1. Clinical Meeting
Presented by
Dr. Maimuna Sayeed
Dr. Aysha Sabiha
Residents (Phase A)
Paediatric Gastroenterology & Nutrition

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

3. Presenting complaints
• Gradual weakness of all four limbs for 10 days.
• Difficulty in swallowing for 5 days.

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

8. Feeding history
He is on family diet.

9. Developmental history
Age appropriate. Now reads in class 6.

10. Immunization history
Immunized as per EPI schedule.

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.

13. Treatment history
Nothing Significant.

14. Physical examination

15. General examination
• Appearance : Well alert, conscious
• Decubitus : On choice
• Pallor
• Jaundice
• Cyanosis
• Dehydration Absent
• Clubbing
• Koilonychia
• Leukonychia
• Edema

16. General examination (cont.)
• BCG mark: Present.
• Skin survey: Normal.
• Lymph nodes: Not palpable.
• Bony tenderness: Absent.
• Sign of meningeal irritation: Absent.
• Eyes & ENT: No abnormality.
• JVP: Not raised.
• Back & spines: Normal.

17. General examination (cont.)
Vital signs
• Temperature: 98°F.
• Pulse: 88 b/min.
• Respiratory Rate: 20 breaths/min.
• Blood Pressure: 120/80 mmHg (SBP & DBP lies
between 90th to 95th centile).

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)

19. Systemic examination

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

26. Respiratory system
• Palpation:
– Trachea – central.
– Apex beat - on left 5th intercostal space.
– Chest expansibility – Normal.
– Vocal fremitus – Normal.
• Percussion: Resonant.
• Auscultation:
– Breath sound - vesicular, no added sound.
– Vocal resonance - normal.

27. Cardiovascular system
• Inspection:
– No visible pulsation.
– Pulse: 88 b/min.
• Palpation:
– Apex beat: left 5th ICS just medial to mid clavicular line.
– Thrill: absent.
– P2: not palpable.
– Lt. parasternal heave: absent.
• Auscultation:
– 1st & 2nd heart sounds audible in all 4 areas.
– Murmur: absent.

28. Gastrointestinal system
• Oral cavity: Healthy.
• Abdomen proper:
– Inspection
• Abdomen is normal in size and shape.
• Umbilicus centrally placed and inverted.
• No visible vein or peristalsis.
– Palpation
• Local temperature- normal, Tenderness - absent.
• No organomegaly.
• Percussion.
• Fluid thrill & Shifting dullness – absent.
– Auscultation
• Bowel sound – present.

29. Other system
Examination of other systems revealed no abnormality.

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.

32. Provisional diagnosis

33. Provisional diagnosis
Acute Flaccid Paralysis
most probably due to
Guillain Barré Syndrome

34. Differential diagnosis
Transverse Myelitis

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

37. INVESTIGATIONS
• CBC – Hb - 12.5 gm/ dl
ESR - 40 mm in 1st hour
TC - 11,000/cmm
Neutrophil - 74%
Lymphocyte - 14%
Monocyte - 4%
Eosinophil - 3%
Platelet count - 2,50,000/cumm
• Urine R/E – Pus cells 0-2/HPF, RBC - Nil

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

40. Final Diagnosis
Guillain Barre Syndrome (Acute Motor
Axonal Neuropathy)

41. Treatment
• Counseling
• Tab. Paracetamol
• Inj. IVIG
• Physiotherapy
• Regular monitoring of vital signs & follow
up regarding progression of paralysis,
autonomic invoolvement, breathing
difficulties, swallowing difficulties, speech
difficulties.

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

44. Inj. IVIG was given from 16/03/17 to 20/03/17.

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

47. During discharge:
• Advice about Physiotherapy
• F/U after 14 days

48. Thank you