27y/o with weakness and tingling sensation of hands and feet

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A 27 year old male, waiter by occupation, presented with complains of pain and burning sensation in his soles since 3days. 

History of presenting illness: 

Patient was apparently asymptomatic 50 days back. 

• He begins his list of complaints from 17th of January, when he got his COVID 19 vaccine (COVISHIELD). He reported fever and generalized weakness that night. 
• He took TAB.DOLO 650mg and fever came down the next morning (18th Jan) 
• From 19-21st Jan, he was active and was helping his friend set up his pharmacy, where he claims to have been exposed to a lot of dust. He developed cough, insidious in onset, productive in nature, purulent sputum, no h/o blood staining. He used a syrup(unknown) for cough but it didn’t subside. During this period, he also experienced loss of appetite and claims to not have eaten anything from 22nd-31st Jan. He distinctly remembers an episode where he tried to drink water and couldn’t hold it in his mouth and he felt like it came out of his nose.
• On 31st Jan, he went to get an Chest X ray for his cough. At this point, he could walk and perform his normal activities. 
• On Feb 1st, he experienced tingling sensation in his hands below his wrist and feet below his ankle, generalized body pain, headache and back pain. 
• On Feb 4th, he went to a neurologist and got a CT done, there were no abnormal findings. 
• 5th Feb, there was deviation of mouth towards right and he couldn’t close his left eye.From 1st -5th Feb, he could walk with support. 
• Since there was no relief from the tingling sensation, pain and burning sensation in his hands and feet, on 8th Feb, he went to NIMS in an ambulance. At this point, he couldn’t stand, walk or sit without support. 
• On 9th Feb, his backache got so severe that he couldn’t sit and since he couldn’t swallow, Ryle’s tube was inserted and feeds were started. 
• On 10th of Feb, he says the pain in his hands and feet increased on touch . 
• On 11th of Feb, he was given IVIG. And he says after a couple of days, he didn’t feel that weak but the tingling sensation and pain persisted. He was asked to take physiotherapy but his attenders say he refused,citing too much pain. 
• He was discharged from NIMS on 24th Feb. His attenders say he still complained of pain  during discharge and he was told that the pin would remain for a few months. 
• Since 1 week now, he’s complaining of burning sensation in his hands below wrist and feet below ankle and is unable to walk on his own. Requires two people to support him to walk. He is unable to mix his food or button his shirt and grasp things. 
• His mother says that as a child he never walked properly, he used to drag his feet and used to fall often. 

No history of diarrhoea, no difficulty in raising hand above head, no bowel/bladder incontinence, no breathing difficulty, no ophthalmoplegia. 

Past history: 

He was never diagnosed with Diabetes, Hypertension, thyroid disorders, epilepsy or TB. 

Family history: 

His mother was diagnosed with Diabetes mellitus and is on regular medication for it. 

No similar complaints in the family. 

Treatment history: 

1. Tab. PREBAGA NT 75/10mg BD

2. Tab. TOLPERITAS D TID 

3. OPTINEURON OP

4. Physiotherapy 

Personal history: 

Diet: mixed, doesn’t like consuming milk and curd. Only consumes chicken. 

Appetite: previously decreased, now better and less tolerance for spice 

Sleep: Adequate 

Bowel and bladder movement: Regular 

General examination: 

Patient is conscious, coherent and Irritable if anyone touches him. 

He is lying supine on the bed. 

Mild pallor present. 

No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy or edema. 

Temp: afebrile 

PR: 88bpm

BP: 130/70 mm hg 

SpO2: 98% at RA 

GRBS: 103 mg/dl

CVS examination: 

S1 S2 present 

No murmurs, thrills. 

Respiratory System examination: 

Bilateral Airway Entry present. 

No wheeze, dyspnoea or adventitious sounds. 

CNS: 

HMF: intact. Conscious. 

Tone:   R.     L

UL.     N.      N 

LL.     N.      N 

Power:  R.     L

UL.       5/5.  5/5

LL.       5/5.  5/5

Cranial nerve examination: 

VIIth: cannot blow, whistle. 

Deviation to right side on smiling. 

Deviation of mouth to the right side and unable to close left eye. 

Reflexes:    R.     L

B.               ++.     ++

T.               +.     + 

S.               ++     ++

K.               ++    ++

A.             Couldn’t elicit

Investigations:

Chest X ray

ECG

BGT:  O positive 

Hemogram: 

Hb: 13.5

TLC: 14,900

N: 77

L: 13

Plt: 6.66

CUE: 

Colour: reddish 

Albumin: ++++

Sugar: nil

Pus cells: 6-8

Epithelial cells: 2-4

RBCs: 10-12

Bacteria present.

RFT: 

S. Creat: 0.9

Na: 131

K: 4.0

Cl: 98

UA: 3.4

LFT: 

Tb: 1.17

DB: 0.31

SGOT: 40

SGPT: 155

AlkP: 427

Total proteins: 6.9

Albumin: 3.5

A/G: 1.03

Diagnosis: 

Guillain Barre Syndrome 

Treatment: 

1. Tab. ULTRACET 1/2 QID

2. Tab. Pan 40mg PO/OD 

3. Tab. Supra dyn PO/OD

9/3/22 

Ward   

S:- complaints of weakness and tingling sensation in hands below wrist and feet below ankle 

O:-

Patient is conscious, coherent, cooperative

No signs of pallor, icterus, cyanosis, lymphadenopathy, pedal edema

BP- 130/70mmhg

PR- 75 bpm

RR- 20 cpm

CVS- S1,S2 heard, no murmurs, 

Respiratory system:- BAE + , Nvbs heard

P/A :- soft, non tender

CNS  :-     R.         L

Tone.       N.         N

Power.      N.        N

Reflexes  

    Biceps  2+.      2+

    Triceps. 2+.       2+

     Supinator 2+.     2+

     Knee       2+.       2+

     Ankle.     Couldn’t elicit due to pain 

Plantar - Flexor

Finger nose coordination:- present, no past pointing

GRBS: 105 mg/ dl

A:- Guillain Barre syndrome ( resolving)

P: 

1) TAB, ULTRACET 1/2 tab QID 

2. TAB. PAN PO/ OD

10/3/22 

Ward   

S:- complaints of weakness and tingling sensation in hands below wrist and feet below ankle and complaints of stiffness in his hands since yesterday night 

O:-

Patient is conscious, coherent, cooperative

No signs of pallor, icterus, cyanosis, lymphadenopathy, pedal edema

BP- 130/100mmhg

PR- 86 bpm

RR- 19 cpm

CVS- S1,S2 heard, no murmurs, 

Respiratory system:- BAE + , Nvbs heard

P/A :- soft, non tender

CNS  :-     R.         L

Tone.       N.         N

Power.      N.        N

Reflexes  

    Biceps  2+.      2+

    Triceps. 2+.       2+

     Supinator 2+.     2+

     Knee       2+.       2+

     Ankle.     Couldn’t elicit due to pain 

Plantar - Flexor

A:- Guillain Barre syndrome ( resolving) and ? Bell’s palsy 

P: 

1) TAB, ULTRACET 1/2 tab QID 

2. TAB. PAN PO/ OD

Psychiatry referral (10/3/22)