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Examination

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History

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  • Demographic Information:

    The patient is a 38-year-old man diagnosed with Guillain Barré syndrome (GBS).

  • History of Present Illness:

    Approximately 4 weeks before his admission the patient began to notice sensory changes and distal weakness in his hands and feet following an upper respiratory infection. He also reported weakness of his arms and midline neck pain that radiated into both arms. During the acute care phase of his hospitalization, the patient was treated with two rounds of intravenous immunoglobulin (IVIG) infusions. Over a period of 3 weeks, his weakness progressed proximally through both legs and arms to his trunk and facial muscles. He was transferred to an inpatient rehabilitation facility for intensive speech, occupational, and physical therapy to maximize his communication skills, functional mobility, and ability to perform activities of daily living (ADL) before returning home with his family. At time of admission to inpatient rehabilitation, complications included atrial fibrillation, autonomic dysfunction, aspiration pneumonia, hyponatremia, panic attacks, dysphasia (requiring placement of a percutaneous endoscopic gastrostomy [PEG] tube and continuous feedings), and a 20-pound weight loss.

  • Medications:

    • Enoxaparin 40 mg to prevent blood clots

    • Ocular lubricant one drop each eye every 12 hours to prevent dry eyes

    • Lansoprazole 30 mg for acid reflux

    • Lisinopril 10 mg for autonomic dysfunction

    • Metoprolol 50 mg for autonomic dysfunction

    • Pregabalin 25 mg for neuropathic pain

    • Promethazine 25 mg for nausea/vomiting

    • Acetaminophen-oxycodone 325 mg for pain as needed (PRN)

    • Bisacodyl 10 mg for constipation PRN

    • Hydromorphone 1 to 2 mg for pain PRN

    • Lorazepam 0.5 to 1 mg for anxiety PRN

    • Metoclopramide 5 mg for nausea PRN

  • Diagnostic Tests

    • Lumbar puncture: elevated protein level consistent with GBS

    • Magnetic resonance imaging (MRI) of cervical spine: C7 neural foraminal narrowing indicating radiculopathy (right greater than left); mild canal narrowing at C6–C7 without cord impingement

    • Computerized tomography (CT) scan: atelectasis of lower lobe of the left lung

    • Modified barium swallow: good swallowing and control of yogurt and pudding (i.e., thick semisolid material); less than optimal handling of nectar thick and thick liquids with anterior penetration and significant tracheal aspiration

    • Electrocardiogram (EKG): atrial fibrillation

  • Medical History:

    • Before the onset of GBS, the patient's medical history was unremarkable.

  • Social History:

    The patient lives with his wife and two children, age six and three. They live in a one-story ranch style home with one stair to enter. The bathroom has a walk-in shower with grab bars. His wife is able to provide intermittent physical assistance and supervision. The patient is self-employed doing home remodeling and landscaping. He enjoys yard work and going out to dinner with his wife and friends.

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Systems Review

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  • Cardiovascular/Pulmonary:

    • Temperature: 97.88°F (36.6°C)

    • Pulse: 100 beats per minute

    • Blood pressure: 129/88 mmHg

    • Respirations: 16 breaths/minute

    • Oxygen saturation: 91% (room air)

  • Integumentary:

    • Skin is intact; however, patient has very little adipose tissue over bony prominences and is at high risk for skin breakdown.

  • Musculoskeletal:

    • Height: 5 ft, 9 in.

    • Weight: 124.5 ...

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