Cased Based Discussion - Copy.pptx.......

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1. CASE BASED DISCUSSION Presented By

2. Subjective Assessment Demographic Data: A 37 year old female who is a journalist. She is right hand dominant, admitted in Medicine ward, and assessment was taken on 16 th August 2024.

3. Chief complaint Patient complaints of Weakness over both Upper limb and lower limb Difficulty in standing without support and unable to walk. Difficulty in performing daily activities like combing her hair, writing, typing, bathing etc. Generalised Whole body pain (16/08/24 - 18/08/2024)

4. Family history: No relevant history Past history: Low back pain ( on & off since 2 years) Medical history: K/C/O Hypothyroidism since 4 years on medication ( TAB Thyronom 150mg ; 1-0-0)

5. Personal history Diet: Mixed Sleep: Disturbed (2-3 hrs of sleep on & off) Appetite: Reduced Bowel & Bladder: Regular & Continent ( Catherized ) Habits: None Physical Activity: Does not exercise Leisure activity: Patient likes to read novels and watch movies and reels in her past time.

6. Occupational history Patient works as a journalist in a local news paper company. Her work consists of : Travelling to locations for procuring news. Riding scooter to reach different news locations. Long hours of sitting and typing the articles.

7. PAIN ASSESMENT (16/08/2024) Site : Whole body Type : Dull aching Onset : Gradual ( started after administration of inj methyl prednisolone) NPRS : At rest (after medication) On Activity Aggravating factor : After administration of 1 mg dose of inj methyl prednisolone in the morning Relieving factor : On exercise

8. Present Medications Medication Dosage Uses Side Effects TAB Ultracet 4mg 1-0-1 Painkiller Nausea, vomiting, dizziness, and constipation INJ Methyl Prednisolone 1g 1-0-0 * 5 days Steroid medication Nausea, vomiting, heartburn, headache, dizziness, trouble sleeping, appetite changes, increased sweating, Weight fluctuations, Increase in Blood sugar levels TAB Wysolone 20mg, 1-0-0 * 3 days Suppresses Immune system & provides relief from inflammation signs of low potassium levels (such as constipation and a fast heartbeat), signs of increased sugar in the blood and urine (such as increased thirst and frequent urination), high blood pressure, thinner skin, and impaired wound healing

9. Present Medications Medication Dosage Uses Side Effects TAB Thyronom 150mg 1-0-0 Hypothyroidism Palpitations, Vomiting, Anxiety, Diarrhea, Weight loss, Increased appetite, Tremors TAB Panpro 40mg 1-0-0 Antacid nausea, vomiting, headache, dizziness, flatulence, diarrhea , and stomach pain TAB Cobalvit forte 1-0-0 Nutritional supplement ( alpha lipoic acid , vitamin B12 ) Dizziness, Sleepiness, Tiredness

10. Objective assessment General Examination Vital Signs Temperature- 98° F HR- 72bpm BP- 130/80 mmHg RR- 19 bpm SpO2- 97% on Room air

11. Objective assessment Patient was conscious & drowsy Built: Moderately built Attitude of limb: In supine lying Upper limb- B/L shoulder neutral, elbow flexed & wrist in neutral. Lower limb- Right knee extended, Ankle plantar flexed. Left hip externally rotated, knee extended, ankle neutral. No Obvious muscle wasting seen

12. Objective assessment Posture (In sitting): Anterior: No deviations observed Lateral: No deviations observed Posterior: No deviations observed Mode of ventilation- Room Air Breathing Pattern: Thoraco-Abdominal IE ratio: 1:2 External Appliance : Urinary Catheter IV line present at Right dorsal aspect of hand

13. On Auscultation Lung segment Quality Upper lobe NVBS B/L equal air entry Middle lobe NVBS B/L equal air entry Lower lobe NVBS B/L equal air entry No added sounds CVS: S1 S2 heard

14. On Examination Higher Mental Function Level of consciousness: Alert MMSE: 29/30 Behaviour : Cooperative Emotional status: Calm

15. CRANIAL NERVE Examination CRANIAL NERVE RIGHT LEFT OLFACTORY NERVE INTACT INTACT OPTIC NERVE Visual equity Visual field INTACT INTACT OCCULOMOTOR, TROCHLEAR, ABDUCENS INTACT INTACT TRIGEMINAL: Motor Sensory ALTERED INTACT ALTERED INTACT FACIAL Motor Sensory ALTERED INTACT ALTERED INTACT VESTIBULO-COCHLEAR: Webers test Rhinne test INTACT INTACT ALTERED ALTERED GLOSSOPHARYNGEAL INTACT SPINAL ACCESSORY NERVE INTACT INTACT HYPOGLOSSAL NERVE INTACT INTACT

16. SENSORY Examination SUPERFICIAL SENSATION UPPER LIMB RIGHT LEFT LOWER LIMB RIGHT LEFT Pain Intact Intact Intact Intact Temperature Intact Intact Intact Intact Light touch Intact Intact Intact Intact DEEP SENSATION Movement Sense Intact Intact Intact Intact Position Sense Intact Intact Intact Intact Vibration Intact Intact Intact Intact CORTICAL SENSATION Tactile localization Intact Intact Intact Intact Stereognosis Intact Intact

17. Range of Motion Right Left Shoulder: Flexion 0-170 0-170 Extension 0-50 0-50 Abduction 0-175 0-175 Internal rotation 0-70 0-70 External Rotation 0-90 0-90 Elbow: Flexion 0-135 0-135 Extension 135-0 135-0 Wrist Flexion 0-80 0-80 Extension 0-70 0-70 Ulnar Deviation 0-30 0-30 Radial Deviation 0-20 0-20 Right Left Hip: Flexion 0-110 0-110 Extension 0-30 0-30 Abduction 0-30 0-30 Adduction 30-0 30-0 Knee Flexion 0-130 0-130 Extension 130-0 130-0 Ankle Dorsi Flexion 0-20 0-15 Plantar flexion 0-30 0-30

18. MMT ( mrc ) Right Left Shoulder: Flexors 4/5 3/5 Extensors 4/5 3/5 Abductors 4/5 3/5 Internal rotators 4/5 3/5 External Rotators 4/5 3/5 Elbow : Flexors 4/5 3/5 Extensors 4/5 3/5 Wrist: Flexors 4/5 3/5 Extensors 4/5 3/5 Right Left Hip: Flexors 3/5 3/5 Extensors 3/5 3/5 Abductors 3/5 3/5 Adductors 3/5 3/5 Knee: Flexors 4/5 3/5 Extensors 4/5 3/5 Ankle: Dorsi Flexors 3/5 3/5 Plantar flexors 3/5 3/5

19. REFLEXES Deep tendon reflex Right Left Biceps 1+ 1+ Triceps 1+ 1+ Supinator 1+ 1+ Knee 1+ 1+ Ankle 1+ 1+ Superficial Reflexes Right Left Corneal Present Present Abdominal Present Present Plantar Present Present

20. BALANCE EVALUATION: Berg balance scale : 11/56 (16/08/2024) FUNCTIONAL EVALUATION: Barthel Index: 30/100 (16/08/2024) GAIT EVALUATION: (17/08/2024) Gait: Parallel bar walking with one person support Step length : Right 30cm Left 28cm Stride length : Right – 62cm Left – 58cm Cadence: 30 steps/ min

21. investigations MRI : Spine (27/07/2024) Disc Bulge at L4-L5 indenting thecal sac, however no neural compression. NCV Report (27/07/2024) Significant reduced bilateral tibial CMAP amplitude absent F waves. Doppler study both limbs (03/08/2024) No evidence of deep venous thrombosis to bilateral lower limbs. EMG Essentially normal EMG study

22. Outcome measures OUTCOME MEASURES SCORE INTERPRETATION MMSE 29/30 No cognitive impairment Barthel Index 35/100 Very dependent Morse fall scale 20 Low fall risk Sunnybrook Facial Grading system 9 Moderate Facial weakness SF 36 (17/08/24) 86/100 Good Fatigue assessment scale 25 Mild fatigue Berg Balance Scale 11/56 High risk of fall

23. Medical Diagnosis Acute inflammatory demyelinating polyneuropathy, LMN facial palsy with CN V involvement. Physiotherapy Diagnosis Weakness of bilateral upper limb and lower limb, difficulty in standing & walking without support and facial deviation towards left side secondary to AIDP.

24. Problem list: based on ICF checklist Body structures and function Activity limitations & participation restriction Environmental Factors STRUCTURE OF THE NERVOUS SYSTEM s120 Spinal cord & Peripheral nerves STRUCTURE RELATED TO MOVEMENT s730 Upper extremity (arm, hand) s750 Lower extremity (leg, foot) MOBILITY Lifting and carrying objects Fine hand use (picking up, grasping, writing) Walking, Moving around using equipment Using transportation Driving SELF CARE Washing oneself (bathing, drying, washing hands, etc ) Caring for body parts (brushing teeth, grooming, etc.) Toileting & Dressing Looking after one`s health DOMESTIC LIFE COMMUNITY & SOCIAL LIFE Climate Less resource of personal care providers and health related professionals Personal indoor & outdoor transportation Personal Factors: Supportive Family members and coworkers Issues with time management Inability to work efficiently Impairment of Body functions: SENSORY FUNCTIONS AND PAIN b280 Pain NEUROMUSCULOSKELETAL AND MOVEMENT RELATED FUNCTIONS b730 Muscle power

25. Physiotherapy treatment Goals Treatment Progression Improve Facial Muscles grading Facial Muscle Exercises: 3-4 times per day, 5 minutes each exercise in front of a mirror Raising Eyebrow, Blowing, Snarling, Clenching Teeth, Smiling Progression resistance on the unaffected side and assist the affected side to increase muscle engagement. Improve Upper limb Strength Upper limb strengthening: Bicep curls, Tricep extension, shoulder flexion & abduction) Using 0.5 kgs dumbbell for left upper limb ( 10 reps x 2 sets; along with rest period) 1 kg dumbbell for right upper limb ( 10 reps x 2 sets) 1kg dumbbell for left Upper limb 2kg dumbbell for Right upper limb

26. Physiotherapy treatment Goals Treatment Progression Improve Lower limb strength Dynamic quads (10 reps, 5 sec hold) SLR with 0.5kgs (10reps x 2 sets) Progression resistance on the unaffected side and assist the affected side to increase muscle engagement. For grip strength and fine motor activities Hand ball activities Holding different types of grips, Performing & practicing functional activities such as writing 2-3 sentences in English & Kannada, Typing a paragraph in the phone etc. Writing more 10 sentences in English and Kannada

27. Physiotherapy treatment Goals Treatment Progression Balance & Gait Training Sit to Stand exercise using wall bar (10 repetitions per set, 2 sets ) Weight shifting in standing with support Parallel Bar walking Initially 3 rounds, with 30sec rest between rounds. Stepping up & down on a low stool with support ( 10 reps each side) Single leg standing with support Initially for 3 sec each leg Sit to Stand + Arranging Balls on Wall Bar (10-12 reps, with one ball placed after each sit-to-stand.) Weight shifting in standing with support ( progressed to without support) Progressed to 7 rounds after 1 week with 30sec rest after every 2 rounds Progressed to 5 secs

28. Prognosis Pain: ( 19/08/2024) NPRS : On rest - 01/10 on activity – 0/10 Barthel index : 70/100 (23/08/2024) BBS: 23/56 (23/08/2024)

29. References Shahrizaila , N., Lehmann, H. C., & Kuwabara , S. (2021). Guillain-Barré syndrome. The Lancet, 397(10280), 1214–1228. doi:10.1016/s0140-6736(21)00517-1 Simatos Arsenault, N., Vincent, P.-O., Yu, B. H. S., Bastien, R., & Sweeney, A. (2016). Influence of Exercise on Patients with Guillain-Barré Syndrome: A Systematic Review. Physiotherapy Canada, 68(4), 367–376.

30. THANK YOU