Age: 60.0
Sex: M
Vaccine: TDAP, TDAP
Symptoms: Asthenia, Blood immunoglobulin G, Blood immunoglobulin M, CSF glucose, CSF protein
Clinical narrative: 7/18/2006 sore throat x 4 days, weakness in both legs. Dx: Guillain Barre syndrome. 7/19/06 progressive weakness in legs and hands. 7/19/06 Hospital; 8/5/06 discharged to extended care.  08/23/06-received from Dr:  office note 7/18/06: Returned to office on this date after Tdap on 7/7/06:  C/O sore throat for 4 days weakness both legs.  Quick Strep no results documented.  PE: patellar to ankles DTR absent        motion: leg extension, toe extension and plantar flexion all seen to be WNL        able to walk on toes without difficulty.  Impression: acute pharyngitis with weakness in legs, consider Guillain Barre although no objective signs at this time.   DC Summary from DOS: 7/19-8/5/06  Reason for admission: weakness  Chief Complaint: acute onset of progressive weakness. On [[name]] of admissions woke up and noted tingling and weakness in his hands, dropped bar of soap several time while showering. Continued to have weakness in lower extremities.   Received DPT booster 7/7/06 and also exposed to gastroenteritis.  DC DX: Guillain Barré syndrome  DC to extended care facility. Hospital Course: difficulty walking and raising his arms (right worse than left) above his head due to weakness, numbness in toes and finger tips as well as "tightness" in calves and thighs. Denies SOB, recent tick bits, bowel or bladder incontinence. No headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty or difficulties producing or comprehending speech. Denied fever, chills, night sweats, recent weight loss or gain, cough, chest pain or tightness, palpitations, nausea, vomiting, diarrhea, constipation or abdominal pain, change in bowel or bladder habits, dysuria, arthralgias or myalgias.  PE: WNL. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses bilaterally.  Neurologic: WNL: thigh adduction and abduction 5/5/ bilaterally. Foot inversion and eversion 4/5/ bilaterally, neck extensors and flexors 5/5 bilaterally.  Sensory: diminished JPS to but not large amplitude movements at the great toes bilaterally. Loss of vibratory sense to the level of medial malleoli bilaterally, stocking and glove distribution diminution of pinprick and cold sensation bilaterally.  Coordination: no intention tremor, dysdiadochokinesia noted. No dysmetria on FNF bilaterally (with elbow supported).   Plantar response was mute bilaterally.  Gait: slowed initiation, wide based essentially he locked the kneeds and waddled, appeared very unsteady.  Exam on DC:   DTRs absent, Sens: LT L>R in feet, equal o/w  Coor-FNF dysmetric but in proportion to weakness  CSF: protein 69, glucose 60, WBC 1 RBC 2, Poly 18, Lymphs 59, Monos 24.  HX, exam findings lab results consistent with a diagnosis of Guillain-Barre Syndrome, inciting source was nto found, with mycoplasma IgM negative, Lyme negative, C jejuni IgG negative.  DC to rehabilitation facility. Per information received from the annual follow up, he still has muscle weakness but improving.   Per 60 day follow up: 11-3-06 continues rehab. 3x/ week continues fatigue, can walk up and down stairs. This patient has a physician visit scheduled for February.