2. Particulars of the patient
• Name : Anas
• Age : 11 years
• Sex : Male
• Address : Comilla
• Date of admission : 13.03.17
• Date of examination : 13.03.17
• Informant : Mother
4. History of present illness
According to the statement of the patient’s mother, her
son was reasonably well 10 days back. Then he
developed weakness of lower limbs, which was
ascending in nature, and involving the upper limbs on
the following day. Due to his weakness, he fell from the
staircase and was hurt in his head and legs 7 days back.
Weakness was symmetrical & not associated with loss
of bowel & bladder control. He had also complains of
difficulty in swallowing for the last 5 days.
5. History of present illness (cont.)
There was a H/O URTI 2 weeks prior to the onset of
illness. He had no H/O fever, trauma, diarrhoea,
convulsion, breathing difficulties or such type of illness
in the past. There is no H/O recent vaccination. With
above complaints he got admitted in BSMMU for
further evaluation & management.
6. History of past illness
H/O URTI 2 weeks prior to this illness.
7. Birth history
• Antenatal: Mother was on irregular antenatal check
up.
• Natal: Delivered by NVD at term at home without
any complications.
• Postnatal: Uneventful
11. Family history
• He is the 3rd issue of his non-consanguineous
parents.
• No H/O same type of illness in family or community.
12. Socioeconomic history
• Belongs to lower middle class family.
• Father used to work abroad, now he is unemployed
& mother is a homemaker.
• Lives in a tin-shed house.
• Uses sanitary latrine.
• Drinks tube-well water.
18. General examination (cont.)
Anthropometry
• Height: 148 cm
(Lies on 75th centile)
• Weight: 45 kg
(Lies between 75th to 90th
centile)
• BMI 21 kg/m2
(Lies between 85th to 90th
centile)
20. Nervous system
• Higher psychic function:
– State of consciousness - conscious, GCS 15/15.
– Orientation - Orientated to time, place and person.
– Memory and intelligence - Normal.
– Speech - Normal.
– Behaviour – Normal.
• Cranial nerves:
– Facial nerve bilateral LMN type palsy and bulbar palsy
– Others: no abnormality detected
21. Nervous system (cont.)
Motor system
Upper limb Right Left
Bulk Normal Normal
Tone Diminished Diminished
Power 4/5 4/5
DTR Diminished Diminished
Co-ordination Intact Intact
Involuntary
movement
Absent Absent
22. Nervous system (cont.)
Motor system
Lower limb Right Left
Bulk Normal Normal
Tone Diminished Diminished
Power 3/5 3/5
DTR Diminished Diminished
Plantar response Flexor Flexor
Co-ordination Intact Intact
Involuntary
movement
Absent Absent
23. Nervous system (cont.)
• Sensory System: Intact.
• Cerebellar Function Test: Intact.
• Gait: Normal.
24. Locomotor system
• Look:
– No joint swelling.
– No redness.
– No deformity or periarticular muscle wasting.
• Feel:
– Local temperature: normal.
– Joint tenderness: present.
• Move:
– Movement was not restricted.
Joints Wrist Elbow Knee Ankle
Tenderness absent absent 2/4 absent
25. Respiratory system
• Inspection :
– Shape of chest - normal
– Respiratory rate - 20 breath/min
– SPO2 97% without O2
– Single breath count test – 25
– Movement of the chest - symmetrical
– Intercostal recession - absent
– Visible pulsation - absent
30. Salient feature
Anas, 11 year old boy, 3rd issue of non-consanguineous
parents, immunized, hailing from Comilla, presented
with the complaints of weakness of all four limbs for 10
days, which was symmetric & ascending in nature. He
also developed dysphagia for last 5 days. He had H/O
URTI 2 weeks prior to onset of illness. He had no
history of incontinence of bowel & bladder, fever,
trauma, recent vaccination, gastroenteritis or
breathing difficulties.
31. Salient feature (cont.)
On examination Anas was conscious, co-operative,
vitals within normal limit, anthropometrically well-
thriving, bulk of the muscles of all four limbs was
normal with symmetrical hypotonia, decreased muscle
power 4/5 in upper limbs and 3/5 in lower limbs,
diminished DTR of all limbs, flexor plantar response,
sensory intact, bulbar palsy with bilateral lower motor
neuron type of facial nerve palsy present. Arthralgia of
both knee joint present. Other systems were normal.
35. Points in Favour
Acute Flaccid Paralysis:
Age suggestive
Duration of illness 10
days
Weakness of all four
limbs
Hypotonia
Diminished muscle power
of all four limbs
Deep tendon reflexes-
Diminished
Guillain-Barre
Syndrome:
H/O URTI 2weeks prior
to this illness
Symmetrical ascending
flaccid paralysis
Cranial nerve
involvement
36. Transverse Myelitis
Points in Favour:
• (Acute flaccid paralysis)
Age suggestive
Duration of illness 2 weeks
Weakness of all four limbs
Hypotonia
Diminished muscle power
of all four limbs
Deep tendon reflexes-
Diminished
• H/O URTI 2weeks prior to
this illness
Points against:
Intact sensory system
No bowel bladder
involvement
Cranial nerve involvement
38. INVESTIGATIONS (contd.)
• CSF study :
Colour- Watery, Appearance- Clear
Total cell count (WBC) – 2 cells/cumm
(Lymphocytes 100%)
Protein- 94 mg/dl
Sugar- 3.9 mmol/l
Microorganism & AFB - Not found
39. INVESTIGATIONS (contd.)
• Nerve conduction study - Acute motor
polyradiculoneuropathy that is axonal in nature.
• Stool for wild polio virus detection
42. Follow-up on Day 2 (14.03.17)
Subjective Objective Assessment Plan
Pain in lower
limbs
Pt is concious, oriented
Vital signs:
RR - 20 b/min
Pulse – 92/min
BP- 110/80 mm of Hg
(SBP 50th-90th, DBP
90th-95th centile)
Motor examination:
Both UL & LL- Tone
diminished
Jerks-reduced
Power-3/5 in LL, 4/5 in
UL
Sensory - intact
Planter response -
Flexor
Bowel - moved
?Neuropathic pain Tab. Gabapentin
Tab. Ibuprofen
43. Follow-up on Day 3 (15.03.17)
Subjective Objective Assessment Plan
No new
complaints
Pt is concious, oriented
Vital signs:
RR - 22 b/min
Pulse - 96/min
BP- 125/90 mm of Hg (SBP
95th-99th, DBP >99th)
Motor examination:
Both UL & LL- Tone
diminished
Jerks-reduced
Power-3/5 in LL, 4/5 in UL
Sensory - intact
Planter response - Flexor
Bowel – moved
HTN
(Autonomic
involvement)
Add
antihypertensive -
Nifedipine
45. Follow-up on Day 11 (23.03.17)
Subjective Objective Assessment Plan
No new
complaints
Pt is concious, oriented
Vital signs:
Temp. 98°F
RR - 22 b/min
Pulse - 86/min
BP- 100/70 mm of Hg (SBP
<50th, DBP 50th-90th centile)
Motor examination:
Both UL & LL- Tone
diminished
Jerks-reduced
Power-4/5 in LL, 4/5 in UL
Sensory – intact
Cranial nerves- Intact
Planter response - Flexor
Bowel - moved
Improving Hold
antihypertensive
46. Follow-up on Day 13 (25.03.17)
Subjective Objective Assessment Plan
No new complaints
(Antihypertensive
free for 2 days)
Pt is concious, oriented
Vital signs:
Temp. 98°F
RR - 18 b/min
Pulse - 88/min
BP- 100/65 mm of Hg (SBP
<50th, DBP 50th-90th centile)
Motor examination:
Both UL & LL- Tone
diminished
Jerks-reduced
Power-4/5 in LL, 4/5 in UL
Sensory – intact
Cranial nerves- Intact
Planter response - Flexor
Bowel - moved
Improving Discharge with
advice