Age: 19.0
Sex: M
Vaccine: HEPAB, MNQ, TDAP
Symptoms: Nausea, Nuclear magnetic resonance imaging normal, Odynophagia, Oropharyngeal pain, Pain in extremity
Clinical narrative: The pt reported to boot camp on 8/11/08.  He had his first set of immunizations on 08/13/08.  On 9/9/08 the pt was seen by his PCM for a 2 week history of a productive cough and a one week history of sinus pain, watery eyes, rhinorrhea, sore throat, pain with swallowing.  Several other members of the platoon were ill with similar symptoms.  At the same time he was also seen for a bilateral foot rash which was treated with oral steroids and resolved in 2 days.  The URI symptoms were treated with SUDAFED, CEPACOL lozenges, TYLENOL, and MUCINEX.  On 9/18/08 the pt was seen for a 2 day history of severe (9/10) bilateral calf pain.  Of note, the pt did not report that he was also experiencing numbness in both of his feet.  The pt had a temp of 99.0.  Treated with 24 hours of bed rest.  See labs below.   9/19/08 the pt continued to complain of bilateral calf pain.  The pt was was afebrile, VSS.  Overuse MYOSITIS was suspected based upon a mildly elevated CPK and suggestive MRI.  See labs and studies-below.  The pt was put on light duty for the weekend, to follow-up on 9/22/08.  The pt was seen on 9/20/08 for vomiting X 4.  The pt was afebrile, VSS.  The pt denied abdominal pain or diarrhea.  The pt did not mention that he was experiencing numbness over his "entire body".  He was treated with PHENERGAN and SIQ'd for 24 hours.  9/22/08 the pt was seen for his scheduled follow up at 0659.  He denied pain in his legs or further vomiting.  The pt did not mention that he was having numbness and weakness in his upper and lower extremities.  At 1434 the pt  was seen in the Acute Care Clinic stating that "his whole body was numb but mainly his hands and feet."  The pt reported that he still had his URI symptoms.  The provider noted that the pt "was unable to walk normally; he was unable to stand up by self with his crutches and was helped into a wheelchair; no SOB, no respiratory distress; peak flows 250 pre and post ALBUTEROL--pt reports being unable to fully put lips around peak flow meter as lips are numb."  CXR-wnl.  The pt was transferred to military hospital.  A Lumbar Puncture was performed and the results (see below) and clinical presentation were consistent with Guillain-Barre syndrome.  The pt was transferred to civilian hospital.  On 9/23/08 IV IG 400mg/kg was started for 5 days.  The pt had a PICC line and feeding tube inserted on 9/25/08.  On 9/29/08 the pt was discharged from acute care ("with improvement in appendicular weakness; but continues to have significant bifacial and pharyngeal weakness; medically stable with good respiratory function") and transferred to acute rehab.  It was noted that the pt was taking PERCOCET prn for headaches and had taken ZOFRAN for nausea.  On 10/10/08 the pt was discharged from hospital.  It was noted that the pt had recently had "bouts of intermittent migraine headaches and nausea.  The symptoms were noted when the pt was upright and resolved when supine.  It was concluded that they were related to low CSF pressure.  Anesthesia performed a blood patch "that resulted in almost immediate resolution of the patient's symptoms.  Upon discharge the pt was taking DEPAKOTE 500mg qhs for prophylaxis and IMITREX 100mg q2h prn.  The pt was transferred to Military hospital.  At that time he was evaluated by physical therapy: "the pt presents with decreased endurance, flexibility and strength".  He was placed in Med Hold on 10/11/08.  10/16/08 seen by PCP-plan to taper off DEPAKOTE due to elevated LFTs (see labs below).  On 11/7/08 it was noted that the pt has recurrence of his migraine headaches.  LFTs were wnl.  The pt was taken off MAXALT due to ineffectiveness and started on IMITREX prn.  The pt was started on TOPAMAX QD on 11/12/08 due to more than 4 headaches/week.  The pt's migraines have been controlled on TOPAMAX 100mg qd.  On 12/10/08 PT noted: "strength of the upper extremities was normal; no lower extremity weakness was observed".  Symptoms: Headache, Migraine, Weakness, Numbness, Dysphasia, Nausea w/vomiting, Numbness, Muscle Pain, Numbness, Flu-like symptoms >96 hours, Cough, productive.  1/12/09 Reviewed hospital medical records of 9/22-9/29 & 9/29-10/10/2008. FINAL DX: GBS; s/p LP headache & nausea; migrainous headaches. Records reveal patient experienced diffuse weakness, ascending paralysis, bifacial paresis, dysphagia, areflexia, slow motor movements, fetigue,    Tx w/IVIG, feeding tube insertion.  Improved slowly & d/c to inpatient rehab unit & finally to military treatment.  12/31/08  Reviewed military medical records of 9/22/2008. FINAL DX: generalized weakness, greatest BLEs; facial weakness/slurred speech; likely Guillain Barre Syndrome Records reveal patient experienced BLE weakness & numbness & difficulty standing, numbness mainly in feet & hands, tongue & facial numbness. Had bilat calf pain x 3 wks, cough & congestion, bronchitis, itchy watery eyes, chills.  Neuro consult.  BLEs areflexic. LP done.