Pick any Acute Disease: Use Guillain-Barré syndrome . Follow the Soap Note Rubric as a guide Use APA format and must include minimum of 2 Scholarly Citations. Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program) Copy paste from websites or textbooks will not be accepted or tolerated. The use of templates is ok, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.

SOAP Note: Guillain-Barré Syndrome

Subjective:
A 45-year-old male patient, Mr. Smith, presents to the clinic with complaints of ascending weakness, difficulty walking, and numbness in his legs. The patient reports that his symptoms started two weeks ago, following a mild upper respiratory tract infection. He denies any recent trauma or travel. Additionally, he states that his bowel and bladder function is intact, and he denies any difficulty with speech or swallowing. The patient has no significant past medical or surgical history, and he is not taking any medications. He works as an accountant and denies smoking or alcohol use.

Objective:
On physical examination, the patient is cooperative, alert, and oriented to person, place, and time. Vital signs are within normal limits. The neurological examination reveals symmetric proximal muscle weakness in the lower extremities, with 4/5 strength in hip flexors and 3/5 strength in ankle dorsiflexors. Deep tendon reflexes are absent, and there is decreased sensation to light touch and pinprick in a stocking-glove distribution. Cranial nerves, coordination, and sensory modalities are otherwise intact. Examination of other systems reveals no abnormalities.

Assessment:
Based on the patient’s clinical presentation and physical examination findings, the most likely diagnosis for Mr. Smith is Guillain-Barré syndrome (GBS). GBS is a rare autoimmune disorder characterized by symmetric ascending muscle weakness and areflexia or hyporeflexia. The exact etiology of GBS is unclear; however, it often follows an antecedent infection, most commonly respiratory or gastrointestinal in nature. In GBS, the immune system mistakenly attacks the peripheral nerves, leading to demyelination and axonal damage.

Plan:
1. Confirm the diagnosis: In order to confirm the diagnosis of GBS, additional testing is warranted. Electrophysiological studies such as nerve conduction studies (NCS) and electromyography (EMG) can be performed to evaluate the degree of nerve damage and the presence of demyelination versus axonal damage. Cerebrospinal fluid (CSF) analysis, including protein levels and cell count, should also be obtained to support the diagnosis.

2. Symptomatic management: Due to the potentially rapid progression of GBS, hospital admission is recommended for close monitoring and initiation of treatment. Intravenous immunoglobulin (IVIG) or plasmapheresis should be considered as the mainstay of treatment to reduce the duration and severity of symptoms. Pain management with non-opioid analgesics should be provided, and physical therapy should be initiated to prevent joint contractures and maintain muscle strength.

3. Respiratory support: Given the potential involvement of respiratory muscles in GBS, it is crucial to monitor for any signs of respiratory distress or failure. Serial pulmonary function tests should be performed to assess respiratory muscle strength. Intubation and mechanical ventilation may be necessary in severe cases of respiratory compromise.

4. Prophylaxis: Given the prolonged immobilization often associated with GBS, patients are at increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Thus, prophylactic measures such as intermittent pneumatic compression devices and low molecular weight heparin should be initiated to prevent thromboembolic events.

5. Psychological support and rehabilitation: GBS can have significant physical and psychological consequences. Therefore, it is important to provide psychological support to the patient and their family. Additionally, early rehabilitation including physical therapy, occupational therapy, and speech therapy should be incorporated to promote functional recovery and reduce long-term disabilities.

References:

1. Dimachkie MM, Barohn RJ. Guillain-Barré syndrome and variants. Neurol Clin. 2013;31(2):491-510.
2. Van den Bergh PYK, Rajabally YA. GBS classification and diagnostic criteria. Lancet Neurol. 2018;17(5):422-423.