DIAGOSIS: Guillain - Barre syndrome
The patient is a 21- year- old Saudi male who was admitted in April 1995 to King Faisal Specialist Hospital & research center and diagnosed with acute Guillain – Barre syndrome. At that time he had a history of weakness that started while playing football. A few hours later he developed calf pain and then had an ascending paraalysis that led to quadriplegia. The patient was admitted to the hospital and underwent evaluation and was diagnosed with acute Guillain – Barre syndrome and treated. The past medical history at that time was significant for a probable diagnosis of polio at age five. Since that time, the patient improved and became able to walk independently. His nerve conduction improved.
I began seeing this patient on 14 May 1997 and at that time the patient reported that he was ambulating independently, however he had residual distal weakness. His motor examination at that time revealed a deltoid strength of 5, biceps 5, triceps 5, wrist extensors 4, wrist flexors 4, finger flexors 4, iliopsoas 5, quadriceps 5, tibialis anterior 1, gastrocnemius 4, extensor hallucis longus 1. The patient at that time was diagnosed with vitamin D deficiency and vitamin D replacment therapy was instituted.
The patient was most recently seen today and is more or less stable. He feels now that with the cold weather, his handwriting is worse and he has some pain in his left leg. His examination is otherwise unchanged.
The patient’s father and I discussed outside referrals for a cure for this disorder, and I explained to him the diagnosis of Guillain – Barre and suggested that we repeat nerve conduction studies. The father agreed with this approach. My plan is to schedule him for an outpatient electromyography and nerve conduction studies, and to follow him up in my clinic afterwards to discuss the results of this study with the patient and his father.
Note: This medical report is being dictated for patient care purposes and does not constitute a referral.
SIGNATURE -----------------------------------------------------------------
Edward James Cupler, MD
Consultant Neurologist
Diplomate, American Board of Neurology ( U.S.A)
Department of Neurosciences
D: 13 December 1998
T: 26 December 1998/fg
C: Department of Neuroscienes
Dr . Mohammed Ashfaq Ezad, King Saud hospital, Unaizah (MRN: 78371)
Dr . E . Cupler
KING DOM OF SAUDI ARABIA
MINISTRY OF Health
General Directorate of Health Affairs, Gassim
KFSH
Therapeutic Services Department
Date: 11/04/1422 ( 02/07/2001 ) MEDICAL REPORT
NAME OF THE PATIENT: MAGID
AGE/ SEX: 22 YEARS OLD / MALE
SAUDI NATIONALTY
DIAGNOSIS: - GUILLAN BARRE SYNDROME
This 22-year-old Saudi male patient was seen in the outpatients clinic with the above-mentioned diagnosis for review.
His condition started in the year 1415 when the had subacute severe weakness of both upper and lower limbs following 3 days of respiratory illness.
He was initially complaining of paraesthenal climbing stairs. He was followed up over the last 5 years in King Faisal specialist hospital & RC, Riyadh. The initial severe weakness improved but condition remained static with no further improvement of his leg weakness.
On Examination:
Patient fully conscious, thin built with wasting of all upper and lower limb muscles particularly distal ones.
Power was only mildly impaired in proximal upper limb muscles but lower limb proximal and distal muscles are weak with zero grade of power in ankle dorsiflexors and plantar flexors.
Sensations intact. Reflexes depressed. Plantar bilaterally flexor.
Conclusion / Recommendations:
The patient is still disabled by effects of his neuropathy and is in need for further follow up and physiotherapy.
DR. EL GAMRI E. MOHD
DR. HESHAM NADRAH
Consultant Neurologist/ Chief of Medicine
Hospital Director
