Cases for finals #3 – Examination

Speech – normal

HMF – normal

Cranial nerves – normal

Limbs

  • Tone – normal
  • Power – 4/5 weakness distal ULs; 3/5 hip flexion; 2/5 distally
  • Reflexes – absent
  • Sensation – normal

Gait – unable to walk without tripping

Okay, so this chap is in big trouble.

Flaccid paralysis is the main problem (tone normal) and it is so severe that he can scarcely walk. 3/5 means you can easily overcome him on the bed and 2/5 means he can’t beat gravity.

The lack of reflexes is key – you might be shit at reflexes but you’re can’t be that shit! Also, even if you are, the story is very worrying and you are almost there from the history alone.

The lack of bladder and bowel dysfunction suggests spinal cord is unlikely.

Diagnosis – Acute Inflammatory Demyelinating Polyneuropathy (AIDP) aka Guillain-Barre Syndrome

Management:

  • Funnily enough, it’s the ABC, SALT, senior/specialist review thing again. Don’t be winging this one!
  • You might want to check some bloods including inflammatory markers, really looking for biochemical anomalies that can affect nerve function (hypocalcaemia) or systemic vasculitis (raised ESR, CRP). All of this is unlikely.
  • In practice, we often end up scanning the spine, even if the signs point to GBS. We usually perform an LP, looking for CSF with very few white cells but an elevated protein.
    NCS can be very helpful BUT, alas, if the LP and NCS are done too early, they can be falsely reassuring.
  • We tend to treat with IVIG now and a proportion of patients will need ICU and ventilatory support – so please be careful with them.

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