents a Guillain-Barre syndrome possibly related to his recent influenza vaccination.  Other considerations are also in the differential and will be addressed by the neurology consultant Dr.  Consideration would be given to the use of IgG and possibly lumbar puncture will be performed as well as imaging of the spinal cord as baseline evaluation is undertaken.   Further evaluation and intervention will depend on the recommendations from neurology consultation. Inpatient Rehab Admission Note:  DATE OF ADMISSION:   01/28/2013 DATE OF DISCHARGE:    HISTORY AND PHYSICAL REASON FOR ADMISSION:   Guillain-Barre syndrome. I reviewed and concurred with the findings of the Preadmission Screening documentation and approved this patient for admission to the Inpatient Rehabilitation Unit. HISTORY OF THE PRESENT ILLNESS:   Patient is a 72-year-old who was admitted into the acute care section on January 15, 2013, with a 48-hour history of gradually worsening weakness.  Dr. concluded that his signs and symptoms were indicative of progressive bilateral symmetrical polyneuropathy, most likely representing Guillain-Barre syndrome possibly related to his recent influenza vaccination.  The neurologist, on January 16 concluded that the examination suggested acute all polyradiculoneuropathy concerning for Guillain-Barre syndrome, acute inflammatory demyelinating polyradiculoneuropathy (AIDP).  He recommended a 5-day course of IV immunoglobulin which the patient tolerated.  Tthe nephrologist, on January 26 concluded that the patient had hyponatremia likely as a result of the syndrome of inappropriate antidiuretic hormone.  He put the patient on fluid restriction and gave him Lasix for free water diuresis. This improved the serum sodium which came up to 130 on January 28 from being 128 on January 27th from being 123 on January 25, 2013.  On January 26, WBC 6.7, hemoglobin 13.9, hematocrit 41.9.  MRI of the thoracic spine was done on January 16 that showed a normal thoracic cord signal, but there are multiple small disk protrusions without canal stenosis.  Cervical spine on January 16 showed multilevel degenerative disk disease and facet arthropathy.  On January 4, Clostridium difficile was negative.  This test was done when he had colitis.  The patient complains that his hands and feet are a little weaker today than 2 days ago. He continues to have significant weakness in all extremities and severe impairment in mobility, self care and safety. Rehab necessity for this admission: To improve the patient's impairments in mobility, self-care, and safety (Refer to the preadmission screen for details about functional impairments). There is a reasonable expectation of measurable improvement, which will be of practical value to this patient within a reasonable period of time. This patient requires and can tolerate at least 3 hours per day of skilled therapy at least 5 days per week. This patient requires active and ongoing interdisciplinary intervention acting in a coordinated fashion. The level of intensive, interdisciplinary and highly-coordinated rehabilitation services are not available as an outpatient, through home health or in a skilled nursing facility in intensity, quantity and quality. Medical necessity for this admission/co-morbid condition which would impact this admission: Guillain-Barre syndrome. Hypertension with variable blood pressure. Atrial fibrillation. Urine retention during this admission and a Foley catheter was reinserted. PAST MEDICAL HISTORY AND SIGNIFICANT SURGICAL HISTORY:    Recent ischemic colitis which resulted in rectal bleeding and thrombotic component for which he was started on aspirin and Plavix.  Paroxysmal atrial fibrillation for which he has been on Multaq for several months.  Prior to that, he was on amiodarone which was discontinued due to several side effects.  No history of myocardial infarction.  Dilatation of left atrium with normal left ventricular systolic function.  No diabetes.  No hypertension.  No asthma.  No COPD.  No tuberculosis.  No polio.  No emotional disorder.  No other mental illnesses.  No cerebrovascular accident.  No multiple sclerosis. FAMILY HISTORY:   One brother has atrial fibrillation.  Mother also has atrial fibrillation. SOCIAL HISTORY:   He lives with his wife in a 1-story house with 3 steps to get into.  He quit smoking in 1960s.  He does not use any alcoholic beverages on a regular basis. The patient's prior level of functioning:  (Refer to the preadmission screen for details). REVIEW OF SYSTEMS:   HEENT:  No headache.  No dizziness.  No earache.  No ear drainage.  No buzzing in ears.  Hearing is impaired slightly bilaterally and he uses a hearing aid on his left ear, but he is not using it at this moment.  No eye pain.  Vision problems are corrected with bifocals.  No double vision.  Nose stuffiness.  Since the colitis, he has been taking soft foods.  No nosebleeds.  No sinus problems.  No bleeding gums. No mouth sores.  Dry mouth.  No excessive thirst. NECK:  No neck pain.  No neck stiffness.  No difficulty swallowing. CARDIORESPIRATORY:  No chest pain.  No palpitations.  No shortness of breath.  No wheezing. GASTROINTESTINAL:  No poor appetite.  No abdominal pain.  Constipation.  No diarrhea.  No incontinence of stools.  No blood in stools.  Occasional heartburn which is relieved with Tums. UROGENITAL:  No burning when urinating.  No urine frequency.  No incontinence of urine.  Not voiding large quantities of urine.  Has a history of nocturia once per night.  He does have a Foley catheter as mentioned above. MUSCULOSKELETAL:  No muscle pain.  No muscle stiffness.  No leg cramps.  Muscle spasms in the low back last night. NEUROLOGICAL:  No fainting.  No seizures.  Tingling and numbness in hands and feet.  He also has numbness and tingling from the tips of fingers up to mid forearms, from the tips of toes to mid calves. No tremors.  No nervousness.  No depressed mood. SKIN:  No skin rash.  No skin itching.  No skin lumps. CURRENT MEDICATIONS:   As per medication reconciliation. ALLERGIES:   INFLUENZA VIRUS VACCINE has been considered as the cause for this Guillain-Barre syndrome. DIET:   General. PHYSICAL EXAMINATION:   VITAL SIGNS:  Blood pressure  141/88. Pulse 81.  Respirations 16.  Temperature 97.  Height 6 feet 3 inches. HEENT:  Pupils 1 mm in diameter, round and reacting to light. Fundi reveal arteriosclerosis.  Ear canals are clear.  Tympanic membranes are visualized.  Throat is clear. NECK:  Supple. LUNGS:  Clear. HEART:  S1 and S2 heard, but no S3 or S4.  Irregularly irregular.  Systolic murmur is heard in all the cardiac areas. BREASTS: ABDOMEN:  Soft and nontender.  No masses or organomegaly.  Bowel sounds are within normal limits.  Hernial orifices are within normal limits. UROGENITAL:  Scrotum is red.  Foley catheter is noted. RECTAL:  Examination, prostatic bed is flat.  No nodules.  No tenderness. EXTREMITIES:  No edema of the feet is noted. COMMUNICATION:   Within functional limits. COGNITION:   Within functional limits. Cranial nerves screening II through XII External ocular muscles are intact. Face is symmetrical. Tongue is in the midline and moves symmetrically. Gag reflex is intact. Sensation over the face is intact. Pin prick is absent from the tips of all the fingers to mid palms and up to knuckles dorsally.  Pin prick is also absent from the tips of all the toes to the ankles. Proprioception is absent in the fingers, wrists, toes and ankles, impaired in the elbows. Muscle tone is impaired in all extremities. MUSCLE STRENGTH:  Right upper extremity: Shoulder 2-, elbow flexion 0, elbow extension 2-, wrist 2-, fingers 2-. Right lower extremity: Hip flexion 2-, hip extension 2-, knee extension 0, knee flexion 0, ankle dorsiflexion 0, plantar flexion 2-. Left upper extremity: Shoulder 2-, elbow flexion 2-, elbow extension 2-, wrist 2-, fingers 2-. Left lower extremity: Hip flexion 2-, hip extension 2-, knee extension 2-, knee flexion 0, ankle dorsiflexion 0 and plantar flexion 2-. Deep tendon reflexes: 0/2. Babinski sign is not present bilaterally. Coordination could not be tested in the extremities due to severe weakness as mentioned above. PASSIVE RANGE OF MOTION:  Upper extremities: Within functional limits. Lower extremities: Hips flexion 90 degrees, knees flexion 140 degrees, ankles plantar flexion 35 degrees, dorsiflexion lacks by 20 degrees to neutral on the right and lacks by 15 degrees to neutral on the left. DIAGNOSIS:   Principal Diagnosis: Guillain-Barre syndrome. Secondary Diagnoses: Syndrome of inappropriate antidiuretic hormone secretion. Gastroesophageal reflux disease. Recent urinary retention. History of ischemic colitis in the recent past. CONCLUSIONS:   The patient can follow verbal and visual commands. The patient has impaired mobility, self-care skills, and safety. The patient will benefit from intensive interdisciplinary rehabilitation program to improve all the above-mentioned impairments. These are the patient's goals and also our goals.  The goals are realistic at this time. The above mentioned status of this patient is compared to that noted in the Preadmission Assessment document and I conclude that there have been no significant changes. PLAN UPON ADMISSION TO INPATIENT REHAB:   To continue the above-mentioned medications. The patient will attend physical therapy, occupational therapy, and social services as per written order. The patient will be followed by Drs. Code status discussed and the patient wants to be resuscitated.  This is a rational decision. We will give him above-the-knee thromboembolic deterrent stockings and sequential compression devices.  We will do neuro checks every shift and p.r.n. We will start him on Lovenox for VTE prophylaxis only if okay with Dr.   We will start him on Senokot-S, saline nasal spray, and Dulcolax suppository today after therapies.  We will also let Dr. know right away that his hands and feet are weaker today than 2 days ago. Patient still hospitalized as of this date.