今天去医院，Hospitalist,K医生很高兴地告诉我，我们一起看过的一个病人的临床诊断结果出来了， GQ1B Ab (IgG)1:3200 （正常1:100)。因此，我们的临床诊断Miller Fisher Syndrome得到确诊。虽然，临床上我也已当Miller Fisher Syndrome处理了，病人也能自己走出医院了，但他是一个不愿买医保的中产阶级，出院后也没按医生要求来我诊所复诊，但心中还是关心着这个病例。回顾这个病例，进出医院ER两次，差点被漏诊，自己是这个病例的第二次ER的会诊神内医生，因为不典型，所以自己也差点漏掉，还是良好的鉴别诊断习惯，才没使病人再被漏诊。以下是我的神内病历，从中可以看出当时的诊断思路变化过程。

DATE OF CONSULTATION:  05/16/2013 

REASON FOR CONSULTATION:  As you know, this is a 53-year-old, Caucasian male, who was admitted yesterday to the hospital actually, and I was asked to see the patient today for a questionable complex migraine versus transient ischemic attack.

HISTORY OF PRESENT ILLNESS:  The history-taking was directly from the patient himself.  The patient was in his usual state of health until recently about a month ago when he was diagnosed with hypertension, and the patient was started on lisinopril 20 mg p.o. daily.  He presented to the emergency room with generalized numbness, unsteady gait, blurry vision, and high blood pressure on May 14, when he stayed for about 5-6 hours and had a CAT scan of the head without contrast, which was read as negative.  His blood pressure was 190/87.  He was given clonidine 0.2 mg and blood pressure dropped down to 160/68, and then the patient was discharged.  The patient, yesterday morning when he got up, he experienced the same symptoms as a generalized numbness that he recalled as from the top of the head to the tip of the toes bilaterally, a severe numbness.  The patient denied a migraine headache, but he stated he has a headache all the time that was not anything unusual.  He recalled that he had a similar episode back in November of 1996.  However, the episode of numbness was on the left side only and he was told it was probably a transient ischemic attack or a migraine variant.  The patient was not on aspirin.  The patient denied any nausea or vomiting, any conscious change, any fever, or any severe neck pain.  But, the patient stated that because of the numbness he fell one time the day before yesterday.  At the time of this interview, he already had an MRI of the brain with and without contrast, and an MRA of the brain and neck, and they were all reported as negative for acute pathology or significant stenosis or aneurysm.  The patient has been put on aspirin since this admission.

PAST MEDICAL AND SURGICAL HISTORY:  1.  Hypertension.2.  Questionable complex migraine versus transient ischemic attack.3.  Rotator cuff surgery of the left shoulder.4.  Arthroscopy of both knees.5.  Colonoscopy in 2010. FAMILY HISTORY:  Heart attack, breast cancer.

SOCIAL HISTORY:  The patient drinks socially.  Denies smoking or drug abuse.  The patient is divorced.  He lives with his son.  He works as a loan officer. ALLERGIES:  No known drug allergies.

MEDICATIONS:  Home medication charted as lisinopril.

REVIEW OF SYSTEMS:  As stated above, but otherwise unknown.

PHYSICAL EXAMINATION: 

VITAL SIGNS:  The patient's vital signs were stable, afebrile.  The patient had elevated blood pressure noticed at 187/92.

NECK:  Supple.HEENT:  There was no discharge from ears, nose, or eyes.

GENERAL:  The patient was not in acute distress.  The patient was lying on the hospital bed.

NEUROLOGIC:  The patient was awake, alert and oriented to time, place and person.  Speech and language were intact.  Memory was within normal limits.  The patient was cooperative.  The patient's pupils were equal and round.  The extraocular movements intact were intact.  There was no nystagmus.  There was no visual field or visual acuity deficits.  There was no facial weakness.  Tongue was in the midline.  The patient was able to follow commands and move all the extremities with no focal weakness.  Muscle tone was within normal limits.  There were no abnormal movements.  Sensory check was intact to joint position.  The patient's coordination check for the rapid alternating movements of the upper extremities was symmetric.  Finger-to-nose was intact.  There was no footdrop on either side.  The patient's deep tendon reflexes were about 1.  Toes were downgoing bilaterally.  Gait was cautious。

DIAGNOSTIC STUDIES:  

LABORATORY DATA:  Results were reviewed as stated above.

IMPRESSION: 

1.  Probable malignant hypertension with generalized paresthesia.

2.  Generalized paresthesia does not fit the acute stroke or transient ischemic attack pattern.

3.  History of questionable transient ischemic attack versus a migraine variant in the past.

4.  Chronic headache, unknown etiology.

PLAN: 

1.  I have had a discussion about my impression, workup, and options of management.

2.  Spinal tap to rule out atypical BGS.

3.  Since this does not sound like a neurological presentation as the generalized bilateral paresthesias are from the top of the head to the tip of the toes, I am going to sign-off the case from today if the CSF was negative. Neurology will follow up only when needed.  The patient, however, should follow up with the primary care doctor closely.4.  Aspirin 81 mg p.o. daily recommended.

 

DATE OF FOLLOW-UP:

 

 05/17/2013

SUBJECTIVE:  This is a 53-year-old Caucasian male whom I have been following for difficult gait with generalized paresthesia.  Review of the patient's history and lab results of spinal tap, the patient's WBC was slightly increased with same as protein.  Given the history of upper respiratory infection a week prior to admission, GBS(Guillain Barre syndrome, AIDP)/Miller-Fisher syndrome needed to be considered as a differential diagnosis from a neurological standpoint though the patient's blood pressure is significantly high still this morning at 184/115.  Overnight, the patient had no new complaints.  The patient denies breathing difficulty, bladder/bowel dysfunction but occasionally has cough when drinking.  The patient stated his last normal walking was on Tuesday and prior to this admission, when the patient walked his dog, he fell one time and that is something new for him.

 

OBJECTIVE:  

NEUROLOGIC:  The patient was sitting in the bed.  The patient was awake, alert and oriented and the patient was able to cooperate and the patient's speech and language were intact.  The patient showed no significant findings of focal weakness.  The patient, however, had reflexes diminished bilaterally, pretty much areflexia.  The patient was able to get up and walk, but more unsteadiness than yesterday noticed with wide gait, even not on H/T walking.  There was no interval neurological change otherwise.

DIAGNOSTIC STUDIES: 

LABORATORY DATA:  Laboratory results reviewed.  Spinal tap/CSF as stated above.

ASSESSMENT:  From a neurological standpoint, Guillain Barre syndrome/acute inflammatory demyelinating polyneuropathy/Miller-Fisher syndrome, atypical, has to be considered as one of the differentials.  This patient came in with a history of upper respiratory infection 1 week prior to this admission with ataxia, areflexia. Other differential from a neurological point of view, transverse myelitis should also considered, though not supposed to be "numbness from top of the head to tip of toes". 

PLAN: 

1.  I have had a discussion about my impression, workup and options of treatment with the patient this morning.

2.  Check stat IgA recommended to prepare for IVIG treatment.  If IgA is normal, the patient should be given IVIG.  I would recommend IVIG treatment for 5 days, 400 mg/kg per day for 5 days, each one over 4-6 hours.  Pay attention to allergic reaction.

3.  Fall precautions.

4.  Physical therapy and occupational therapy evaluation recommended.

5.  The patient should be treated in the hospital and please do not discharge the patient before the IVIG is done.

6.  Check vital capacity twice a day.  If the vital capacity goes down below 1 L, the patient shall be transferred to ICU and critical care evaluation needs to be called upon.

7.  Check anti-GQ1B.

8.  I will sign off the patient and I will ask Christie on-call doctor/neurologist to cover the patient over this weekend from May 18, 2013 to May 19, 2013. The case and plan as above has been discussed with the admitting attending this morning via telephone.  Voice ID#: 730581