RT, 8/M

Mendoza | Paulino
General Data
RT, 8/M Roman Catholic, right-handed, student, from Quezon
Province.

Chief Complaint: bilateral lower extremities weakness

Informant: Mother
Reliability: 90%
History of Present Illness
1 week PTA, onset of undocumented fever. No other symptoms
were noted. No medications were taken. Fever resolved after 5
days.
One week PTA, onset of bilateral lower extremity weakness, slow
progressing, starting from the feet, then the knee, and hips. This
leads to the patients inability to stand and walk. No trauma, pain,
tenderness, and other constitutional symptoms noted. Also,
reported onset of cough, and colds. Patient was brought to a
private clinic. Blood work was done which is normal.
History of Present Illness
5 days PTA, Patient was then brought to a local hospital. X-ray,
blood work, and urine collected. No noted infections, trauma, and
laboratory works have normal results. Was told to seek consult at
PGH.
On the interim, noted worsening of lower extremities weakness.
DOA: Patient consulted at PGH OPD, noted to have low spO2 and
difficulty of breathing, hence the ER admission.
Review of Systems
(+) - difficulty of breathing

(-) - fever, nausea, vomiting, palpitations, chest pain, abdominal

discomfort, diarrhea, constipation, joint pains, dysphagia, hoarseness
Birth and Maternal History
Born Full Term at home via Spontaneous Vaginal Delivery assisted by a
midwife.
No neonatal complications noted
Mother had antenatal care at the LHC. Regular folic acid, multivitamins,
and calcium carbonate intake.
Unremarkable antenatal period.
Immunization
Only known immunization is for BCG.

No other immunizations were given.

Past Medical
(+) history of previous hospitalization for febrile seizures at 3 years old.
Prior to hospitalization, 2 episodes of generalized tonic-clonic seizures
associated with high-grade fever (undocumented) lasting less than a
minute each with loss of consciousness.
(-) BA, allergies, HTN, DM, Cancer, stroke, TB, bleeding disorders,
No current medications
Family Medical
(+) - hypertension (maternal grandfather)

(-) - DM, BA, Cancer, stroke, TB, bleeding disorders, seizures,

neuropathies
Personal and Social
Lives with grandparents. Parents work on the city

Lives on a rural neighborhood.

Growth and Developmental
At par with age

Currently at Grade 2. No failing grades, and misbehavior incidence.

Very active and playful.
Noted stuttering
Nutritional
Exclusively breastfed for only 1 week.
Mixed feeding of formula milk together with breast milk until 8
months old.
8 months started introduction of soft food

Current diet includes rice, pork, chicken, noodles, processed meat.

Barely eating vegetables, and fruits.

Eat three full meals a day.

Physical Examination
Anthropometrics

Weight: 17.3 kgs

Height: 120 cm

Weight for age (z = -2)

Length for age (z = -1)
BMI 12.01 (z = -2)
Physical Examination
Vital Signs awake, coherent, in cardiorespiratory distress
HR: 100 RR: 32 BP: 90/60 T: 36.8 O2 Sat: 90-92%
HEENT - anicteric sclerae, pink palpebral conjunctiva, no CLADs
Chest and Lungs - equal chest expansion, clear breath sounds
Cardiac - normal rate, regular rhythm, distinct heart sounds, no
murmurs
Abdomen - soft flabby abdomen, no tenderness and masses upon
palpation, intact rectal vault, good squeeze, stool per examining
finger
GU straight phallus with properly positioned meatus, descended
testes
Physical Examination
Extremities - full and equal peripheral pulses, pink nail beds, no
clubbing
Back - no vertebral deformities, ecchymoses and lesions
Skin - no primary or secondary skin lesions
Neuro
Areflexia of lower extremities (patellar, Achilles)
MMT LE, UE
Intact sensation on all dermatomal levels
Unremarkable Cranial Nerves, Meningeals, Cerebellar tests
Acute Flaccid Paralysis
General term used for a group of conditions that presents with abrupt
(<2 weeks) loss of motor function, with loss of muscular tone.

Etiologies could include abnormalities on peripheral nerves,

neuromuscular junction, or the muscle itself.
Differential Diagnoses
Rule In Rule Out

Guillain-Barre Syndrome Lower extremities weakness

Ascending paralysis
History of recent infection
Symmetric progression
Dyspnea
Poor oxygen saturation
Multiple Sclerosis Lower extremities weakness Common in women 20 to 40
Multiple neurologic
complaints (vision
abnormalities, vertigo, )
Differential Diagnoses
Rule In Rule Out

Polymyositis Lower extremities weakness Proximal muscles affected

Symmetric progressive first
Occurs in legs first
Dyspnea
Poor oxygen saturation
Myasthenia gravis Lower extremities weakness Periodic weakness
Dyspnea Worsens through day
Diplopia
Dysarthria
Acute Flaccid Paralysis

Guillain-Barre Syndrome
Primary Working Impression
Guillain-Barre Syndrome
Acute inflammatory demyelinating polyneuropathy

Autoimmune demyelinating disorder

Usually caused by recent viral infection, surgery, stress. Associated with

Campylobacter jejuni infection, and very rarely influenza vaccination

Rapidly progressive bilateral weakness starting from the distal

extremities extending proximally. Presents with absent DTRs, and may
involve respiratory muscles.
Guillain-Barre Syndrome
Mortality rate is <5%
85% of patients make complete or near-complete recovery
Recovery usually takes around 1 year
Management: Diagnostics
Baseline CBC, Serum Electrolytes, Serum CRP, Urinalysis
Lumbar puncture
Increased protein (>55mg/dl), normal pressure, normal glucose, with little or
no pleocytosis (albuminocytologic dissociation)
Nerve Conduction Velocity
Widespread demyelination
Decreased nerve conduction velocity

AFP Surveillance
2 stool samples
For surveillance of Poliomyelitis
Management: Therapeutics
Respiratory - mainly for mechanical support
ET: 5.5 Level: 16
Initial mechanical ventilation settings:
FiO2: 30% RR: 20 PIP/PEEP: 12IT:0.8
Will wean to CPAP 30/4

Daily morning ABG to assess blood pH and compensatory mechanisms:

Titrate mechanical ventilation settings accordingly
Management: Therapeutics
Maintenance fluid: 1385 ml

Feeding
100 CC q3 EBM per NGT
NPO, maintained on heplock feeding

Fluids
IVF: D5NR at 33cc / hr
TFI: 115 (additional 15% due to the mechanical ventilation)
Management: Therapeutics
Medications
IVIG may speed up the recovery
May resolve on its own
Plasmapharesis
Used for very severe cases

Analgesia for neuropathic pain

Patient has no reported neuropathic pain
Management: IVIG
IVIG for D5

Adverse reactions: flushing, chest tightness, dizziness, fever, chills,

nausea, vomiting, hypersensitivity

Monitor every 15 minutes for the 1st hour, every 30 minutes for the
2nd hour, then every hour until the infusion is complete
Watch out for / Complications
Respiratory failure
Blood pressure, heart rate, temperature significant changes
Preventive Medicine
Referral to Rehab Med
Immunization Schedule
Child-proofing the house to suit his needs
Address the nutrition of the patient.