28 year old male with Guillain-Barré syndrome

 

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Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

M. Abhignya.       Roll. No 71.      9th sem

*28 year old male presented with complaints of pain in feet and plams and unable to walk

Patient was apparently asymptomatic till 17th January 2022  when he took 1st dose of  Covishield vaccine that night he developed low grade fever and body pains which subsided on taking medications. Then he went to work for 3 days  where he was exposed to dust then he developed *Fever : which was intermittent and high-grade associated with chills and headache 

*Mild Cough with expectoration 

*Shortness of breath (Grade 4)

*Generalised weakness and body pains

*Decreased appetite 

*Developed tingling paresthesias in both upperlimbs below wrist and lower limbs below ankle then gradually he developed difficulty in walking and  weakness of both the Lower limbs in the form of slippage of slippers without knowledge. 

* Next day he developed difficulty in getting up from sitting position. Initially he was able to walk independently but weekeness gradually progressed and now he requires support of people

*After 2 days he developed weakness in both upperlimbs in the form of difficulty in holding objects , gripping, mixing food while eating. 

*then next he developed  deviation of mouth to right side and inability to close left eye

* Mild difficulty in swallowing and had choking episodes

*Has nasal regurgitation of water 

*No loss of consciousness 

Past history :

No history of similar complaints in the past

Not a known case of  HTN, DM,  CAD,  TB,  Epilepsy

Personal history :

Takes mixed diet

Appetite is normal 

Sleep - reduced due to pain

Bowel and bladder - Burning micturation 

No addictions 

No allergies 

General examination 

The patient was examined in a well-lit room after informed consent was taken.

He is conscious, coherent, cooperative, well oriented to time, place and person. He was well nourished and moderately built.

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

Vitals:

PR: 75bpm

RR: 14cpm

BP: 110/90 mmHg

Temperature: afebrile

Systemic examination:

CNS

HIGHER MENTAL FUNCTIONS:

Oriented to time,place,person

Memory : immediate,recent, remote intact

Speech: slurred

No delusions or hallucinations

CRANIAL NERVES: 

1- not tested

2- counting fingers+

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

 7-

     Mild loss of wrinkling on left side of forehead

      Unable to close left eye completely 

     Nasolabial fold on left side is not prominent 

     Deviation of angle of mouth to right side

8- Normal hearing

9,10-normal

11,12- normal.

MOTOR EXAMINATION:

TONE: Noramal 

Bulk : Normal 

POWER :   Right        Left

Upper limb 4/5              4/5

Lower limb 4/5              4/5

Reflexes : Right                 Left

Biceps:       2+                      2+

Triceps:      2+                      2+

Supinator   2+                     2+

Knee:          3+                     3+

Ankle:          -                         -

Sensory system : Normal

Autonomic nervous system: Normal 

Investigations: