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{{Guillain-Barré syndrome}}
{{Guillain-Barré syndrome}}
{{CMG}}; {{AE}} [[Priyamvada Singh|Priyamvada Singh, MBBS]] [mailto:psingh13579@gmail.com]
{{CMG}}; {{AE}} {{Fs}}


==Overview==
==Overview==
It is included in the wider group of [[peripheral neuropathy|peripheral neuropathies]]. The physical examination findings usually indicates features due to [[autonomic dysfunction]] and [[demyelination]] of [[peripheral nerves]]. Fluctuation in vitals can be seen and may present as hyper or hypothermia, hypo or hypertension, brady or tachycardia. Progressive, symmetric, bilateral, flaccid, ascending paralysis progressing over weeks to days time is the common finding. Hypotonia, hyporeflexia, areflexia can be seen.[[Sensory]] system may be involved but generally it is mild. [[Ataxia]] and difficulty in walking may be seen despite great muscle strength due to involvement of [[proprioception]] and [[oculoparesis]].
Physical examination of patients with Guillain Barre syndrome is usually remarkable for abnormal [[gait]], [[heart rate]] and [[blood pressure]] disturbance, [[ophthalmoplegia]], [[papilledema]], facial [[myokymia]], [[vocal cord paralysis]], [[urinary retention]],  [[hyperreflexia]] or [[areflexia]], bilateral distal and proximal [[muscle weakness]] and unilateral or bilateral sensory abnormality.


==Physical Examination==
==Physical Examination==
Physical examination of patients with [disease name] is usually normal.
Physical examination of patients with Guillain Barre syndrome is usually remarkable for:
 
OR
 
Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
 
OR
 
The presence of [finding(s)] on physical examination is diagnostic of [disease name].
 
OR
 
The presence of [finding(s)] on physical examination is highly suggestive of [disease name].


===Appearance of the Patient===
===Appearance of the Patient===
*Patients with [disease name] usually appear [general appearance].  
*Patients with Guillain Barre syndrome might have abnormal [[gait]].<ref name="pmid11320188">{{cite journal |vauthors=Mori M, Kuwabara S, Fukutake T, Yuki N, Hattori T |title=Clinical features and prognosis of Miller Fisher syndrome |journal=Neurology |volume=56 |issue=8 |pages=1104–6 |date=April 2001 |pmid=11320188 |doi= |url=}}</ref>


===Vital Signs===
===Vital Signs===


*High-grade / low-grade fever
*[[Tachycardia]] or bradycardia
*[[Hypothermia]] / hyperthermia may be present
*[[Blood pressure]] disturbance<ref name=":1">{{Victor, M., 2001. Diseases of spinal cord peripheral nerve and muscle. Principles of Neurology}}</ref>
*[[Tachycardia]] with regular pulse or (ir)regularly irregular pulse
*[[Bradycardia]] with regular pulse or (ir)regularly irregular pulse
*Tachypnea / bradypnea
*Kussmal respirations may be present in _____ (advanced disease state)
*Weak/bounding pulse / pulsus alternans / paradoxical pulse / asymmetric pulse
*High/low blood pressure with normal pulse pressure / [[wide pulse pressure]] / [[narrow pulse pressure]]


===Skin===
===Skin===
* Skin examination of patients with [disease name] is usually normal.
* Skin examination of patients with Guillain Barre syndrome is usually normal.
OR
* We might see evidence of recent [[chicken pox]] disease.<ref name="pmid3404161">{{cite journal |vauthors=Winer JB, Hughes RA, Anderson MJ, Jones DM, Kangro H, Watkins RP |title=A prospective study of acute idiopathic neuropathy. II. Antecedent events |journal=J. Neurol. Neurosurg. Psychiatry |volume=51 |issue=5 |pages=613–8 |date=May 1988 |pmid=3404161 |pmc=1033063 |doi= |url=}}</ref>
*[[Cyanosis]]  
*[[Jaundice]]
* [[Pallor]]
* Bruises
 
<gallery widths="150px">
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>
 
===HEENT===
===HEENT===
* HEENT examination of patients with [disease name] is usually normal.
* Extra-ocular movements may be abnormal.<ref name="pmid11320188" />
OR
*Ophthalmoscopic exam may be abnormal with findings of [[papilledema]].<ref name="pmid13493684">{{cite journal |vauthors=JOYNT RJ |title=Mechanism of production of papilledema in the Guillain-Barre syndrome |journal=Neurology |volume=8 |issue=1 |pages=8–12 |date=January 1958 |pmid=13493684 |doi= |url=}}</ref>
* Abnormalities of the head/hair may include ___
* Hearing acuity may be reduced.<ref name="pmid3399076">{{cite journal |vauthors=Nelson KR, Gilmore RL, Massey A |title=Acoustic nerve conduction abnormalities in Guillain-Barré syndrome |journal=Neurology |volume=38 |issue=8 |pages=1263–6 |date=August 1988 |pmid=3399076 |doi= |url=}}</ref>
* Evidence of trauma
* [[Myokymia|Facial myokymia]] (Involuntary facial movement)<ref name="pmid6681885">{{cite journal |vauthors=Mateer JE, Gutmann L, McComas CF |title=Myokymia in Guillain-Barré syndrome |journal=Neurology |volume=33 |issue=3 |pages=374–6 |date=March 1983 |pmid=6681885 |doi= |url=}}</ref>
* Icteric sclera
* [[Vocal cord]] [[paralysis]] (Difficulty speaking)<ref name="pmid8441543">{{cite journal |vauthors=Panosian MS, Quatela VC |title=Guillain-Barré syndrome presenting as acute bilateral vocal cord paralysis |journal=Otolaryngol Head Neck Surg |volume=108 |issue=2 |pages=171–3 |date=February 1993 |pmid=8441543 |doi=10.1177/019459989310800211 |url=}}</ref>
* [[Nystagmus]]
* Extra-ocular movements may be abnormal
*Pupils non-reactive to light / non-reactive to accommodation / non-reactive to neither light nor accommodation
*Ophthalmoscopic exam may be abnormal with findings of ___
* Hearing acuity may be reduced
*[[Weber test]] may be abnormal (Note: A positive Weber test is considered a normal finding / A negative Weber test is considered an abnormal finding. To avoid confusion, you may write "abnormal Weber test".)
*[[Rinne test]] may be positive (Note: A positive Rinne test is considered a normal finding / A negative Rinne test is considered an abnormal finding. To avoid confusion, you may write "abnormal Rinne test".)
* [[Exudate]] from the ear canal
* Tenderness upon palpation of the ear pinnae/tragus (anterior to ear canal)
*Inflamed nares / congested nares
* [[Purulent]] exudate from the nares
* Facial tenderness
* Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae


===Neck===
===Neck===
* Neck examination of patients with [disease name] is usually normal.
* We might see some [[Lymphadenopathy]] because of prior infection with [[EBV]] or [[CMV]].<ref name="pmid8784256">{{cite journal |vauthors=Irie S, Saito T, Nakamura K, Kanazawa N, Ogino M, Nukazawa T, Ito H, Tamai Y, Kowa H |title=Association of anti-GM2 antibodies in Guillain-Barré syndrome with acute cytomegalovirus infection |journal=J. Neuroimmunol. |volume=68 |issue=1-2 |pages=19–26 |date=August 1996 |pmid=8784256 |doi= |url=}}</ref><ref name="pmid3404161" />
OR
* Using accessory muscle for breathing in severe cases.
*[[Jugular venous distension]]
*[[Carotid bruits]] may be auscultated unilaterally/bilaterally using the bell/diaphragm of the otoscope
*[[Lymphadenopathy]] (describe location, size, tenderness, mobility, and symmetry)
*[[Thyromegaly]] / thyroid nodules
*[[Hepatojugular reflux]]
 
===Lungs===
===Lungs===
* Pulmonary examination of patients with [disease name] is usually normal.
* Pulmonary examination of patients with Guillain barre syndrome is usually normal.
OR
* Asymmetric chest expansion OR decreased chest expansion
*Lungs are hyporesonant OR hyperresonant
*Fine/coarse [[crackles]] upon auscultation of the lung bases/apices unilaterally/bilaterally
*Rhonchi
*Vesicular breath sounds OR distant breath sounds
*Expiratory wheezing OR inspiratory wheezing with normal OR delayed expiratory phase
*[[Wheezing]] may be present
*[[Egophony]] present/absent
*[[Bronchophony]] present/absent
*Normal/reduced [[tactile fremitus]]
 
===Heart===
===Heart===
* Cardiovascular examination of patients with [disease name] is usually normal.
* Cardiovascular examination of patients with Guillain Barre syndrome is usually normal.
OR
*Chest tenderness upon palpation
*PMI within 2 cm of the sternum  (PMI) / Displaced point of maximal impulse (PMI) suggestive of ____
*[[Heave]] / [[thrill]]
*[[Friction rub]]
*[[Heart sounds#First heart tone S1, the "lub"(components M1 and T1)|S1]]
*[[Heart sounds#Second heart tone S2 the "dub"(components A2 and P2)|S2]]
*[[Heart sounds#Third heart sound S3|S3]]
*[[Heart sounds#Fourth heart sound S4|S4]]
*[[Heart sounds#Summation Gallop|Gallops]]
*A high/low grade early/late [[systolic murmur]] / [[diastolic murmur]] best heard at the base/apex/(specific valve region) may be heard using the bell/diaphgram of the stethoscope
 
===Abdomen===
===Abdomen===
* Abdominal examination of patients with [disease name] is usually normal.
* Abdominal examination of patients with Guillain Barre syndrome is usually normal.
OR
*[[Abdominal distension]]
*[[Abdominal tenderness]] in the right/left upper/lower abdominal quadrant
*[[Rebound tenderness]] (positive Blumberg sign)
*A palpable abdominal mass in the right/left upper/lower abdominal quadrant
*Guarding may be present
*[[Hepatomegaly]] / [[splenomegaly]] / [[hepatosplenomegaly]]
*Additional findings, such as obturator test, psoas test, McBurney point test, Murphy test
 
===Back===
===Back===
* Back examination of patients with [disease name] is usually normal.
* Back examination of patients with Guillain Barre syndrome is usually normal.
OR
*Point tenderness over __ vertebrae (e.g. L3-L4)
*Sacral edema
*Costovertebral angle tenderness bilaterally/unilaterally
*Buffalo hump
 
===Genitourinary===
===Genitourinary===
* Genitourinary examination of patients with [disease name] is usually normal.
* Evidences of [[urinary retention]] may be present.<ref name=":1" />
OR
*A pelvic/adnexal mass may be palpated
*Inflamed mucosa
*Clear/(color), foul-smelling/odorless penile/vaginal discharge
 
===Neuromuscular===
===Neuromuscular===
* Neuromuscular examination of patients with [disease name] is usually normal.
*Patient is usually oriented to persons, place, and time.
OR
* Altered mental status may be present.
*Patient is usually oriented to persons, place, and time
* [[Glasgow coma scale]] is 15/ 15
* Altered mental status
* Based on the type of GBS, [[hyperreflexia]] or [[areflexia]] may be present.
* Glasgow coma scale is ___ / 15
* Bilateral distal and proximal muscle weakness is present.
* Clonus may be present
* Reduced muscle force especially in lower extremities.
* Hyperreflexia / hyporeflexia / areflexia
*Unilateral or bilateral sensory abnormality especially in deep sensation in the upper/lower extremities.
* Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
*Abnormal gait is present in [[Miller Fisher Syndrome|Miller Fisher type]] of GBS.<ref name="pmid160003352">{{cite journal |vauthors=Cochen V, Arnulf I, Demeret S, Neulat ML, Gourlet V, Drouot X, Moutereau S, Derenne JP, Similowski T, Willer JC, Pierrot-Deseiligny C, Bolgert F |title=Vivid dreams, hallucinations, psychosis and REM sleep in Guillain-Barré syndrome |journal=Brain |volume=128 |issue=Pt 11 |pages=2535–45 |date=November 2005 |pmid=16000335 |doi=10.1093/brain/awh585 |url=}}</ref><ref name=":0">{{cite book | last = Mattle | first = Heinrich | title = Fundamentals of neurology : an illustrated guide | publisher = Thieme | location = Stuttgart New York | year = 2017 | isbn = 9783131364524 }}</ref><ref name="pmid12084449">{{cite journal |vauthors=Kuwabara S, Nakata M, Sung JY, Mori M, Kato N, Hattori T, Koga M, Yuki N |title=Hyperreflexia in axonal Guillain-Barré syndrome subsequent to Campylobacter jejuni enteritis |journal=J. Neurol. Sci. |volume=199 |issue=1-2 |pages=89–92 |date=July 2002 |pmid=12084449 |doi= |url=}}</ref><ref name="pmid">{{cite journal |vauthors=Kuwabara S, Ogawara K, Koga M, Mori M, Hattori T, Yuki N |title=Hyperreflexia in Guillain-Barré syndrome: relation with acute motor axonal neuropathy and anti-GM1 antibody |journal=J. Neurol. Neurosurg. Psychiatry |volume=67 |issue=2 |pages=180–4 |date=August 1999 |pmid= |pmc=1736477 |doi= |url=}}</ref><ref name=":1" />
* Muscle rigidity
* Proximal/distal muscle weakness unilaterally/bilaterally
* ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
*Unilateral/bilateral upper/lower extremity weakness
*Unilateral/bilateral sensory loss in the upper/lower extremity
*Positive straight leg raise test
*Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
*Positive/negative Trendelenburg sign
*Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
*Normal finger-to-nose test / Dysmetria
*Absent/present dysdiadochokinesia (palm tapping test)


===Extremities===
===Extremities===
* Extremities examination of patients with [disease name] is usually normal.
* Extremities examination of patients with Guillain Barre syndrome is usually normal.
OR
*[[Clubbing]]
*[[Cyanosis]]
*Pitting/non-pitting [[edema]] of the upper/lower extremities
*Muscle atrophy
*Fasciculations in the upper/lower extremity


==References==
==References==

Latest revision as of 17:04, 27 December 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Overview

Physical examination of patients with Guillain Barre syndrome is usually remarkable for abnormal gait, heart rate and blood pressure disturbance, ophthalmoplegia, papilledema, facial myokymia, vocal cord paralysis, urinary retention, hyperreflexia or areflexia, bilateral distal and proximal muscle weakness and unilateral or bilateral sensory abnormality.

Physical Examination

Physical examination of patients with Guillain Barre syndrome is usually remarkable for:

Appearance of the Patient

  • Patients with Guillain Barre syndrome might have abnormal gait.[1]

Vital Signs

Skin

  • Skin examination of patients with Guillain Barre syndrome is usually normal.
  • We might see evidence of recent chicken pox disease.[3]

HEENT

Neck

  • We might see some Lymphadenopathy because of prior infection with EBV or CMV.[8][3]
  • Using accessory muscle for breathing in severe cases.

Lungs

  • Pulmonary examination of patients with Guillain barre syndrome is usually normal.

Heart

  • Cardiovascular examination of patients with Guillain Barre syndrome is usually normal.

Abdomen

  • Abdominal examination of patients with Guillain Barre syndrome is usually normal.

Back

  • Back examination of patients with Guillain Barre syndrome is usually normal.

Genitourinary

Neuromuscular

  • Patient is usually oriented to persons, place, and time.
  • Altered mental status may be present.
  • Glasgow coma scale is 15/ 15
  • Based on the type of GBS, hyperreflexia or areflexia may be present.
  • Bilateral distal and proximal muscle weakness is present.
  • Reduced muscle force especially in lower extremities.
  • Unilateral or bilateral sensory abnormality especially in deep sensation in the upper/lower extremities.
  • Abnormal gait is present in Miller Fisher type of GBS.[9][10][11][12][2]

Extremities

  • Extremities examination of patients with Guillain Barre syndrome is usually normal.

References

  1. ↑ 1.0 1.1 Mori M, Kuwabara S, Fukutake T, Yuki N, Hattori T (April 2001). "Clinical features and prognosis of Miller Fisher syndrome". Neurology. 56 (8): 1104–6. PMID 11320188.
  2. ↑ 2.0 2.1 2.2 Template:Victor, M., 2001. Diseases of spinal cord peripheral nerve and muscle. Principles of Neurology
  3. ↑ 3.0 3.1 Winer JB, Hughes RA, Anderson MJ, Jones DM, Kangro H, Watkins RP (May 1988). "A prospective study of acute idiopathic neuropathy. II. Antecedent events". J. Neurol. Neurosurg. Psychiatry. 51 (5): 613–8. PMC 1033063. PMID 3404161.
  4. ↑ JOYNT RJ (January 1958). "Mechanism of production of papilledema in the Guillain-Barre syndrome". Neurology. 8 (1): 8–12. PMID 13493684.
  5. ↑ Nelson KR, Gilmore RL, Massey A (August 1988). "Acoustic nerve conduction abnormalities in Guillain-Barré syndrome". Neurology. 38 (8): 1263–6. PMID 3399076.
  6. ↑ Mateer JE, Gutmann L, McComas CF (March 1983). "Myokymia in Guillain-Barré syndrome". Neurology. 33 (3): 374–6. PMID 6681885.
  7. ↑ Panosian MS, Quatela VC (February 1993). "Guillain-Barré syndrome presenting as acute bilateral vocal cord paralysis". Otolaryngol Head Neck Surg. 108 (2): 171–3. doi:10.1177/019459989310800211. PMID 8441543.
  8. ↑ Irie S, Saito T, Nakamura K, Kanazawa N, Ogino M, Nukazawa T, Ito H, Tamai Y, Kowa H (August 1996). "Association of anti-GM2 antibodies in Guillain-Barré syndrome with acute cytomegalovirus infection". J. Neuroimmunol. 68 (1–2): 19–26. PMID 8784256.
  9. ↑ Cochen V, Arnulf I, Demeret S, Neulat ML, Gourlet V, Drouot X, Moutereau S, Derenne JP, Similowski T, Willer JC, Pierrot-Deseiligny C, Bolgert F (November 2005). "Vivid dreams, hallucinations, psychosis and REM sleep in Guillain-Barré syndrome". Brain. 128 (Pt 11): 2535–45. doi:10.1093/brain/awh585. PMID 16000335.
  10. ↑ Mattle, Heinrich (2017). Fundamentals of neurology : an illustrated guide. Stuttgart New York: Thieme. ISBN 9783131364524.
  11. ↑ Kuwabara S, Nakata M, Sung JY, Mori M, Kato N, Hattori T, Koga M, Yuki N (July 2002). "Hyperreflexia in axonal Guillain-Barré syndrome subsequent to Campylobacter jejuni enteritis". J. Neurol. Sci. 199 (1–2): 89–92. PMID 12084449.
  12. ↑ Kuwabara S, Ogawara K, Koga M, Mori M, Hattori T, Yuki N (August 1999). "Hyperreflexia in Guillain-Barré syndrome: relation with acute motor axonal neuropathy and anti-GM1 antibody". J. Neurol. Neurosurg. Psychiatry. 67 (2): 180–4. PMC 1736477.

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