1. Block 9B

2.  AB, 66M  Married  right-handed  from Cavite  Chief complaint: generalized weakness

3.  1 month prior to admission  Patient complained of severe intermittent low back pain characterized as shooting in character, radiating to bilateral lower extremities. (-) numbness (-) weakness (-) incontinence  Sought consult at PGH Orthopedics  Assessment: Spondylolisthesis L2-L3

4.  2 weeks prior to admission  Patient complained of ascending weakness of bilateral lower extremities, allegedly with no sensory deficits. Still ambulatory but would walk with the aid of a cane.  1 week prior to admission  Can no longer ambulate, wheelchair-bound, weakness up to the thigh level. No associated dyspnea, dysphagia or sensory deficits. There was urinary retention, which eventually resolved.

5.  4 days PTA  Weakness of bilateral upper extremities with no associated dyspnea or pysphagia. (+) anorexia.  Sought consult in PGH

6.  Not known hypertension or DM  (-) PTB, BA, CVD  (+) non-healing wound, right foot (2009)  (-) Food and drug allergy  No previous surgery or hospitalization

7.  (+) HTN  (+) DM  (-) PTB, BA, CVD, HD

8.  Occasional smoker  Heavy alcoholic beverage drinker  Copra farm owner  Lives with children and wife

9. AB, 66/M

10. GeneralAwake, stretcher-bound, not in cardiorespiratory distress Vital Signs:BP: 140/90 HR: 96 RR: 20 T: afebrile HEENTPink conjunctivae, anicteric sclerae, (-)ANM/CLAD/NVE Chest/LungsEqual chest expansion, clear breath sounds, no rales/crackles/wheezes CVSAdynamic precordium, distinct heart sounds, (-) murmur AbdomenFlabby, soft, normoactive bowel sounds, (-) hepatosplenomegaly, (-) masses/tenderness GUEssentially normal Skin/Extremitie s Pink nailbeds, CRT<2 sec,full and equal pulses, (-) edema/jaundice/cyanosis

11.  Alert, opens eyes spontaneously, speaks in sentences, follows commands  Cranial Nerve Examination INot assessed II2-3 mm EBRTL III, IV, VIEOMs intact VBrisk corneals VIINo facial asymmetry VIIIWeber: Lateralizes to L, AD: BC> AC AS: AC>BC IXGood gag reflex XUvula midline XIGood shoulder shrug XIITongue midline

12.  No sensory deficits  Motor Exam: RLRL Shoulder abduction33Hip flexion00 Shoulder adduction33Hip extension00 Elbow flexion44Knee flexion00 Elbow extension44Knee extension00 Wrist flexion44Ankle plantarflexion 00 Wrist extension44Ankle dorsiflexion 00 Gripgood

13.  DTRs: areflexia all extremities  (-) clonus/ Babinski  Supple neck  (-) nystagmus

14. AB, 66/M

15. Lab TestResult CBC2/18: Hgb 82 Hct 0.236 Plt 215 WBC 21.6 N 0.962 L 0.026 M 0.009 E 0.003 2/23: Hgb 83 Hct 0.254 Plt 208 WBC 11.3 N 0.880 L 0.072 M 0.046 E 0.00 Blood Chem BUN 7.19 Crea 67 UA 0.16 Alb 13 HDL 0.25 LDL 2.6 Trig 0.81 Chole 3.22 Mg 0.74 Na 126 K 4.4 Cl 74 HbA1c 5.7 ABGpH 7.461 pCO2 25.6 PO2 86.6 HCO3 18.2 O2sat 97 BE -3.0 PT/PTT12.5/15.4/0.66/1.47; 36.6/40.3 UrinalysisDark yellow, turbid, 1.015, 7.0, (-) sugar, 1+ protein, 1-4 RBC, abundant WBC, few EC, 3+ bacteria, (-) MT/cast/crystal Urine GSPMN 5-10, Gram (+) cocci in pairs> 25/OIF

16. AB, 66/M

17.  Guillain-Barre Syndrome  Complicated UTI, resloving  Sacral decubitus ulcer, grade 2  Multiple electrolyte imbalance, resolving  Spondylolisthesis L2-L3  Dyslipidemia  Anemia, multifactorial  Sensorineural hearing loss, AS

18. AB, 66/M

19.  Ceftriaxone 2g IV OD  Metronidazole 500/cap q6  FeSO4 + FA  Simvastatin 40 mg OD  Celebrex PRN  Lactulose 30 cc BID

21.  Acute inflammatory demyelinating or axonal polyneuropathy  Common cause of acute or subacute generalized paralysis  Mild respiratory or gastrointestinal infection precedes the neuropathic symptoms

22.  Paresthesias and numbness in toes and fingers  Symmetrical weakness, lower extremities before upper extremities  Pain or aching discomfort in muscles often hip, thigh and back  Variable sensory losses  Hypo- or areflexia  Cranial nerve palsies come later  Autonomic function disturbances

26.  Acute spinal cord injury  Poliomyelitis  Carcinomatous meningitis  Botulism  Polyneuropathy of critical illness

27.  Electrodiagnostic studies  EMG- reduction in the amplitude of muscle action potentials, slowed conduction velocity, and conduction block in motor nerves singly or in combination  Prolonged distal latencies and prolonged or absent F- reflexes  CSF examination  Suggestive of demyelination without evidence of active infection  Spine MRI  Lumbosacral area enhancement of nerve roots with gadolinium

28.  Aimed primarily at immunomodulation  Intravenous immunoglobulin (IVIG)  Adults: 2g/kg IV over 2-5 days  Children: 0.4 g/kg/d IV for 5 d; 2 g/kg once or 1 g/kg/d over 2 d  Plasmapheresis may decrease the severity and shorten the duration of GBS  Removal of 200-250 ml/kg of plasma in 4-6 treatments on alternate days or on sgort period if no coagulopathy  Potential complications; autonomic instability, hypercalcemia, bleeding

29.  Consultation with neurologist, rehab,medicine specialist, and intensivist if necessary  Occupational Therapy  Physical therapy  passive movement and positioning of limbs to prevent pressure palsies and, later, mild resistance exercisesoccupational therapist  Prevention of decubitus ulcers