# In the Unit ed States Court of Federal Claims

OFFICE OF SPECIAL MASTERS

No. 14

- 931V Filed: March 18 , 201 9

* * * * * * * * * * * * * * * LISA JOHNSON,

Petitioner,

v.

SECRETARY OF HEALTH AND HUMAN SERVICES,

Respondent. *

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* To Be Published

Finding of Facts; Onset; Influenza (“Flu”) Vaccine; Polymyalgia Rheumatica (“PMR”)

* * * * * * * * * * * * * * *

Howard Gold, Esq ., Gold Law Firm, LLC, Wellesley Hills, MA, for petitioner. Heather Pearlman, Esq ., U.S. Department of Justice, Washington, DC, for respondent.

RULING ON ONSET 1

Roth , Special Master:

On October 1, 2014, Lisa Johnson (“p etitioner”) filed a petition pro s e , pursuant to the National Vaccine Injury Compensation Program , 42 U.S.C. § 300aa

- 10 et seq

. 2 ( “Vaccine Act ” or “the Program” )

. Petitioner alleged that as a result of an i nfluenza (“flu”) vaccination she received

on October 9, 2011, she developed polymyalgia rheumatic a (“PMR ”). Petition at 1, ECF No. 1.

Respondent submits that the medical records do not support a compensable injury. Additionally, and for purposes of this hearing, respondent submits that onset is an issue making a

1 This Ruling has been designated “to be published,” which means I am directing it to be posted on the Court of Federal Claims’s website, in accordance with the E

- Government Act of 2002, Pub. L. No. 107

- 347, 116 Stat. 2899, 2913 (codified as amended at 44 U.S.C. § 3501 note (2006)). This means the Ruling will be available to anyone with access to the internet. However, the parties may object to the Ruling ’s inclusion of certain kinds of confidential information. Specifically, under Vaccine Rule 18(b), each party has fou rteen days within which to request redaction “of any information furnished by that party: (1) that is a trade secret or commercial or financial in substance and is privileged or confidential; or (2) that includes medical files or similar files, the disclos ure of which would constitute a clearly unwarranted invasion of privacy.” Vaccine Rule 18(b). Otherwise, the whole Ruling will be available to the public. Id

.

2 National Childhood Vaccine Injury Act of 1986, Pub. L. No. 99

- 660, 100 Stat. 3755. Hereinafter , for ease of citation, all “§” references to the Vaccine Act will be to the pertinent subparagraph of 42 U.S.C. § 300aa (2012).2

t emporal associ ation impossible. Rule 4(c ) Report (“Resp. Rpt.”) at 9 n. 7; Respondent’s Post

Hearing Brief (“Resp. Br.) at 10

- 11.

A fact h earing was held on March 26, 2018, during which petitioner testified via videoconferencing.

This R uling is intended to clarify the onset of petitioner’s complaints of PMR and must be given to each expert witness for the purpose of authoring expert reports

. In writing their reports, the experts must rely on the factual findings contained in this Ruling.

Upon careful review of all the medical records, medical literature, affidavits and testimony, I find that the contemporaneous medical records and histories provided by petitioner to her medical providers more accurately reflect the timeline of her health events than her affidavits and testimony

. Specific factual findings are set forth in detail below

. In summary, I find that petitioner’s onset of PMR occurred in March of 2012.

I. Procedural History

For purposes of the onset hearing, t he p etition was filed pro se on October 1, 2014 and assigned to Special Master Hamilton

- Fieldman. See generally , Petition, ECF No. 1 ; Notice of Assignment, ECF No. 3

. On December 3, 2014, Howard Gold substitu ted in as counsel of record for petitioner. ECF No. 8. An Amended Petition ( “ Am. Pet. ” ) , medical records

, an affidavit, 3 and a Statement of Completion were filed on March 5, 201 5. Petitioner’s Exhibits (“Pet. Ex.”) 1

- 6, E CF No. 15; Am. Pet. , Statement of Completion, ECF No. 16

. The Amended Petition stated, “On or about January 1, 2012, Lisa began to experience muscle fatigue and pain

, parti cularly in the morning.” Am

. Pet. at 2.

Respondent filed his Rule 4( c) Report on May 28, 2015 , stating that this matter was not appropriate for compensation

. ECF No. 19. Respondent submitted , “[P]etitioner’s symptoms as she described historically while seeking medic al treatment began in Jan uary

- February 2012 at the earliest and may have started in March 2012.” Resp. Rpt. at 9 n.7

. During a status conference held on June 3, 2015, petitioner’s counsel conceded that the first medical visit after vaccination was on April 30, 2012 but maintained that the onset of petitioner’s injury occurre d on or about January 1, 2012. Scheduling Order at 1, ECF No. 22. Counsel asked for time to determine if ad ditional documentation of onset existed. Id

. Respondent submitted that petitioner reported p ins and needles sensation and pain in her legs during an October 3, 2011, visit with her physician; therefore, the onset of her symptoms may have pre

- dated her vaccination

. Id

. Pet itioner was ordered to file an a ffidavit and/or other supportive information regarding the timing of onset of her al leged injury. Id

. Petitioner filed a supplemental affidavit on July 1, 2015 along with additional documentation. Pet. Ex. 7

, ECF No. 23.

3 Petitioner’s affidavit was filed as Pet. Ex. 2. ECF No. 15.3

On Augu st 8, 2015, respondent filed a status r eport (“Resp. S.R”) advising that he had reviewed the additional documents filed by petitioner and his position had not changed

. Resp. S.R., ECF No. 24.

This matter was reassig ned to me on January 14, 2016. See ECF No s . 31, 32

. An onset hearing took place in Washi ngton, D.C.

, on March 26, 2018. Following the h earing, petitioner was ordered to produce all blood tests and lab reports performed at her place of employ ment fro m July 2009 through and including July 201 2; P atient Intake Forms for visits with Dr. McPhillip s on October 3, 2011, April 30, 2012 and June 7, 2012 ; and t he New Patient Intake Form for July 11, 2012 and intake form for August 8, 2012 fro m Dr. Fadi Badlissi. Scheduling Order at 1

, ECF No. 61.

On May 25, 2018, petitioner filed a s tatus report (“Pet. S.R.”) advising that there were no record s of any of the blood test s she performed on herself at her place of employment. Pet. S.R. at 1, ECF No. 62. She f

urth er advised that all of Dr. Badlissi’s records had been filed as Pet. Ex. 5, and no additional intake forms existed. Id

. On Ju ne 6, 2018, petitioner filed a s tatus report stating that all of Dr. McPhillips’ record s had been filed as Pet. Ex. 4; no additional intake forms existed. Pet. S.R. at 1, ECF No. 66.

P ost

- hearing brief

s were filed on August 20, 2018 and October 6, 2018, respectively

. See ECF No s

. 71 , 74

. This matter is now ripe for ruling

.

II. The Factual Record

A. Petitioner’s History Prior to the Flu Vaccine

Petition er was born on August 3, 1955. Pet. Ex. 1 at 1. She has been married for forty years and has two sons, Curtis and Brett. Tr. 6

- 7. Petitioner has a degree in Medical Technology from Lasell College in Newto n, Massachusetts, and a post

- college certification as a medical administrator. Tr. 8. For the past t wo years, she has worked as a nursing lab coordinator for an Accelerated Bachelor’s Degree in Science and Nursing Program at Northeastern University . Tr. 7. Previously, and at the time of the allegedly causal vaccination

, she worked for Diagnostic Laborato ry Medicine (“Diagnostic”) for nineteen years as a field supervisor, dispatching four phlebotomists into the field for over 400 calls a month. Tr. 7

- 9. From 2009 to 2013, petitioner received a yearly flu vaccine, including the allegedly causal vaccine, thr ough Sargent and Associates, a su bcontractor hired by Diagnostic . Tr. 36, 44

- 45; Pet. Ex. 3 at 1; Pet. Ex. 4 at 47. She also had received hepatitis B and measles

- mumps

- rubella vaccinations in the past. Tr. 45; Pet. Ex. 4 at 47.

Petitioner’s prior medical history includes antibiotic

- induced h epatitis, gastroesophageal reflux disease (“ GERD ”) , Morton’s neuroma

, osteopenia, and diverticulosis. Tr. 38

- 39; Pet. Ex. 4 at 2, 8, 15. She has a history of tick bites, one on October 9, 2008, after which she was tested for Lyme disease, and one in May of 2011, for which she was treated prophylactically with antibiotics

.4

Tr. 38; Pet. Ex. 4 at 1, 19. P etitioner described her self as in excellent health prior to her October 9, 2011 flu vaccine. Tr. 10; Pet. Ex. 2 at 1.

On May 16, 2011, petitioner presented to her primary care physician, Dr. McPhillips

, for routine exam ination

. Pet. Ex. 4 at 20. She ha d been going to Dr. Mc Phillips for several years and had a “fairly good” relationship with her. Tr. 75

- 76. P etitioner reported working full time in an area lab oratory ; her children were older and had graduated from college

. Pet. Ex. 4 at 20. She was considering retiring to So uth Carolina with her husband. Id

. D r. McPhillips described petitioner as

a 55

- year

- old woman in excellent health

. Id

. Recommendations for calcium and vitamin D supplements were reviewed and bone density testing and a mammogram were scheduled. Id

. at 21. The remainde r of the record is redacted

. Id

. At hearing , p etitioner did not recall taking calcium and vitamin D. Tr. 99

- 100. She recalled a bone density test being ordered and stated that it was routine. Tr. 100.

In June of 2011, petitioner’s husband moved to South Carolina for a job. Tr. 17. They moved out of the home they rented , and petitioner rent ed a room at a ho me in Bedford. Tr. 67.

Petitioner next presented to Dr. McPhillips on August 4, 2011, with complai nts of post

menopausal spotting. Pet. Ex. 4 at 23. Dr. McPhillips ordered an ultrasound, CBC, 4 and Pap smear. Id

. Bone density testing performed on September 16, 2011, was normal at two sites in her left hip, but revealed osteopenia in her spine at L1 t h rough L4. Pet. Ex. 4 at 28

- 29. I asked petitioner if the bone density testing concentrate d on her left hip because she had left hip pain . Tr. 100. She recalled having left hip pain “occasionally,” but did not recall if she had left hip pain in May of 2011 or when the last time was that she had left hip pain. Tr. 100

- 01.

Petitioner presented to Dr. McPhillips o n October 3, 2011 with complaints of pins and needles on her left lateral calf on occasion, occasional left lower medial thigh discomfort and occasional pain going from her low back to her left lateral thigh. Pet. Ex. 4 at 31. She did not have weakness or difficulty with stairs or brisk walking. Id

. She did not have morning stiffness but was stretching in the morning. Id

. She did not engag e in regular exercise. Id

. Dr. McPhillips noted that petitioner had normal peripheral vasculature; she suggested that an L4/5 nerve root irritation was causing intermittent tingling. Id

. She recommended r egular exercise and stretching. Id

. If her symptoms increased, further evaluation would be ordered

. Id

. Her active medications on that date included estradiol cream and omeprazole . The remainder of that portion of the record was redacted

. Id

.

Petitioner testified that she had “strange pins and needles feelings in my lower outside and inner leg, thigh,” that had been going on for a “short while, but it would have been enough for me

4 A “CBC,” or complete blood count, is a series of tests of the peripheral blood, including measurements of red blood cell count, hemoglobin, hematocrit, white blood cell count, and platelet count. The CBC is inexpensive and easily and rapidly performed. It is frequently used as a screening test. See M OSBY ’ S M ANUAL OF D IAGNOSTIC AND L ABORATORY T ESTS 156

- 57 ( Kathleen Desk Pagana & Timothy J. Pagana eds., 6 th ed. 2018) [hereinafter M OSBY ’ S ].5

to come see her.” Tr. 14

- 15. She recalled that Dr. McPhillips at tributed this to “something in the lower back that may have pinched my leg.” Tr. 15.

When asked about the back pain, petitioner did not recall where the pain originated from, but though t it was “[s]omething like sciatica.” Tr. 71. She could not recall whether she had lower back pain when moving from a sitting to a standing position. Tr. 71. She could not remember whether she had difficulty getting out of bed in the morning. Tr. 73. She could not recall whether she took Advil or other medicati on for pain. Tr. 72

- 73. She could not recall being prescribed medication or physical therapy for her back pain at that time . Tr. 101. She recalled being told to exercise, but could not recall what she did for exercise, sayi ng, “I may have walked, I may hav e done the treadmill, something like that.” Tr. 72. She could not re call when the back pain began or when it resolved. Tr. 72. She did not recall any events related to the onset of the back pain. Tr. 102

- 03. Petitioner agreed that when she saw Dr. McPhilli ps o n August 4, 2011 , she did not have back pain; therefore, the pain must have started sometime between August of 2011 and October 3, 2011. Tr. 102.

B. Petitioner’s History Following the Flu Vaccine

Petitioner received the flu vaccine on October 9, 2011 while at work

. Pet. Ex. 3 at 1. Petitioner provided two affidavits in this case, one on March 5, 2015 and one on June 30, 2015. Pet. Ex. 2; Pet. Ex. 7. In her first affidavit, petitioner stated, “Beginning around New Year’s 2012 I began to have difficulty getting out of bed in the morning due to muscle fatigue and muscle aches.” Pet. Ex. 2 at 1. In her second affidavit, petitioner stated that her symptoms “began no later than Christmas week in 2011” when she “began to have difficulty physically getting out of my bed due to muscle fatigue and muscle aches.” Pet. Ex. 7 at 1. At hearing, p etitioner testified that she began to experience elbow and hip pain, achy muscles, and difficulty with daily activities during Christmas of 2011 and New Year’s of 2012. Tr. 1 5

- 16.

Petitioner submitted that between November of 2011 through March of 2012, she was caring for her elderly parents , was unable to take time for her own medical needs and did not appreciate the extent of her illness . Pet. Ex. 7 at 2. More specifically, p etitioner explain ed that between November of 2011 and March of 2012, her father had five hospitalizations due to coronary heart failure, a valve replacement, and aortic stenosis. 5 Tr. 18, 20, 28. She was helping her mother with her chronical ly

- ill father, taking her father to doctor’s appointments

, and assisting with his in

- patient needs. Tr. 19

- 20, 28. She also did the grocery shopping for her parents and paid the bills. Tr. 51

- 52. Her mother was 88, and “[s]he was doing okay, but she was fr ail, and she wasn’t quite sure of herself.” Tr. 21.

Petitioner stated that they did not celebrate Thanksgiving in 2011 because her father was discharged from the hospital on November 16, 2011. Tr. 50

- 51. Her father was in the hospital again from December 18 to 22, 2011; she tried to help her mother with Christmas decorating and cooking but felt like she did not have the strength she usually had. Tr. 16

- 17. “I thought, well,

5 These hospitalizations occurred on Nov. 11

- 16, 2011; Dec. 18

- 22, 2011; Jan. 4

- 9, 2012; Jan. 28

- 30, 2012; and Feb. 24

- 29, 2012. Tr. 20 ; see generally Pet. Ex. 7.6

okay, I’m doing too much.... But I’m not much of a complainer, so I just said, o kay, we’re going to see if this works through.” Tr. 16

- 17

, 47

.

Petitioner testified that around the end of February of 2012, her mother began complaining of confusion and hallucinations and was diagnosed with glioblastoma. 6 Tr. 21

- 22. She was hospitalize d at the same hospital where petitioner’s father was being treated

. Tr. 22. No treatment was rendered due to her age. Tr. 23. Both of h er parents were sent to the same rehabilitation center where they stayed together until her mother’s passing at the end of March of 2012. Tr. 23; Pet. Ex. 7 at 2. Her father stayed at the center for about two weeks after her mother’s death and was then sent home. Tr. 23

- 24. At that time, s he became her father’s full

- time careta ker since she was the most available of her siblings. Pet. Ex. 7 at 2. Petitioner stated that visiting nurses and nursing agencies came to the house to care for her father

, while she coordinated that care and gave him his medication . Tr. 69. She moved her father to an a ssisted living facility around the end of summer of 2012 and his house was sold. Tr. 91

- 92.

In her affidavit, pe titioner stated by February of 2012, she was living at her parents’ home while her husband was living in South Carolina. 7 Pet. Ex. 7 at 2. At hearing, she testified that between November of 2011 and February of 2012, she “pretty much” moved in with her parents, work ed from 5:00 am until 1:30 pm and then went to their home to deal with their needs. Tr. 19, 28

- 29

, 37 . She later stated that she did not live with her parents full

- time. “I was leaving at night, [and] sleeping where I rented my place.” Tr. 68

- 69. Petitioner ultimately stated that she moved into her parents’ house shortly before her mother died in March because her father needed the hel p. Tr. 67

- 68.

Petitioner agreed that after her October 9, 2011 flu vaccination

, she visited Dr. McPhillips on two occasion s , April 30, 2012 and June 7, 2012

. Pet. Ex. 2 at 2.

On April 30, 2012, petitioner presented to Dr. McPhillips with elbow and hip pain. Pet. Ex. 4 at 32. Dr. McPhillips’ record for that visit reads:

... [B] ilateral elbow pain right greater than left and bilateral lateral hip pain right greater than left. She feels she is too old to be aching like this

. She works on the treadmill several days a week and does not do other exercise.... She has no numbness or tingling he [sic] denies weakness of her extremities. Patient has history of low back pain with radiation to the left but this resolved several months a go.

Pet. Ex. 4 at 32. Dr. McPhillips’ assessment was bilateral hip abductor tendinitis / gluteus medius syndrome with no evidence of iliotibial band or trochanteric bursitis. Id

. An exercise routine to include non

- weightbearing activities or elliptical exer cise and physical therapy if things were not improving was recommended

. Id

. Petitioner’s elbow pain w as diagnosed as medial epicondylitis;

6 Glioblastoma is the most malignant type of astrocytoma, one of the most common primary tumors of the brain. Glioblastoma is classified as Grade IV and grows rapidly. Glioblastoma

, D ORLAND ’ S I LLUSTRATED M EDICAL D ICTIONARY 784 (32 ed. 2012) [hereinafter D OR LAND ’ S ].

7 Petitioner’s husband relocated to South Carolina in June or July of 2011 to work for a friend. Tr. 17.7

s he was directed to sleep with her elbows straight and wrapped in towels

, and to avoid resting her elbows on armrests. Id

. Dr. McPhillips deferred bloodwork for petitioner’s next visit which was scheduled for the following month. Id

. An entry under “Medications” was redacted

. Id

. At hearing, p etitioner was provided with the record for that date and confirmed that it was an accurate description of her complaints at th at time but stated she had reported she was “too young to feel like this” not “too old.” Tr. 24

- 26; Pet. Ex. 4 at 32. Petitioner added that she went to see Dr. McPhillips in April of 2012 when she “realized that what I was experiencing had not gone away, and I needed to have it, you know, addressed.” Tr. 24.

In her second affidavit, petitioner distinguished her October 2011 complaints of pi ns an d needles from the muscle aches, fatigue and soreness “over many areas of my body” that she experienced following the influenza vaccine

. ” Pet. Ex. 7 at 2. At hearing, she described it as “[S]oreness, as opposed to numbness and tingling. Very sore. Like sor e muscles, as if you over exercised.” Tr. 70

- 71

. She added that her shoulder, elbow, h ip joints and muscles felt very sore since the Christmas/New Year’s holiday of 2011. Tr. 24

- 25. She later described the symptoms i n December of 2011, as “more like an insidious feeling of something just creeping up on you, where
you

— you know something is different, and you’re not quite sure what it is.” Tr. 98. She then stated that the soreness and achiness around Christmas of 2011 was similar to the sore ness and achiness she experienced in April of 2012, “but in a more vague way.” The hip pain was similar. Tr. 97. She stated her symptoms in April w ere “elbow pain that [Dr. McPhillips] attributed to tendonitis.” Tr. 24. She added that she felt the worst in the morning , took two Advil in the mo rning and two at around 1 p.m., and felt better by the afternoon as she moved around. Tr. 27.

The record for April 30, 2012, does not mention aching, morning stiffness

, or joint inflammation. Tr. 52. There is no ment ion of petitioner ta king Advil or having difficulty getting out of bed. Tr. 58

- 59. Petitioner was unable to recall if she was taking Advil at that time. Tr. 75.

The record for April 30, 2012 d id not reflect a timeline reported to Dr. McPhillips of when petitioner’s complaints began , the ir duration or the ir progression. Tr. 77

- 79. When asked why she did not advise Dr. McPhillips of the duration of her symptoms or when they began

, petitioner
stat ed , “I thought she might have some ideas of maybe it was arth ritis or something. She

— and I do believe she did x

- rays of my shoulders.” Tr. 77. When it was pointed out that she did not complain in April about her shoulders, only her elbows, petitioner stated that she must have complained about her shoulders in July. Tr. 77. Petitioner stated she told Dr. McPhillips that she “had soreness that had been going on for too long,” later specifying, “Four months.” Tr. 79

- 80. The record did not document how long her complaints had persisted. Tr. 79.

Dr. McPhillip s’ record for April 30, 2012 did not reflect what petitioner was testifying to or how long she had been having problems with her hips and elbows

. Petitioner stated that would be information one would typically mention to his or her doctor. Tr. 76, 78. Petitioner sta ted that she had no reason to believe that Dr. McPhillips did not write down everything that she told her. Tr. 82.

In an effort to reconcile petitioner’s testimony with what was contained in the record, she

was questioned about her reported use of a treadmill after her October 2011 visit with Dr.8

McPhillips to determine the onset of petitioner’s hip pain, soreness, and achiness as oppose d to the calf tingling and low er back pain into her leg

. Tr. 73

- 75. Petitioner stated that “several days a week,” during her lunch break

, she walked on a treadmill in the building adjoining her office but could not recall how many months or even which months she used the treadmill

. Tr. 73

- 74. “I don’t think it lasted long. The facility revoked the privileges. ” 8 Tr. 87. When asked if she then
start ed walking outside instead, she stated tha t she does like to walk and to be outside, “ so it’s possible. ” Tr. 87

- 88. I asked petitioner whether she thought walking on the treadmill helped her low er back pain ; s he could not recall . Tr. 75.

Dr. McPhillips deferred ordering any blood work at the April 30, 2012 appointment . Tr. 53. However, petitioner testified to having p erformed her own blood work at her place of employment that showed an elevated ESR

, which she reported to Dr. McPhillips. Tr. 56

- 57, 85

. She could not recall whether she did the blood work in April, May, or June of 2012. Tr. 55

- 56, 84. She believed it was in April, knew that an elevated ESR indicated inflammation, and noted “it’s probably what prompted me to go” to Dr. McPhillips. Tr. 55

- 57. The April 30, 2012 medical record did not document any blood work showing an elevated ESR being reported by petitioner. Tr. 58.

Petitioner was questioned about the circumstan ces in which she performed blood work at her place of employment. She explained “if something was happening,” she would have blood drawn and run through the analyzer to have controls for herself. Tr. 83. Other times, a group of employees would be asked to do bloodwork on themselves for use as normal controls. Tr. 83. During her 19 years at the lab, she had blood work done as part of a c ontrol group “maybe once a
year, ” but she could not recall what time of year that blood work occurred. Tr. 83

- 84

. Petitione r initially testified that she was unable to obtain the blood work result she performed on herself because “it was off the record. It was not a documented lab report...” but later testified that all blood draws, whether done as part of a control group or at her own behest would be in her personnel file. Tr. 53

- 54, 84. She stated that o ver the years, she has had blood drawn at her own insistence five times. 9 Tr. 84

- 85. Petitioner provided no explanation as to why she had previously requested blood draws for herself.

Petitioner did not return to Dr. McPhillips until June 7, 2012

, which was a previously scheduled routine examination. Tr. 30. The record for the June 7, 2012 visit states:

A rthralgias myalgias

- complaini ng of bilateral hips, shoulders and elbow pain wh en she awakens in the morning. Feels sore for the first 4 hours of the day. Things got better aft er taking 2 Advil which he [sic] now tak es when she gets up with food. The r est of the day she feels well. Patient took labs on herself where she works

–

8 Records from the gym were requested but were not filed

.

9 Records of these blood draws were ordered post

- hearing, but none was filed.9

sedimentati on rate 10 was 35 and CRP 11 was 1.7. Patient denies rash, joint warmth or swelling

, fevers, chills, sweats

. No change in her energy level. Denies any nail changes or skin changes, denie s dr y eye or dry mouth. LMP age 52.

Pet. Ex. 4 at 33. Dr. McPhillips further noted that petitioner’s mother had passed away in the spring, and petitioner was living with her 88

- year

- old father, who had chronic congestive heart failure. Id . at 33

- 34. Petit ioner was no longer exercising. Id . at 33. Her exam was normal. Id . at 34, 36. Dr. McPhillips’ assessment was “56 year

- old woman with increase in myalgi as

– repeat labs pending. Aske [sic] Rheumatology to see pt for ? connective tissue disease.” Id . at 34. Another entry was redacted

. Id

.

Petitioner testified that in June of 2012, she told Dr. McPhillips that her elbows, hips, and shoulders felt worse . Tr. 30. U nlike the medical record for the April 30, 2012 visit, the record for June 7, 2012 specifically documented complaints of joint and muscle pain, pain in both hips and shoulder s, and morning soreness lasting for about four hours. Tr. 59

- 60. Petitioner testified that this was the same pain she was experiencing at her April vis it with Dr. McPhillips

. Tr. 31, 60. P etitioner could not recall when her joint and muscle pain bega n or when she began ha ving difficulty getting out of b ed. Tr. 81. When asked if her symptoms were significantly worse bet ween April 30, 2012 and June 7, 2012, she responded, “I think by the time I saw her, yes.” Tr. 90. Petitioner testified that she started to take Advil probably in May or June, “because I saw [Dr.] Badlissi in July.” Tr. 81. The record does not reflect any phone calls from petitioner to D r. McPhillips between April and June of 2012 report ing any changes in her health . Tr. 81. Petitioner stated that her symptoms did not affect her ability to work. Tr. 90. The June record did not contain any timeline of the onset of her symptoms . Tr. 82.

Petitioner testified that on June 7, 2012, she told Dr. McPhillips she had done her own blood work and had an elevated ESR at 35. Tr. 55. The record for June 7, 2012 reflects this information . Tr. 55. When I asked petitioner if she expressed concern to the doctor about the elevated level, she stated

, “I knew it indicated inflammation. I knew it indicated a problem.” Tr. 85. Petitioner stated she had no r ecollection “of when those [ blood tests] were done,” suggesting that there may have been more than the one test performed at her work closer to June of 2012. Tr. 56. According to petitioner, the blood work from June of 2012 was done on her own impetus and not as part of a control group. Tr. 84.

At that appointment, Dr. McPhillips ordered blood work which showed an elevated ESR

, low vitamin D, and normal rheumatoid factor and CRP . Tr. 60, 85

- 86 ; Pet. Ex. 4 at 37

- 39. Petitioner tested negative for Lyme disease. Pet. Ex. 4 at 40 . Petitioner stated that Dr. McPhillips referred her to a rheumatologist, Dr. Bad lissi, for myalgias and possible rheumatoid work up following the June visit. Tr. 31, 86 ; Pet. Ex. 2 at 2

.

10 “ Sedimentation rate,” also known as “erythrocyte sedimentation rate” or “ESR,” is a non

- specific test used to detect illnesses associated with acute and chronic infection, inflammation, and tissue necrosis or infarction. ESR

, M OSBY ’ S at 199.

11 “CRP,” or C

- reactive protein , is a protein used to indicate an inflammatory illness. It is elevated in patients with a bacterial infectious disease, tissue necrosis, or an inflammatory disorder. A positive test result indicates the presence, but not the cause, of the disease. C

- reactive protein
, M OSBY ’ S at 165

- 66.10

On July 11, 2012, petitioner presented to Dr. Badlissi, a rheumatologist at Harvard Medical Faculty Physicians Musculoske le tal Clinic

. Pet. Ex. 5 at 1. She complained of arthralgias and myalgi as f

or the past five to six months

. S he noticed soreness and pain in her shoulde rs , hips and back which g radually got worse. She noticed more pain in the morning with stiffness that last ed for two hours. She reported stiffness when she sat in the car for a long time . She reported being under a lot of stress in her life as her father got ill recen tly and passed away

. Id

. Dr. Badlissi noted that petitioner’s mother had PMR. Id

. Upon exam ination

, petitioner had normal muscle strength in her upper and lower extremities with no synovitis in her joints. Id . at 2. She had proximal muscle tenderness in the shoulder area, but n ormal abduction on external and internal rotation of both shoulders although a sso ciated with pain. Id. She had normal range of motion in both hips

. Id. Her laboratory workup from June 7, 2 012 showed an elevated ESR but normal CRP, CBC, creatinine, 12 ALT, 13 low level of hydroxyvitamin D and negative for rheumatoid factor, 14 anti

- CCP
ant ibodies, 15 Lyme serologies, and Western blot. 16 Id. “She had laboratory workup done locally and her lab prior to that which showed normal CRP and C

- reactive protein mildly elevated at 35.” Id. Dr. Badlissi advised petitioner that her symptoms were consiste nt with PMR

. Id . He recommended 1 0 mg of prednisone , advising that a dramatic response would confirm a diagnosis of PMR. Id . After discussing the side effects of prednisone , petitioner opted to delay pred nisone and instead try exercise and continue ibuprof en. Id

.

A t hearing, petitioner recalled providing a history to Dr. Badlissi of five to six months

. Tr. 33

- 34. “I would have described sore muscles, difficulty getting up in the morning, soreness throughout the day, something very different about myself. It was unusual.” Stiffness getting out of the car would have been incorporated in that. Tr. 86

- 87. Petitioner ad ded she was uncertain if she told Dr. Badlissi that she had difficulty getting out of bed, but she certainly was having difficulty doing so. Tr. 86. She explained that when she said her symptoms had gradually gotten worse, she meant that the pain and stiff ness in her shoulders, elbows, and hips would not go away.

12 Creatinine is a breakdown product of creatine phosphate, which is used in skeletal muscle contraction. Creatinine

, M OSBY ’ S at 171. Increased creatinine levels can indicate impaired renal function. Id

.

13 ALT stands for “alanine aminotransferase” and is also known as serum glutamic

- pyruvic transaminase. ALT

, M OSBY ’ S at 36

- 37. ALT is an enzyme found predominantly in the liver. Id

. Injury disease affecting the liver will caused elevated ALT levels; therefore , this test is used to help identify liver diseases. Id

.

14 Rheumatoid factor (“RF”) is a combination of IgM, IgG, and IgA antibodies, which are formed in response to abnormal IgG antibodies. Rheumatoid factor

, M OSBY ’ S at 409

- 10. Tests for RF are directed toward identification of IgM antibodies. Id

. Approximately 80% of patients with RA have a positive RF, but a negative RF does not exclude a diagnosis of RA. Id . at 410.

15 Anti

- CCP antibodies , or anticyclic

- citrullinated peptide antibodies, appear early in the course of rheumatoid arthritis and are present in the blood of most patients with disease. Anticyclic

- Citrullinated Peptide Antibody

, M OSBY ’ S at 64

- 65. Other autoimmune inflammatory diseases are rarely associated with elevated anti

- CCP levels, which makes this test useful in differentiating rheumatoid arthritis from other conditions that can resemble RA, such as PMR. Id

.

16 The Western blo t assa y can specifically identify IgG and IgM antibodies and is used in diagnosing Lyme disease. Lyme Disease
, M OSBY ’ S at 3 13

- 14.11

Tr. 89

- 90. She estimated that her symptoms became worse in June of 2012 . Tr. 90.

When asked if she told Dr. Badlissi about having pain in December of 2011, she stated that he “did lots of testing ” but was not a “big conversationalist

, ” which was why she switched doctors. 17 Tr. 62. Petitioner was asked how Dr. Badlissi obtained all the information contained in h is record. Tr. 34, 62

- 63. Petitioner thought she probably filled out a form with her medi cal history and complaints at Dr. Badlissi’s office but then stated she did not recall filling out a form. Tr. 87. She did not recall whether Dr. Badlissi specifically asked when her symptoms began. Tr. 63.

Petitioner explained that the five

- to six

- month timeframe referred to when she “[f]irst recognized pain that was not going away...where I realized it was a problem. Before that, it was discomfort.” Tr. 61

- 62. She added, “He interprets it as five to six months. I don’t know whether that was somethi ng that he may have condensed into that time or whether he just did not include the

– you know, the beginning of the year.” Tr. 62. When asked if she thought the record was inaccurate, she re sponded, “No, I’m not saying I’m contradicting it, just maybe I’m describing the worst of my symptoms during that time.” Tr. 62

- 63. Petitioner did note that one part of the record from July 11, 2012, was wrong; her mother

, not her father

, passed away. Tr. 33.

Petitioner was asked about her mother’s history of PMR as documented in Dr. Badlissi’s record. Tr. 63

- 64. She stated that her mother was diagnosed with PMR in her l ate fifties or early sixties and was treated with high doses of steroids for about two years. Tr. 41

- 42. She had an immediate response to the prednisone. Tr. 4 3

. She recalled her mother saying that her PMR had a rapid onset and she could not get out of bed one morning. Tr. 42. When asked if her mother had complained of morning stiffness, pet itioner stated that her mother did not complain

. Tr. 42. Petitioner stated it was never determined whether a flu vaccine was related to her mother’s PMR. Tr. 103. When asked what other rheumatic diseases there were in her family history as noted in her med ical records, petitioner stated she did not know to what that record referred. Tr. 41; Pet. Ex. 5 at 1.

Dr. Badlissi ’s record highlighted petitioner’s hesitancy in taking prednisone when it was offered in July but the next record in August documented a d ramatic response to prednisone. Pet. Ex. 5 at 1

- 2, 4. When asked what made her change her mind

, petitioner stated “Because prednisone in a short

- term duration is powerful and effective, and I wanted to get rid of that. As far as having something that was a ttacking my system, I needed something to fight back and it wasn’t going to be Advil. And he said by testing with that, you’ll

– it will determine whether it’s PMR.” Tr. 64

- 65.

Petitioner returned to Dr. Badliss i on August 7, 2012 for a follow

- up concerning her PMR

. Pet. Ex. 5 at 4. She was started on 10 mg of prednisone on July 12, 2012 and reported a 90% improvement in her pain and stiffness within 2

- 3 days. Id . According to Dr. Badlissi, petitioner’s positive response to prednisone confirmed th e diagnosis of PMR. Id

. Petitioner had a normal CRP, but a mildly elevated ESR. Id

. Dr. Badlissi lowered her dosage of prednisone from 10 mg to 9
mg. Id

.

17 Petitioner began treating with Dr. Zangara, over a year later, on September 27, 2013.12

Petitioner returned to Dr. Badlissi on September 12, 2012 for “a clinical diagnosis of polymyalgia rheumatica with negative inflammatory markers

. ” Pet. Ex. 5 at 6. She was noted to be doing well; she denied stiffne ss or pain in her arms or legs and had been on 9 mg of prednisone since August 8 without any adverse reactions

. Id

. She had normal range of motion in both shoulders, no proximal muscle tenderness in the deltoid s , quadriceps

, or hamstrings

, a nd no synovitis in her joints. Id . Dr. Badlissi ordered a prednisone taper to 8 mg and 7 mg before going down to 6 mg on November 1 , 2012

. Id

.

Petitioner continued to treat with Dr. Badlissi over the next year. Her prednisone dosage was adjusted several times and her symptoms varied. See generally Pet. Ex. 5.

On September 4, 2013 , petitioner presented to Dr. Badlissi for a follow

- up; she was not having morning stiffness but complained of achiness in her shoulder s and back by the end of the day

. Pet. Ex. 5 at 23. D r. Badlissi documented PMR under good control overall and suggested tapering prednisone from 7 mg to 6 mg

. Id

. Labs for inflammatory markers, ESR, and CRP were ordered and were normal. Id . at 23, 25

- 30.

P etitioner sought a second opinion with Dr. Zangara on Sep tember 27, 2013. Petitioner provided a history of good health until early in 2012 when she developed musculoskeletal aches and pains primarily in the pectoral, shou lder

, and hip girdle areas , without associated weakness

. Pet. Ex. 6 at 5. She reported an elevated ESR , but ot her serologies as normal. Id

. She reported being diagnosed with PMR and placed on 10 mg of prednisone in March of 2012. Id . Around that time, she had bone density testing which showed low level osteopenia. Id

. at 6. Petitioner stated that she was seeking a second opinion because of her difficulties in reducing her prednisone dosage. Id . at 5. She explain ed that, o ver the past year and a half, she had been on vari ous doses of prednisone and had flares secondary to stress. Id

. She had some discomfort at her current dosage of 7 mg , but no inflammation or synovitis. Id . S he reported that her mother had PMR

. Id . at 6. In addition to prednisone, she was taking calcium and vitamin D. Id

. She saw an ENT for voice change and had a negative exam. Id

. She denied other conditions and diseases. Id

. According to Dr. Zangara, her exam was benign. He agreed with the diagnosis of PMR, noting that elevated CRP and ESR were “classic” for PMR, and her response to prednisone also supported the diagnosis. Id . at 6. In Dr. Zangara’s opinion, petitioner had no evidence of rheumatoid arthritis or o ther inflammatory arthropathy. Id

. He suggested the possibility of steroi d sparing use of methotrexate and advised petitioner to undergo bone density testing again due to her long

- term use of steroids. Id . He suggested that she start a p rednisone taper once she felt normal. Id

. at 7.

Pet itioner presented to Dr. McPhillips on October 1, 2013 for an “interval exam.” Pet. Ex. 4 at 46. She was noted to have a history of PMR diagnosed in June of 2012 with an E SR of 47

, CRP of 2. 5, and complaints of arthralgias/myalgias in bilate ral hips, shoulders, and elbow s

. Id

. She was seen by Dr. Badlissi but was now treating with Dr. Zangara. Id

. She was on 7 mg of prednisone. Id

. Dr. McPhillips wrote, “Patient is concerned she may have developed PMR from recei ving the flu shot 2 years ago. Reviewed the exceedingly low numbers to be related

, i .e. 12 individuals to m illions of flu shots provided. Strongly recommende d patient get flu shot today.” Id

. Petitioner received a flu shot on that day without event

. I d . at 48.13

I asked petitioner about thi s d iscussion with Dr. McPhillips. She could not recall when or why she looked for a correlation between the flu vaccine and PMR. Tr. 92. “It was just something that caught my eye at one point.” Tr. 92. She recalled finding a publication that documented ten

ca ses of flu vaccine causing PMR

. Tr. 92

- 93. She printed the publication but did not provide it to Dr. McPhillips . Tr. 92

- 93. D r. McPhillips assured her that the numbers were exceedingly low. Tr. 92, 94; Pet. Ex. 4 at 46, 48. Despite her concerns, p etitioner admitted that she has had the flu vaccine since October 9, 2011

, and “I kept having the flu shot.” Tr. 93. Petitioner agreed that she has had flu and PPSV 23 18 vaccines since October of 2011 without event . Tr. 65

- 66; Pet Ex. 6 at 8

- 9.

The last medical record filed is for an e xamination on October 2, 2014. Petitioner was seen by a nurse practitioner, Tarryn Holman, for a routine exam. Pet. Ex. 4 at 58. Petitioner reported minimal shoulder pain and felt “really well.” Id . Her PMR was stable on low dose prednisone and she was being monitored by Dr. Zangara. Id . at 61. The record documented a history of PMR and receipt of a flu vaccine “last year” without e vent. Id . at 58. She was to receive a flu vaccine this year when ava ilable. Id

. Petitioner received a p neumonia vaccine at this visit

. Id

. at 61

.

III. L egal Standards Regarding Fact Finding

Petitioner bear s the burden of establishing her claims by a preponderance of the evidence. § 13(a)(1). A petitioner must offer evidence that leads the “trier of fact to believe that the existence of a fact is more probable than its nonexistence before [he or she] may find in favor of the party who has the burden to persuade the judge of the fact’s existence .” Moberly v. Sec’y of Health & Human Servs. , 592 F.3d 1315, 1322 n.2 (Fed. C ir. 2010) (citations omitted).

The process for making determinations in Vaccine Program cases regarding factual issues, such as the timing of onset of petitioner’s alleged injur y, begins with analyzing the medical records, which are required to be filed with the petition. § 11(c)(2). Medical records created contemporaneously with the events they describe are presumed to be accurate and “complete” such that they present all releva nt information on a patient’s health problems. Cucuras v. Sec’y of Health & Human Servs. , 993 F.2d 1525, 1528 (Fed. Cir. 1993). This presumption is based on the linked proposition that (i) sick people visit medical professionals; (ii) sick people honestly report their health problems to those professionals; and (iii) medical professionals record what they are told or observe when examining their patients in an accurate manner, so that they are aware of enough relevant facts to make ap propriate treatment dec isions. Sanchez v. Sec’y of Health & Human Servs

., No. 11

- 685V, 2013 WL 1880825, at *2 (Fed. Cl. Spec. Mstr. Apr. 10, 2013); Cucuras v. Sec’y of Health & Human Servs., 26 Cl. Ct. 537, 543 (1992), aff’d, 993 F. 2d. 1525 (Fed. Cir. 1993) (“[i]t strains reaso n to conclude that petitioners would fail to accurately report the onset of their daughter’s s ymptoms. It is equally unlikely that pediatric neurologists, who are trained in taking medical histories concerning the onset of neurologically significant sympto ms, would consistently but erroneously report the onset of seizures a week afte r they in fact occurred”). In making contemporaneous reports, “accuracy has an extra premium” given that the “proper treatment hang[s] in the balance.” Id. A patient’s motivatio n for providing an accurate recount of symptoms is more immediate, as opposed to testimony offered after the events in question, which is

18 The PPSV 23 vaccine is the polyvalent pneumococcal vaccine. D ORLAND ’ S at 1506.14

considered inherently less reliable. Reusser v. Sec’y of Health & Human Servs ., 28 Fed. Cl. 516, 523 (1993); see Murphy v. Sec’y of Health & Human Servs. , 23 Cl. Ct. 726, 733 (1991), aff'd , 968 F.2d 1226 (Fed. Cir. 1992) (citing United States v. U.S. Gypsum Co. , 333 U.S. 364, 396 (1948)). Contemporaneous medical records that are clear, consistent, and complete warran t substantial weight “as trustworthy evidence.” Cucuras , 993 F.2d at 1528. Indeed, “where later testimony conflicts with earlier contemporaneous documents, courts generally give the contemporaneous documentation more weight.” Id.

However, there are situations in which compelling oral testimony may be more persuasive than written records, such as in cases where records are deemed to be incomplete or inaccurate. See Campbell ex rel. Campbell v. Sec’y of Health & Human Servs. , 69 Fed. Cl. 775, 779 (2006) (“[L]ike any norm based upon common sense and experience, this rule should not be treated as an absolute and must yield where the factual predicates for its application are weak or lacking.”). The Court of Federal Claims has listed fou r possible explanations for inconsistencies between contemporaneously created medical records and later testimony: (1) a person’s failure to recount to the medical professional everything that happened during the relevant time period; (2) the medical profe ssional’s failure to document everything reported to her or him; (3) a person’s faulty recollection of the events when presenting testimony; or (4) a person’s purposeful recounting of symptoms that did not exist. La Londe v. Sec’y of Health & Human Servs.

, 110 Fed. Cl. 184, 203

- 04 (2013), aff’d , 746 F.3d 1334 (Fed. Cir. 2014). Ultimately, a determination regarding a witness’s credibility is needed when determining the weight that such testimony should be given

. Andreu v. Sec’y of Health & Human Servs. , 569 F.3d 1367, 1379 (Fed. Cir. 2009); Bradley v. Sec’y of Health & Human Servs. , 991 F.2d 1570, 1575 (Fed. Cir. 1993).

When witness testimony is used to overcome the presumption of accuracy given to contemporaneous medical records, such testimony must be “co nsistent, clear, cogent and compelling.” Sanchez v. Sec’y of Health & Human Servs. , No. 11

- 685V, 2013 WL 1880825, at *3 (Fed. Cl. Spec. Mstr. Apr. 10, 2013) (quoting Blutstein v. Sec’y of Health & Human Servs. , No. 90

- 2808V, 1998 WL 408611, at *85 (Fed. Cl . Spec. Mstr. June 30, 1998)); see, e.g. , Stevenson ex rel. Stevenson v. Sec’y of Health & Human Servs. , No. 90

- 2127V, 1994 WL 808592, at *7 (Fed. Cl. Spec. Mstr. June 27, 1994) (crediting the testimony of a fact witness whose “memory was sound” and “recol lections were consistent with the other factual evidence”). Moreover, despite the weight afforded medical records, special masters are not bound rigidly by those records in determining onset of a petitioner’s symptoms. Vallenzuela v. Sec’y of Health & Huma n Servs. , No. 90

- 1002V, 1991 WL 182241, at *3 (Fed. Cl. Spec. Mstr. Aug. 30, 1991); see also Eng v. Sec’y of Health & Human Servs. , No. 90

- 175V, 1994 WL 67704, at *3 (Fed. Cl. Spec. Mstr. Feb 18, 1994) (explaining that § 13(b)(2) “must be construed so as t o give effect to § 13(b)(1) which directs the special master or court to consider the medical record...but does not require the special master or court to be bound by them”). In short, “the record as a whole” must be considered. § 13(a).

IV. Discussion a nd Findings of Fact

Petitioner alleges that she suffers from PMR as the result of a flu vaccine she received on October 9, 2011.15

PMR “ is an inflammatory condition of unknown cause characterized by aching and morning stiffness in the cervical region a nd shoulder and pelvic girdles. It usually responds rapidly to low doses of corticosteroids and has a favorable prognosis. ” Pet. Ex. 8

- D at 1. 19 PMR manifests as persistent pain with aching and morning stiffness in the neck, shoulder girdle, and pelvic girdle that lasts at least thirty minutes. Id . at 3. The musculoskeletal pain worsens with movement of the affected area and typically interferes with usual daily activities. Id

. The majority of patients (70 to 95%) experienc e shoulder pain causing limitations of active and passive range of motion, while 50 to 70% of patients reported hip and neck involvement. Id

. ; see also Resp. Ex. C, Tab 4 at 2. 20 Approximately one third of patients experience s ystemic symptoms including fev er, malaise or fatigue, anorexia

, and weight loss. Pet. Ex. 8

- D at 3. “ The diagnosis is usually made within two to three months after the onset of symptoms. ” Id

.

Petitioner received the flu vaccine on October 9, 2011. Pet. Ex. 3 at 1. Petitioner’s first medical visit following her vaccination was on April 30, 2012

. At that time, she presented to Dr. McPhillips with elbow and hip pain. Pet. Ex. 4 at 32. She did not report stiffness in the morning, trouble getting out of bed, or any symptoms ongoing for an y length of time. She was purportedly exercising on the treadmill several times a week. Id

. She affirmed she was taking Advil to alleviate he r pain but at hearing testified that she did not take Advil until May or June of 2012. Pet. Ex. 2 at 1; Tr. 81.

Pe titioner pos its that she did not seek medical care until April 30, 2012 despite being symptomatic since the Christmas/New Year holiday of 2011 because she was busy caring for her elderly parents. This was undoubtedly a very stressful time for petitioner du e to her parents’ health issues. Tr. 21

- 22. During this time, petitioner assisted with coordinating health care for her father, but nursing services provided the rest of his care. Tr. 69. Petitioner did not move in with her parents until just prior to her mother’s death on March 29, 2012. Tr. 68. P etitioner continued to work full

time and use d her lunch break to go to the gym to walk on the treadmill. Tr. 58, 72; Pet. Ex. 4 at 32. Dr. McPhillips’ had been petitioner’s doctor for years and her of fice was le ss than a mile away from where petitioner lived. Tr. 37.

At hearing, p etitioner had little independent knowledge or memory of her medical history

or any of the events between the time of her flu vaccination on October 9, 2011 and he r d iagnosis of PMR in July of 2012

, unless provided with a copy of her medical record s by her counsel

. Even then, she would read from the record, adding little to what was contained therein. See Tr. 32, 33, 53, 57, 58, 71, 82, 88

. Therefore, the medical records were more reliable that petitioner’s memory of the events years later.

Further, i t is noteworthy that petitioner did not submit any supporting affidavits from family, friends or c o

- w orkers. Petitioner initially stated that between December of 2011 and March of 2012

, her husband, who had moved to South Carolina in June of 2011 for a job with a friend

, would come home and stay at her parents ’ house with her

. She stated she told him about her health issues

. Tr. 17, 90. When asked what she tol d him, she could not remember. Tr. 90. Later, petitioner

19 Carlo Salvarani et al., Polymyalgia Rheumatica and Giant

- Cell Arteritis

, 3 4 7 NEJM 4 : 261

- 71 (2002).

20 C.E. Owen et al., Recent advances in polymyalgia rheumatica , 45 I NTERN M ED J 1102

- 08 (2015)

.16

testified that her husban d did not come f or Christmas or New Year ’s Eve and probably had not been home from March of 2011 until M arch of 2012

, when he came home for her mother’s funeral

. Tr. 91. She noted that h e probably moved back home around the time they had to sell her father’ s house in the summer of 2012. Tr. 91. Petitioner’s husband did not submit an affidavit or testify on petitioner’s be half. Petitioner testified that she has two adult sons but made no me ntion of them being aware of her health issues . Tr. 6

- 7, 13. Neither son submitted an affidavit

. Petitioner continued to work full

- time throughout this time frame

, but no affidavits from co

- workers or friends were submitted in support of her claims. Tr. 19.

Petitioner’s medical records and testimony support that when she thought something was wrong with her health

, she went to the doctor or otherwise addressed it. In May of 2011, she presented t o Dr. McPhillips following a tick bite , with tick in hand

. Tr. 38; Pet. Ex. 4 at 19. In August of 2 0 11, she presented with two weeks of gynecological issues. Pet. Ex. 4 at 23. On October 3, 2011, she presented w ith onset of back pain radiating into the left leg and pins and needles in her calf

. Id . at 31. Though the record documented her complaints as “occasional

, ” she testified that what she was experiencing was for a “short while, but it would have been enough for me to co me

se e her.” Pet. Ex. 4 at 31; Tr. 14

- 15. Petitioner was unable to provide i ndependent recollection of any events surrounding the onset of her b ack pain, thigh pain

, and pins and needle s in her calves, how or if she treated these symptoms, or when her symptoms resolved. Without the medical record to read, she was unable to provide any independent details. See Tr. 53, 57, 58, 64, 79, 82, 102.

Petitioner affirmed and testified to difficulty getting out of bed in the morning due to muscle fatigue and achiness around Christmas or New Year ’ s Eve of 2011

. Pet . Ex. 2 at 1; Pet. Ex. 7 at 1. She explained that she had muscle soreness, as if s he over

- exercised

, in December. Tr. 70

- 71. Later she stated it was “more like an insidious feeling of something just creeping u p on you, where you

– you know something is different, and you’ re not quite sure what it is.” Tr. 98

. These symptoms were similar to those in April. She felt the worst in the morning, would take Advil and feel better by the afternoon. Tr. 97, 27.

Howeve r, when petitioner presented to Dr. McPhillips on April 30, 2012, after she “realized that what I was experiencing had not gone away, and I needed to have it, you know, addressed ,” she never mentioned any of these symptoms, or that she had ongoing symptoms since Christmas or New Y ear ’ s Eve that were getting worse. She reported only bilateral elbow pain right greater than left and bilateral hip pain, right greater than left. Pet. Ex. 4 at 32. She did report bein g too young to feel like this. Id .; Tr. 26. She agreed that all of the symptoms she had testified to would be information one wou ld mention to his or her physician. Tr. 76, 78

. However, she did not.

Petitioner acknowledge d that she did not contact Dr. McPhillips between April of 2012 and her next regularly scheduled visit on June 7, 2012 with any complaints of progressing symptoms. Tr. 30.

At the June 7, 2012 visit, petitioner reported arthralgias myalgias, bilateral hip pain, shoulder pain, and elbow pain upon waking in the morning which took four hours to go away after taking Advil. She reported having done blood work on herself showing elevated ESR levels. Pet. Ex. 4 at 33. Petitioner agreed that the June 7, 2012 visit documented all of the symptoms that were later diagnosed as PMR. Tr. 59

- 60. She also conceded that she did no t start taking Advil until May17

or June. Tr. 81. She agreed that she did not tell the doctor how long her symptoms had persisted. Tr. 82. When questioned, petitioner could not recall when the joi nt and muscle pain began or when she began having difficulty getting out of bed. Tr. 81. She agreed that her symptoms we re significantly worse in June. Tr. 90.

Petitioner testified that she p erformed blood work on herself at her place of employment which showed an elevated ESR and prompted her presentation to Dr. McPhillips in April of 2012

. Tr. 56

- 57. She explained that she had previously done blood work on herself while at work on five
pr ior occasions . Tr. 84

- 85. She stated that the blood work done at her lab

, whether by her own choice or as part of a control group, wa s part of her personnel record, but she was unable to produce any records. Tr. 53

- 55, 83

- 84. Though she initially stated that she did blood work in April of 2012 which showed an elevat ed ESR, she later could not recall doing so, and at her April 30, 2012 visit, she made no mention of having performed blood work on herself , nor did she report an elevated ESR at that visit. Tr. 56

- 57; Pet. Ex. 4 at 32.

According to petitioner, her symptoms escalated between April and June of 2012 . Tr. 90. It appears reasonable that the escalation of her symptoms between April and June prompted her to conduct blood work on herself, which showed the elevated ESR that she reported to Dr. McPhillips in June of 2012

. Petiti oner testified that she knew an elevated ESR indicated inflammation and “indicated a problem

. ” Tr. 85. Had she performed blood work in April that showed an elevated ESR, she would have undoubtedly been concerned and reported it to Dr. McPhillips in April. Based on the medical records, it is reasonable to conclude that petitioner either did not perform any blood work until just prior to the June 7, 2012 vi sit with Dr. McPhillips or she did

, and the results were normal

.

This conclusion is supported by petitioner’s detailed account provided to Dr. McPhillips at her June 7

, 2012 visit compared to the April visit. It is further supported by the differences in the conclusions reached by Dr. McPhillips at each of the two visit s

. In April

, Dr. McPhillip s concluded that petitioner had tendonitis from leaning on her elbows. Pet. Ex. 4 at 32. Dr. McPhillips did not think much of the complaint of bilateral hip pain , presumptively because petit ioner had hip pain in the past; thus, she did not or der blood work

. Id

. That all changed in June with the details provided by petitioner at that visit including complaints of shoulder and hip pain, difficulty getting out of bed

, and an elevated ESR on self

- testing

. Id . at 33. Dr. McPhillip s then referred her to a rheumatologist, Dr. Badlissi. Id . at 34.

In July of 2012

, when petitioner had her initial examination with Dr. Badlissi, she reported five to six months of symptoms. Pet. Ex. 5 at 1. Over a year later

, in September of 2013

, when she presented to Dr. Zangara for the first time

, she reported onset of symptoms in early 2012 with a diagnosi s of PMR in March of 2012. Pet. Ex. 6 at 5.

Petitioner is a poor historian with little memory for time frames or details

. By petitioner’s own reporting

, it appears that March of 2012 was pivotal to petitioner

, not only due to the death of her mother

, but also as a defining time during which she experienced an onset of symptoms

. The medical records confirm that was formally diagnosed with PMR in July of 2012 when she saw Dr. Badlissi, after taking prednisone

, with a rapid response within days , which is characteristic of PMR. Pet. Ex. 5 at 2, 4. Petitioner alleged that she saw Dr. McPhillips on April 30, 2012 because18

“everything was over” wi th her mother and she “realized that what [she] was experiencing had not
gone away

. ” Tr. 24. It is therefore expected that she would have reported in detail all issues she was having at that time

, as well as an elevated ESR

, had she done the self

- testing at that time

. However, at the April appointment, s he r eported only elbow and hip pain

, and nothing more, which implies that petitioner only had elbow and hip pain

, and none of the other symptoms complained of in June of 2012. This would be consistent with petitioner’s testimony of her approach on October 3, 2011

, when she sought medical care for lower back pain radiating into her left leg with pins and needles of the left calf

. See Pet. Ex. 4 at 31. Her pattern of presenting when she thought there might be a health issue and providing details of that issue is support ed by her history of doing

so and her medical records

. See id

. at 20 (noting petitioner’s presentation to Dr. McPhillips on May 16, 2011, for a routine exam); id

. at 23 (noting petitioner’s pres entation to Dr. McPhillips on August 4, 2011, for post

- menopausal spotting). Dr. McPhillips documented a diagnosis of PMR in June of 2012 as well.

On the whole

, petitioner had little

, if any

, memory of the fact s concerning her medical visits or what her health was without looking at her medical record s

. Even then, she added little

, if anything

, that was not al ready contained in the record. Therefore, petitioner’s report ing of her symptoms to her physicians as con tained in the contemporaneous medical records are more reliable than her affidavits and testimony. Based on petitioner’s contemporaneous medical records and her history of seeking medical care within several weeks of onset of a medical issue

, I find that the medical records support an onset of symptoms in March of 2012 which then escalated between April 30 and June 7, 2012, resulting in the ultimate diagnosis of PMR in July of 2012.

V. Conclusion

Upon detailed review of the record in its entirety , I find that petitioner’s symptoms began in March of 2012

. P etitioner has already filed two expert reports from Dr. Gershwin; however, these rep orts were based on the f acts as provided by petitioner in her affidavits . To continue pursuing her claim, petitioner must file an expert report from Dr. Gershwin which relies on the facts as found in this Ruling. Should petitioner’s expert base his opinion on facts not substantiated by this Ruling, the expert’s report will be disregarded. See Burns by Burns v. Sec’y of Health & Human Servs ., 3 F.3d 415, 417 (Fed. Cir. 1993).

Accordingly, the following is ORDERED:

By Friday, May 17 , 201 9

, petitioner shall file either an expert report that is based on the onset as found herein, or a status repor t indicating how she intends to proceed. Petitioner shall provide a copy of this Onset Ruling to each of her expert witnesses, and her expert(s) shall rely on the timing of onset as I have found it in this Ruling. If petitioner is unable to secure reports from her expert(s) based on the timing of onset as I have found it, she shall file either a motion to dismiss, a joint stipulation for dismissal, or a motion for a ruling on the record, all of which will result in the dismissal of her claim.19

IT IS SO ORDERED.

s/Mindy Michaels Roth Mindy Michaels Roth Special Master