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Author:

Karen Wingert, MEd, PT, RN, BA, SPT

School of Health Professions, University of Missouri-Columbia

Guillain Barré

Physical Therapy Discharge Notes


September 18, 1996

Smith, Linda

Patient Information: Age: 38 y/o bf

Diagnosis Initial onset: Pt d/c from hospital in May after being treated for UTI. Pt returned to ER on May 27 with c/o progressive weakness and tingling in bilateral LEs and pt unable to stand. Pt was admitted and eventually diagnosed with Guillain-Barré. Pt was placed on ventilator during acute stay. Pt was also diagnosed with left lower lobe pneumonia during hospitalization.

Past Medical History: HTN, hysterectomy, peptic ulcer disease.

Social History: Pt had lived independently, but plans to live with parents after d/c. Pt has one step to enter home. Pt is planning on living on first level of home.

Physical Therapy Services: Pt was seen 2-3 times a day for the following services: LE stretching, facilitation and strengthening, bed mobility, and standing balance training, endurance training, gait training, occasional massage and/or hot packs for left hip pain, and pt and family education.

Date of Discharge: 9/18/96


Status at Discharge

Subjective: Pt would occasionally c/o of pain in her left hip with strenuous exercise. PT noted much muscle guarding and tightness. Pain was relieved with deep massage and hot packs. Pt also occasionally c/o pain in bilateral feet. Pt and PT attributed pain to nerve regeneration secondary to pain was mostly muscle spasms and deep pain. PT and physician also suggested orthotics for pt's shoes to assist with ankle control and possibly to decrease pain.

Orientation: Alert and oriented X4.

Posture: No significant abnormalities noted in sitting or static standing. See gait for dynamic standing assessment.

Muscle functions for left and right legs
Muscle Function Left Right
Hip flexion 4-/54/5
Hip extension 3-/53/5
Hip abduction 3/54-/5
Hip adduction 3/54/5
Knee flexion 3/53/5
Knee extension 4/54+/S
Ankle dorsiflexion 2+/S2+/5
Ankle plantarflexion 2+/S3/5

Range of Motion: Bilateral LEs WFL active and passive ROM with tightness noted in bilateral ankles with ankle dorsiflexion to neutral with knee extension and prone knee bends at 62 degrees on right and 72 degrees on left with tightness noted in quadriceps.

Proprioception: Unable to formally assess, but with gait appears diminished in bilateral feet and ankles with left showing greater deficits than right.

Tone: No abnormal tone noted.

Sensation: Pt reported occasional numbness and/or pain in bilateral feet.

Balance
Task Static Dynamic
Sitting Good Good
Standing With walker: Fair+
Without walker: Fair
With walker: Fair+
Without walker: Poor

Endurance: Fair: pt tolerated 30-45 minute PT session with rest breaks and encouragement at times.

Bed mobility
Task Static
Sitting to supine Independent
Supine to sitting Independent
Rolling Independent

Transfer Preparation: Independent

Transfers
Type Evaluation
Mat Stand pivot independent
Bed Stand pivot independent
Floor PT and pt discussed technique for getting up from floor. Pt did not attempt secondary to LE weakness and pain.
Car Stand pivot with supervision

Advanced motor skills
Task Evaluation
Stairs Pt is able to negotiate 6 inch curb with walker with CGA for safety. Pt has been working on increasing quadriceps strengthening by controlling stepping up and down 6 inch step with hand rails with min assist and max verbal cues.
One foot standing Not addressed.
Walking backwards Pt was able to walk backwards (2-5 feet) to wheelchair with wheeled walker with CGA and good knee control.

Wheelchair Propulsion: Independent on level terrain.

Gait: Pt ambulating with wheeled walker 150 feet with SBA. Pt ambulating 1-2 times per session due to endurance and ankle pain. Pt demonstrates following gait deviations: bilateral foot drop, poor heel-contact, decreased cadence, and decreased step length. With fatigue all gait deviations increase, as well as pt develops hip hike on left and her BOS moves forward in walker. Pt has ambulated without assistive device x 1 with HHA/mod assist for balance and increase of above mentioned gait deviations.

Pt/Family Education: Pt's father and sister educated on pt transfers and safety. PT reviewed car transfers with pt and her father. PT also educated pt and her father on mobility and safety for household ambulation. PT educated pt on importance of pacing and time management with physical activities.

Long Term Goal Status:

  1. Pt to independently complete 25 ankle pumps every night to decrease LE swelling and pain (not met consistently)
  2. Independent with HEP (met)
  3. Educated pt and family on safety and mobility (met)
  4. Pt to stand pivot transfer independently and ask for appropriate supervision when fatigued (met)
  5. Pt to ambulate 150 feet with appropriate assistive device with SBA and no significant gait deviations (not met consistently)
  6. PT and pt to review technique to fall safely and how to get up from the floor (met)

Assessment: Pt is a 38 y/o bf diagnosed with Guillain-Barré who has made excellent progress during her rehabilitation stay. Pt has advanced to ambulating with a wheeled walker with only SBA and pt is ready to decrease stability of assistive device with outpatient PT. Pt has also shown almost full return of bilateral LE musculature but will continue to require daily strengthening to maximize return. Pt has much potential to return to premorbid state of physical functioning. Pt was most limited in therapy by pain in either her left hip or bilateral feet, but pain continues to subside with increased physical functioning.

Recommendations: PT recommends outpatient physical therapy 5x a week to increase bilateral LE strength and help pt to achieve premorbid level of physical functioning.

Therapist: Karen Wingert, PT, RN.


One-year Follow-Up

Linda has returned to her full-time job as a computer operator for the University of Missouri. Linda walks unlimited distances and completes all ADLs without assistance. The only residual symptoms are occasional numbness and tingling in both feet.


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School of Health Professions
University of Missouri-Columbia
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