DEPARTMENT OF NEUROLOGY

ALL INDIA INSTITUTE OF MEDICAL SCIENCES

ANSARI NAGAR, NEW DELHI-29

DISCHARGE SUMMARY OPD NO:1

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NAME: MR. ARJUN RAJANI AGE: 69 Y SEX: MALE
UHID NO: 106494054 PHONE NO. 9810049241
WARD: CNT BED: 6008 UNIT: I
ADDRESS: 66, SHEIKH SARAI PHASE-1,NEW DELHI
D.O.A: 3.02.2023 D.O.D: 8.02.2023

DIAGNOSIS:
Acute sensory large fiber neuropathy- Guillain Barre Syndrome
EGRIS 1
HTN

CASE SUMMARY:
A 69/M, Right-handed male, R/o, Sheikh Sarai Phase-1, Delhi, symptomatic
from 30/1/23 with c/o:
1)Acute onset imbalance while walking
2)Tingling sensation in B/L soles & hands since the same period
3)Low-back pain with VAS 8/10 occasionally since the same period

HOPI: Patient was apparently alright till Sunday, 29/1/23, after which on
Monday 30/1/23, after waking up in the morning at 7 am, he experienced
imbalance while walking, walked with cautious & broad, ataxic gait.
Initially he required no support to walk, even went for his morning walk.
However, by Tuesday 31/1/23, he started requiring intermittent support
while walking for more than 5-6 steps 7 experienced difficulty in climbing
up & down-stairs & using western toilet & getting up from sitting position
in the form of difficulty balancing himself.
He also experienced tingling sensation in B/L soles & hand since the same
period.
The difficulty in walking increased if visual cue was removed. There was
positive wash-basin sign.
No h/o weakness/slippage of chappal/difficulty in breaking roti/ buttoning/
unbuttoning shirt/ giving any object overhead.
No H/O difficulty in turning over in bed/ neck holding/ shortness of
breath.
No H/O sensory impairment/ difficulty in perceiving hot & cold sensation/
pain anywhere.
H/O LBP occasionally with VAS 8/10 since the same period with disturbing
sleep pattern+.
No h/s/o cranial nerve involvement.
No H/O tremulousness in upper limb/ lower limb.
No H/O bladder, bowel involvement, orthostatic C/S.
H/O URTI with dry cough 1-2 weeks prior to event present. H/O travel to
Gujarat recently prior to event.
No history of joint pain, rash, oral ulcer, jaundice, CAD.
No H/O significant fever/weight loss/ swelling/ lump/ diarrhea.
No recent H/O vaccination.
No H/O wasting, fasiculations, cramps+.

PAST HISTORY:

H/O HTN under regular treatment for the same (Tab Losar- H in morning,
Losar at night).
No H/O T2DM/ Hypothyroidism/ Bronchial asthma/ Epilepsy/ stroke/ CAD.
No past such episode.
NCS (2/2/23): MNCS: Reduced CMAP with prolonged distal latencies & reduced
CV in both tibial nerves.
SNCS: W/N/L.
F waves: Prolonged in B/L Tibial & Peroneal nerves.
H Reflex: Absent on Left side, reduced on Right side.

MRI Brain & Spine (2/2/23): W/N/L

PSA (15/12/22): 3.69
PSA (29/12/22)= 0.38

PERSONAL HISTORY:
----------------
Non-vegetarian
No addiction
Normal appetite, sleep, bladder, bowel pattern.

FAMILY HISTORY:
--------------
H/O MND-ALS in brother, who died untimely.

EXAMINATION
GENERAL EXAMINATION
-------------------
BP:150/76 mmHg on admission, 134/80 mm Hg on discharge PR:90/min.
PALLOR: ABSENT CLUBBING: ABSENT CYANOSIS: ABSENT
LYMPH NODES: ABSENT PEDAL OEDEMA: ABSENT
ICTERUS: ABSENT
CVS: s1s2 normal heard
RESPIRATORY System: BL NVBS heard
P/A: soft, nontender, no organomegaly

NERVOUS SYSTEM:
--------------
HMF : Conscious, oriented to time/place/person
MMSE : 30/30
CRANIAL NERVES: Pupil BL NSNR
FUNDUS: Normal disc
EOM: full
Rest all CN are WNL
SBC= 35
No skin & nail changes+

MENINGEAL SIGNS: Absent

Neck= Flexion & Extension Full

MOTOR EXAMINATION: RIGHT LEFT

----------------- ----- ----
BULK : Bilateral symmetrical
No atrophy/hypertrophy
TONE : UL-Reduced UL-Reduced
LL-Reduced LL-Reduced
POWER : UL
Shoulder 5/5. 5/5
Elbow. 5/5. 5/5
Wrist. 5/5. 5/5
 Hand grip 100% 100%
LL
Hip. 5/5. 5/5
Knee. 5/5. 5/5
Ankle. 5/5. 5/5

CO-ORDINATION : B/L UL slightly impaired FNF, FC

B/L HSH grossly impaired
Tandem impaired

ABNORMAL MOVEMENTS: Nil

SENSORY EXAMINATION: Normal P/T/T

Early decay of Vibration & impaired JPS+

REFLEXES
--------

DEEP TENDON REFLEXES: -RIGHT LEFT

BICEPS : +1 -

TRICEPS : - -

SUPINATOR : +1 -

KNEE : - -

ANKLE : - -

SUPERFICIAL REFLEXES RIGHT LEFT

-------------------- ----- ----
CORNEAL : present
ABDOMINAL : present
PLANTAR : B/L Flexor
OTHERS :

FRONTAL RELEASE REFLEXES : nil

CEREBELLAR SYSTEM : Impaired B/L LL
GAIT : Ataxic gait, cautious gait
Tandem impaired
Romberg Positive
SKULL & SPINE : Normal
OTHERS :

INVESTIGATION
HEMATOLOGY

Hb (SLS-photometry) 13.40 g/dL 12.0 - 15.0

Hematocrit (Direct Measure) 35.30 % 40 - 50
RBC count (Impedance) 4.58 10^6/μL 3.8 - 4.8
WBC count (Fluo. flow cytometry) 7.95 10³/μl 4.0 - 10.0
Platelet count (Impedance) 341.00 10^3/μL 150 - 410
MCV (Calculated) 77.10 fL 83 - 101
MCH (Calculated) 25.80 pg 27 - 32
MCHC (Calculated) 33.40 g/dL 31.5 - 34.5
RDW-CV (Calculated) 14.20 % 11.6 - 14
Neutro (Fluo. flow cytometry) 61.00 % 40-80%
Lympho (Fluo. flow cytometry) 24.00 % 20-40%
Eosino (Fluo. flow cytometry) 3.00 % 1-6%
Mono (Fluo. flow cytometry) 8.50 % 2-10%
NRBC 0 %
Baso (Fluo. flow cytometry) 0.40 % 0-1%
Neutro - Abs (Calculated) 5.56 10³/μl 2.0-7.0
Lympho- Abs (Calculated) 2.38 10³/μl 1.0-3.0
Eosino - Abs (Calculated) 0.27 10³/μl 0.02 - 0.5
Mono - Abs (Calculated) 0.77 10³/μl 0.2 - 1.0
Baso - Abs (Calculated) 0.04 10³/μl 0.02 - 0.1

BIOCHEMISTRY

Urea (Urease/GLDH) 44 mg/dL 17 - 49

Creatinine (Jaffe compensated) 0.9 mg/dL 0.5-0.9
Uric Acid (enzymatic colorimetric) 5.1 mg/dL 2.4-5.7
Calcium (5-Nitro-5'-methyl-BAPTA) 9.0 mg/dL 8.6 - 10.2
Phosphorus (molybdate UV) 4.2 mg/dL 2.5-4.5
Sodium (Ion Selective Electrodes) 138 mmol/L 135 - 145
Potassium (Ion Selective Electrodes) 5.7 mmol/L 3.5-5.1
Chloride (Ion Selective Electrodes) 105 mmol/L 98-107
Bilirubin (T) (Colorimetric diazo) 0.88 mg/dL 0 - 1.2
Bilirublin (D) (Diazo Gen.2 Jendrassik-Grof) 0.25 mg/dL 0 - 0.2
Bilirubin (I) (Calculated) 0.63 mg/dL 0 - 0.9
ALT (IFCC without pyridoxal phosphate) 16 U/L <=33
AST (IFCC without pyridoxal phosphate) 37 U/L <=32
ALP (IFCC) 67 U/L 35 - 104
Total protein (Biuret) 8.0 g/dL 6.4 - 8.3
Albumin (BCG) 4.0 g/dL 4.0 - 4.9
Globulin (Calculated) 3.0 g/dL 3.0 - 3.7
A/G ratio (Calculated) 1.2 0.8-2.0
 < 10 ng/ml (Severe deficiency)
25 oh
7.0 ng/mL  10 - 25 ng/ml (Mild to moderate
Vitamin D Deficiency)
 25 - 80 ng/ml (Normal)
 3.5 - 20.5 ng/mL
Folate 4.05 ng/mL
 < 3.5 ng/ml (Deficient)

Active B 12
>  25.1 - 165 pmol/L
236.0 pmol/L

Thyroid profile
T3. 124  0.58 - 1.59 ng/ml
T4. 7.8  4.87 - 11.72 ug/dL
TSH. 0.68  0.35 - 4.94 ulU/ml

HbA1c (Turbidimetricinhibitionimmunoassay(TINIA)) 6.25 %

Serum VDRL= Sent, pending

HIV Combo (HIV 1, 2) (ECLIA) 0.26 COI < 1.0 Non Reactive
≥ 1.0 Reactive
Anti HAV IgM (ECLIA) 0.32 COI < 1.0 Non Reactive
≥ 1.0 Reactive
HBs Ag (ECLIA) 0.37 COI < 1.0 Non Reactive
≥ 1.0 Reactive
Anti HBs (ECLIA) 2.62 IU/L < 10.00 Non Immune
≥ 10.00 Immune
IgM Anti HBc 0.06 COI < 1.0 Non Reactive
≥ 1.0 Reactive
Anti HCV Ab (ECLIA) 0.04 COI < 1.0 Non Reactive

iPTH= 10.9
Free PSA= 0.1
CRP= 2.6
Iron= 112
Transferrin= 216
Ferritin= 250
TIBC= 276
LDH= 206
Homocysteine= 26.10
CK= 82
Mg+2= 2.1
URINE R/M= No active sediment
URINE C/S= Sterile

PET CT pending, dated on 15/2/23

USG (W/A + KUB+ Thyroid+ Testis) = W/N/L

CXR PA View= W/N/L
ECG 12 Leads= W/N/L
SPEP= No M Band seen
UPEP= No M Band seen

ANA, ENA, ANCA, anti-dsDNA, ACL= reports pending

NCS (3/2/23): MNCS: Reduced CMAP in B/L Tibial nerve with normal distal
latency & CV.
SNCS: W/N/L
F Wave: Prolonged in B/L Tibial nerve.
H Reflex: B/L Absent.

DISCUSSION:
A 69 year old gentleman, K/C/O HTN on adequate treatment, presented with a
prodrome of dry cough & URTI 1 week prior to an acute- subacute event of
progressive imbalance while walking associated with positive sensory
phenomena in the form of tingling & paresthesias underneath her sole & in
her hands since 30/1/23. This progressed over the next 2-3 days such that
he required 1 person support to walk more than 5-6 steps, climb up & down
stairs, get up from a chair & stand up after using toilet. This was
associated with intermittent excruciating low-back ache with VAS 8-9/10,
which disturbed his sleep at night. NCS done outside on 2/2/23 showed
reduced CMAP with prolonged distal latencies & reduced CV in both tibial
nerves. SNCS: W/N/L. F waves: Prolonged in B/L Tibial & Peroneal nerves. H
Reflex: Absent on Left side, reduced on Right side. MRI Brain & spine done
outside were W/N/L. He presented to us in our OPD on 3/2/23, where on
examination, he was grossly ataxic with positive Romberg’s sign & signs of
sensory large fibre ataxia (diminished joint positive sense & early decay
of vibration sense) with generalized hypo-areflexia & hypotonia. NCS
repeated in our institute revealed reduced CMAP in B/L Tibial nerve with
normal distal latency & CV. SNCS: W/N/L F Wave: Prolonged in B/L Tibial
nerve. H Reflex: B/L Absent. He was admitted with a provisional diagnosis
of GBS, Acute Sensory large fibre neuropathy. He was started on 5 day
course of IVIG- 164 gm total. He reported 30- 40% diminution in his
positive sensory complaints post IVIG. Investigations to rule out secondary
causes of large fibre & dorsal root ganglia were sent, including Autoimmune
profile, monoclonal gammopathy work-up. To rule out any occult malignancy
PET CT was planned & dated on 15/2/23. USG (W/A+ KUB+ Thyroid+ Testis), CXR
were W/N/L. Serum & Urine protein electrophoresis were negative. HTN was
controlled with additional anti-HTN. He is being discharged with stable
vitals & will be followed up in our OPD after 1 month to see subsequent
improvement in his C/S.

ADVISE ON DISCHARGE:
1. Tab Losar-H (50/12.5) mg OD at 8 am in morning
2. Tab Losar 50 mg OD at 8 pm in evening
3. Tab Amlodipine 5 mg BD
4. Tab ME-12 1 tab OD
5. Cap Lumia D3 60 K once/ week
6. Physiotherapy, gait & balance training
7. Salt restricted diet
8. BP monitoring at home twice daily

Follow up in NEUROLOGY OPD after 1 month with, Prof. M. V. Padma, NEUROLOGY

Faculty & HOD in room no: 1 on after prior appointment with ANA, ENA, ANCA,
anti-ds DNA, ACL, Serum VDRL, PET CT reports, BP charting.

Review in Endocrinology OPD in view of HTN

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Dr Sohini Chakraborty

SR NEUROLOGY

AIIMS NEW DELHI