🧠Acute Flaccid Paralysis - Proforma

1. Presenting History

Provide an exhaustive, chronological account of the patient's complaints. You must ask targeted follow-up questions to gauge the depth, severity, and exact trajectory of the illness.

• Weakness / Inability to move limbs:
  • Onset: When exactly did the weakness start? (Acute vs. hyperacute).
  • Progression: Is it ascending (lower limbs $\to$ trunk $\to$ upper limbs) as seen in Guillain-Barré Syndrome (GBS) or descending (cranial nerves $\to$ upper limbs $\to$ lower limbs) as seen in Botulism or snake envenomation?.
  • Symmetry: Is it bilaterally symmetrical (GBS, Transverse Myelitis, Hypokalemic periodic paralysis) or asymmetrical (Poliomyelitis, traumatic neuritis)?.
  • Proximal vs. Distal: Does the child have difficulty getting up from a squatting position/bed (proximal/trunk) or difficulty holding a tumbler/slippers slipping off (distal)?.
  • Fluctuation: Is there diurnal variation or fluctuation in weakness (Myasthenia Gravis)?.
• Pain / Sensory Symptoms:
  • Is there diffuse pain/myalgia throughout the limbs (prominent in early GBS or viral myositis)?.
  • Is there severe radicular back pain or girdle pain (Acute Transverse Myelitis - ATM)?.
  • Is there tingling, numbness, or loss of hot/cold sensation?.
• Cranial Nerve / Bulbar Symptoms:
  • Is there difficulty swallowing, nasal regurgitation of liquids, reduction in voice volume, or choking (Bulbar palsy/CN IX, X)?.
  • Is there drooping of eyelids (ptosis), diplopia, or blurring of vision (CN III, IV, VI / NMJ disorders)?.
  • Is there facial weakness (e.g., sleeping with eyes half-open) (Bilateral facial palsy in GBS)?.
• Respiratory Symptoms (Crucial for Triage):
  • Is there breathlessness, fast breathing, or a weak cough (imminent respiratory failure)?.
• Autonomic Symptoms:
  • Is there excessive sweating, palpitations, or fluctuations in temperature/blood pressure?.
• Sphincter / Bladder & Bowel Symptoms:
  • Is there difficulty initiating micturition, acute retention, or incontinence? (Early, persistent bladder involvement points to ATM, whereas it is transient or absent in GBS/Polio).

2. Negative History (3C 1D Framework)

To arrive at a precise anatomical and etiological diagnosis, you must aggressively rule out conditions. Present this in the following tabular format to the examiner.

3. Other Relevant History

• Past History: Any chronic medical illness (e.g., chronic kidney disease causing uremic neuropathy, lymphoma/leukemia causing infiltration).
• Antenatal/Birth History: Any history of maternal illness, prolonged labor, or birth asphyxia (important if the child is an infant presenting with hypotonia/AFP).
• Nutritional History: Assess for severe malnutrition, vitamin deficiencies (Vitamin B1, B12, scurvy causing pseudo-paralysis).
• Immunization History: Strictly document OPV/IPV status (crucial for AFP surveillance), DPT, and Anti-Rabies Vaccine (ARV).
• Family History: Family history of neuromuscular disorders, periodic paralysis, or autoimmune diseases.
• KAP / Socioeconomic: Knowledge about polio eradication, sanitation, and hygiene.

4. History Summary

Examiners expect a crisp, chronological summary solely based on history before you touch the patient.

Template: "To summarize, we have a [Age]-year-old [Sex], born to [Non-consanguineous/Consanguineous] parents, presenting with an acute onset of [Symmetrical/Asymmetrical], [Ascending/Descending] flaccid weakness of [All four limbs / Specific limbs], progressing over [Duration in hours/days], currently affecting proximal more than distal musculature. This is associated with/without [Pain/Sensory level], with/without [Bulbar/Cranial nerve involvement], with/without [Respiratory distress], and with/without [Bowel/Bladder involvement]. There is a preceding history of [URI/GI illness/Fever], but no history of trauma, tick bites, similar past episodes, or altered sensorium. Based purely on history, this is a case of Acute Flaccid Paralysis localizing most likely to the [Peripheral Nerves/Nerve Roots/Anterior Horn Cell/Spinal Cord], with the primary differential being [Guillain-Barré Syndrome / Acute Transverse Myelitis / Poliomyelitis].".

5. General & Head-to-Toe Examination

Ensure airway, breathing, and circulation (ABC) are stable before proceeding.

• Vitals:
  • Heart Rate & BP: Look for tachycardia, bradycardia, and labile hypertension/hypotension (Cardiovascular dysautonomia common in GBS).
  • Respiratory Rate & Pattern: Look for paradoxical breathing (diaphragmatic weakness), use of accessory muscles, or shallow breaths.
• Anthropometry: Note height, weight, and head circumference.
• General Markers:
  • Observe for signs of Pseudo-paralysis: Does the child cry excessively on handling the limb? Check for scorbutic rosary, joint swelling (hemarthrosis, septic arthritis).
  • Look for tick bites, snake fang marks, cellulitis, or injection abscesses.
• Spine & Cranium:
  • Palpate the spine for severe localized tenderness or gibbus (compressive myelopathy, epidural abscess, TB spine).
• Abdomen:
  • Percuss and palpate the suprapubic area for a distended bladder (indicates autonomic/spinal cord involvement).

6. Systemic Examination (Neurological)

A. Higher Mental Functions (HMF)

Normally preserved in classic AFP (GBS, Polio, ATM). If altered sensorium or behavioral disturbances are present, consider ADEM, meningoencephalitis, or AIP with encephalopathy.

B. Cranial Nerves

• CN II, III, IV, VI: Look for ptosis, ophthalmoplegia, or pupillary areflexia. (Present in Myasthenia, Botulism, Snake bite, Miller Fisher variant of GBS).
• CN VII: Check for bilateral facial weakness. Ask the child to close their eyes tight; check if they sleep with eyes half-open (Bell's phenomenon). Look for loss of nasolabial folds.
• CN IX, X: Check gag reflex, palatal movement, pooling of saliva, nasal twang, or hoarse voice (Bulbar palsy).
• CN XI: Check shoulder shrug and neck turning.
• CN XII: Look for tongue fasciculations or deviation.

C. Motor System

Check limb-by-limb, side-by-side, proximal vs. distal.

• Attitude/Posture: Frog-like posture (severe hypotonia).
• Bulk: Usually normal in acute phases (GBS/ATM). Atrophy/wasting is a late sign (Poliomyelitis).
• Tone: Check resistance to passive movement. Should be flaccid/hypotonic in AFP. (Note: ATM presents with spinal shock/flaccidity initially, becoming spastic later).
• Power (MRC Grading 0-5):
  • Test proximal (shoulder abduction, hip flexion) vs. distal muscles (grip, ankle dorsiflexion).
  • Test Neck Muscles: Can the child lift their head off the bed? (Neck flexor weakness is profound in severe myopathies/GBS).
  • Test Trunk Muscles: Can the child sit up without support?.
  • Test Respiratory Muscles: Single Breath Count (ask child to take a deep breath and count 1-20; decreasing counts indicate impending respiratory failure). Assess shoulder abduction (C5), as C3-C5 controls the diaphragm.
• Reflexes:
  • Deep Tendon Reflexes (DTR): Biceps, Triceps, Supinator, Knee, Ankle. Usually absent or severely diminished (areflexia) in GBS and Polio.
  • Superficial Reflexes: Abdominal, cremasteric.
  • Plantar Response: Mute/No response in profound neuropathy/GBS. Extensor (Babinski positive) strongly points to a Spinal Cord lesion (ATM).

D. Sensory System

• Test pain (pinprick), touch, temperature, joint position, and vibration.
• Crucial: Establish if there is a definitive Sensory Level (e.g., loss of all modalities below T10). This confirms a spinal cord lesion (ATM) over a nerve root lesion (GBS).

E. Cerebellar & Meningeal Signs

• Check for nystagmus or ataxia (Miller Fisher Syndrome).
• Check for Neck stiffness, Kernig's, and Brudzinski's signs. (Meningism can be positive in Poliomyelitis and occasionally GBS).

Tabular Summary of Expected Findings in AFP Differentials

7. Final Summary & Diagnosis

Conclude your presentation with a powerful, comprehensive single string that gives the examiner the exact clinical picture.

Clinical Summary Template: "To conclude, we have a conscious, oriented Age-year-old Sex presenting with an acute-onset, progressive, Symmetrical/Asymmetrical flaccid Quadriplegia / Paraplegia, involving proximal and distal musculature, accompanied by Neck and Trunk muscle weakness. Examination reveals generalized hypotonia, global areflexia, and a Flexor/Extensor/Mute plantar response. There is Presence/Absence of a definitive sensory level, Presence/Absence of bulbar and bilateral facial nerve palsy, and Presence/Absence of bladder distension. Currently, the child is maintaining respiratory effort with a normal single breath count and has stable hemodynamics.".

Final Diagnosis Format: "My final clinical diagnosis is Acute Flaccid Paralysis, most likely a polyradiculoneuropathy secondary to Guillain-Barré Syndrome (Acute Inflammatory Demyelinating Polyradiculoneuropathy), currently in the progressive phase, with bulbar involvement, but without impending respiratory failure or overt dysautonomia.".