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Write-up: tingling sensation at fingertips radiating down arms, ataxia, sluggish reflexes, increased BP, headache Tx''d with Neurontin and Percocet 11/20/09 Hosp. records received for dates 11/13/09, 11/14/09 and 11/19/09. Seen in ER on 11/13. DX: parasthesias, HA. Pt. c/o numbness/tingling in hands/feet, HA, increased BP. Assessment: (+)parasthesias. Pt declined LP. On 11/14 Seen in ER for worsening sx. DX: peripheral neuropathy Presenting SX: c/o tingling, electrical feeling in hands and feet, generalized weakness x3 days ago. Pt. c/o HA, difficulty walking, fatigue/malaise, blurred vision, Pt states received H1N1 last week and gardasil vax this week. Pt admitted for neuro eval. 11/19/09 Pt seen in ER w/ c/o N/V, back pain. DX: post spinal HA. Pt tx for generalized HA and dc. 12/10/09 Hospital neurology consult, progress notes and tests received for DOS 11/14/09-11/17/09 Dx: Prob AIDP, microcytic anemia, back pain Complaint of tingling and numbness progressively worsening. Headache X3 days. Back pain and blurred vision. TX with percocet and ferrous sulfate. 12/11/09 Duplicate ER record for 11/14/09 received and ER record received for DOS 11/19/09 DX: Post spinal headache Patient presented with c/o nausea & vomiting, back pain and abdominal pain. Assess causes-ABD pain from vomiting, nausea caused by headache after lumbar puncture X2 (past week). Treated with Reglan, Morphine and IV fluids. Discharged home. 12/23/09 Hospital discharge summary received for DOS 11/14/09-11/17/09 DX: Possible Guillain-Barre Syndrome. Patient received HPV vaccination and H1N1 flu shot in the same week. Twelve hours after receiving H1N1, the patient experienced tingling and numbness of fingers and toes, which progressed to wrists and feet. The patient then experienced headache, blurred vision, back pain and since morning of admission, experienced generalized weakness. Lumbar puncture and nerve conduction study performed. Discharged home in stable condition.
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