COMPREHENSIVE CLINICAL CLASS

ACUTE FLACCID PARALYSIS

Mentor: Prof.S R CHANDRA
Retired Professor,
NIMHANS, Bengaluru.
Presenter: Dr.Ashray S Patel
1st year PG, Pediatrics,
BMCRI, Bengaluru.
GENERAL DETAILS:
• NAME : Mr.XYZ
• AGE : 15 years
• GENDER: Male
• First born to non-consanguineous parents
• ADDRESS : KR Market, Bengaluru
• RELIGION: Hindu
• INFORMANT : Self and reliable
• DOA: 6.09.20
• DOE: 6.09.20
CHIEF COMPLAINTS:
• Fever with productive cough 2 weeks back.
• Tingling sensation over the feet for 3 days.
• Weakness in both the Lower Limbs for 2 days.
 HISTORY OF PRESENTING ILLNESS:
• A 15 year old boy was apparently normal 2 weeks back when
he developed sudden onset, high grade, intermittent fever,
child being active in the inter-febrile period, lasted for 3 days.
Fever was associated with cough with moderate
expectoration, yellow colour sputum, non foul smelling, not
blood tinged and relieved in 5 days.
No associated chills & rigors.
No pain abdomen, loose stools, vomiting, burning
micturition.
No history of irritability, headache, neck stiffness, confusion
during the illness.
• The boy now complaints of tingling sensation over the feet since two
days following which he developed weakness of both the lower limbs
since the past two days, which he noticed yesterday morning as
heaviness of both the lower limbs following which the weakness has
been gradually progressive from inability to climb
upstairs/downstairs, inability to get up from the floor, repeated falls
on attempting to walk with twisting of ankles, slipping of chappals to
the present stage of unable to move both the lower limbs.
No difficulty in combing hair, in buttoning & unbuttoning the shirt was
noticed.
No difficulty in rolling over bed, getting up from bed, raising head and
holding neck was noticed.
• No history of reduced sensations or pain over the face or
body.
• No history of urinary incontinence or retention, syncopal
attacks.
• No involuntary movements were present.
• No history of difficulty in taking food to mouth, swaying on
attempting to walk, giddiness.
• No history of fatiguability or fluctuating weakness.
• No history of blurring of vision, double vision, impaired
sensation of smell, drooling of saliva, deviation of angle of
mouth, loss of taste sensation, impaired hearing, difficulty in
swallowing, change in voice.
• No history of any breathing difficulty.
• No present history of fever, myalgia, arthralgia, ear pain or discharge,
skin lesions, neck pain, irritability, seizures, altered sensorium.
• No history of pain abdomen, photosensitivity, skin rashes.
• No history of any recent trauma, wound or consumption of
improperly preserved food items.
• Child is vaccinated for polio & has not received any recent
vaccination.
PAST HISTORY:
• No history of similar complaints in the past.
• No history of any other medical disorders.
TREATMENT HISTORY:
• He had taken over the counter medications for his fever and cough
two weeks back details of which are not known.
Antenatal, Natal & Post Natal
History:
• He was born to a 25 year old primi mother at 38 weeks period of
gestation by Normal Vaginal Delivery. Antenatal period was
supervised, Mather had received TT injection & had taken iron, frolic
acid, calcium supplements.
• He cried immediately after birth, weighed 2.5kg. Immediate post
Natal and Neonatal periods were uneventful; breastfeeding was
initiated within an hour of birth & exclusively breastfed for 5 months.
• DEVELOPMENTAL HISTORY: all domains of development were
achieved at appropriate age.
• IMMUNIZATION HISTORY: Immunized upto date according to NIS.
• DIET HISTORY: He consumes a mixed diet with no calorie & protein
deficits.
FAMILY HISTORY:
• No history of similar complaints in the family.
PERSONAL HISTORY:
Consumes a mixed diet.
Appetite normal
Sleep : No change in pattern of sleep
Bowel and Bladder habits: regular
Denies any deleterious habits.

Socioeconomic Status:
Kuppuswamy scale class 3
SUMMARY
15 year old boy of birth order 1, born of non consanguineous marriage,
Full term normal vaginal delivery, belonging to class 3 Kuppuswamy
Scale, all developmental domains achieved appropriate for age & fully
immunized was brought to the OPD with complaints of Fever & Cough 2
weeks back; Acute onset, Symmetrical, Proximal & Distal Lower Limb
weakness progressing to inability to move both the limbs from the past
two days.
No history of sensory, autonomic involvement, no similar history in
family and no other medical conditions.
I would like to think of Guillain-Barre Syndrome, Acute Inflammatory
Demyelinating Polyneuropathy Subtype.
EXAMINATION:
The boy is Conscious, Cooperative; Well oriented to Time, Place and
Person. He looks well nourished.
The boy has been bought in a wheel chair & is unable to get up from sitting
position.

Vitals:
• PR: 76bpm
• BP: 112/78mmHg
• RR: 18 breathes per min
• Temperature: 98.6 degree Fahrenheit
HEAD TO TOE EXAMINATION:
Pallor: not present
Icterus: not present
Cyanosis: not present
Clubbing: not present
Lymphadenopathy: not present
Edema: not present
No Neuro cutaneous markers, skin rashes
NERVOUS SYSTEM EXAMINATION:
HIGHER MENTAL FUNCTIONS:
Conscious, Alert & Cooperative.
Appearance & Behaviour: Normal
Oriented to time, place & person.
Attention span: Normal
Language: Normal
Speech : Normal
Memory : Immediate, recent , remote intact
Intelligence : Normal
Lobar functions : Normal.
CRANIAL NERVE RIGHT LEFT
I Normal Normal
II Visual acuity: 6/6 Visual acuity: 6/6
Visual Field :Normal Visual Field :Normal
Pupil : Round, Regular & Reactive Pupil : Round, Regular & Reactive
Color vision : Normal
Fundus : fundal glow present Color vision : Normal
Fundus : fundal glow present

III,IV,VI Pupillary reflexes: present Pupillary reflexes: present

EOM full range of movement EOM full range of movement

V Sensory: Intact Sensory: Intact

Motor: Intact Motor: Intact
Jaw Jerk: Absent Jaw Jerk: Absent
CRANIAL NERVE LEFT RIGHT

VII Normal Normal

VIII Normal by ticking watch test Normal by ticking watch
test
IX,X Palatal movements present and Palatal movements
equal present and equal
XI Normal Normal

XII Normal Normal

MOTOR SYSTEM:

• BULK:

PARAMETER LEFT[CM] RIGHT[CM]

Arm circumference 17 17
Forearm 14 14
Thigh 25 25
Calf 20 20
TONE:
PARAMETER LEFT RIGHT
Upper limb
I. Flexor Normal Normal
II. Extensor Normal Normal
Lower Limb
I. Flexor Hypotonia Hypotonia
II. Extensor Hypotonia Hypotonia
POWER:
Parameter LEFT RIGHT
1.Movement at shoulder
joint
• Flexion 5 5
• Extension 5 5
• Abduction 5 5
• Adduction 5 5
• Internal rotation 5 5
• External rotation 5 5

2.Movement at elbow
joint
• Flexion 5 5
• Extension 5 5
Parameter LEFT RIGHT
3.Movement at Wrist joint
• Flexion 5 5
• Extension 5 5
• Abduction 5 5
• Adduction 5 5

4.Movement at Hip Joint

• Flexion 0 0
• Extension 0 0
• Abduction 0 0
• Adduction 0 0
• External Rotation 0 0
• Internal Rotation 0 0
Parameter LEFT RIGHT
5.Movement at Knee Joint

• Flexion 0 0
• Extension 0 0

6. Movement at Ankle Joint

• Plantar Flexion 0 0
• Dorsiflexion 0 0

7. Toe Movements

• Flexion 0 0
• Extension 0 0
REFLEXES
Parameter LEFT RIGHT
Superficial reflexes
1. Corneal Present Present
2. Conjunctival Present Present
3. Abdominal Present Present
4. Plantar Absent Absent

Deep Tendon Reflexes

1. Biceps 1+ 1+
2. Triceps 1+ 1+
3. Supinator 1+ 1+
4. Knee Absent Absent
5. Ankle Absent Absent
CO-ORDINATION:
LEFT RIGHT
Upper Limb Normal Normal
Lower Limb Couldn’t elicit Couldn’t elicit

• INVOLUNTARY MOVEMENTS : None

SENSORY SYSTEM:
PARAMETER LEFT RIGHT
Spinothalamic
Sensations
1. Pain Intact Intact
2. Temperature Intact Intact
3. Pressure Intact Intact

Posterior Column
Sensations
1. Fine touch Intact Intact
2. Vibration Intact Intact
3. Proprioception Intact Intact
CORTICAL SENSATION:
PARAMETER LEFT RIGHT
CORTICAL SENSATIONS
• Tactile Localization Intact Intact
• Two point Intact Intact
discrimination
• Stereognosis Intact Intact
• Graphesthesia Intact Intact
CEREBELLUM EXAMINATION:
1.Titubation: Absent
2.Nystagmus: Absent
3.Scanning speech: absent
4.Dysmetria/Past pointing: absent
5.Dysdiadochokinesia: normal
6.Intention tremor: Absent
7.Rebound phenomenon: Absent
8.Pendular knee jerk: Absent
NO SIGNS OF CEREBELLAR DYSFUNCTION PRESENT
No signs of meningeal Irritation
Gait: Couldn’t examine.
Skull & Spine: Normal
OTHER SYSTEM EXAMINATION:
Cardiovascular Examination :
S1S2 heard in all areas.
No added sounds /murmurs.

Respiratory Examination:
Chest movements equal bilaterally
Normal vesicular breath sounds in all areas
No added sounds
Per abdomen examination:
Soft non tender abdomen
No palpable organomegaly
DIAGNOSIS:
• FUNCTIONAL: Guillain-Barre Syndrome, Subtype: Acute
Inflammatory Demyelinating Polyneuropathy.
• ANATOMICAL: Polyradiculoneuropathy
• ETIOLOGY: Immunological (Molecular Mimicry)
THANK YOU