This is a 34 year-old male who is 8 days into his illness. He developed numbness and tingling in his hands, followed by his toes two days later. There is some pain and increased sweating. The numbness has progressed up his legs. Weakness started on day 3 and now he can’t ambulate or lift a utensil to his mouth. No bowel or bladder dysfunction except for some constipation associated with hydrocodone use. No shortness of breath, fever, chills.
Two weeks prior to onset of his symptoms he had severe diarrhea with
1. Bilateral shoulder surgeries
2. Hepatic transaminitis 1 month ago with possible hepatitis A in the
1. Zoloft 100 mg qd
2. Reglan prn nausea
3. Hydrocodone prn
Family History: Noncontributory.
Social History: No pets, no alcohol, no tobacco, no
drugs. Married with three children. Works as a pathology courier.
BP 118/78 HR 94
General: No acute distress. Well-developed, well-nourished
Mental Status: Alert, oriented, cooperative, follows
commands and good memory. Speech without any dysarthria.
HEENT: II: full visual fields, acuity right eye 20/30,
left eye 20/25. PERRLA. III, IV, VI: Extraocular movements full. V: Normal
facial sensation. VII: There is weak eye closure and weak smile IX, X:
Palate elevation is symmetrical in the midline. XI: Sternocleidomastoid
strong bilaterally. XII: Normal tongue bulk and strength.
Motor (Power/Tone/Bulk): No atrophy or contractures. Normal bulk.
Tone flaccid both lower extremities. Strength is symmetrical and rated
at deltoids 2/5, biceps and triceps 4/5. Wrist extension, flexion and
interossei muscles 3/5. Grip 4/5. Hip flexors 0/5. Hip extensors, flexors,
knee extensors and flexors 2/5 bilaterally. Ankle-plantar flexion 5/5
and ankle dorsiflexion 4/5.
Sensory: Normal temperature throughout. Decreased light
touch and vibration in bilateral lower and upper extremities distally.
Reflexes: Deep tendon reflexes trace or absent. Equivocal
Coordination: Slow rapid alternating movements. Unable
to assess finger-to-nose or heel-to-shin because of weakness.
Gait: Not able.
Abnormal Movements: None.
Other Organs: Noncontributory. No edema or rashes.