Age: 54.0
Sex: F
Vaccine: TD
Symptoms: Echocardiogram abnormal, Electromyogram abnormal, Encephalopathy, Fatigue, Gait disturbance
Clinical narrative: The day of the immunization I had a sharp, zinging stabbing in my neck and back that flashed and was gone on 8/13/06 upon waking I walked to the side, could not feel my hands or feet normally, my feet, hands, legs and arms were tingly and numb, my teeth felt like they were being pushed out, face tingly, sore back. 10/3/06-records received for 2 hospitalizations DOS 8/14-8/15/06- DC DX: Hypertensive Urgency Hypertensive encephalopathy Hyperlipidemia Upper respiratory infection Summary: admitted with hypertensive urgency/mild encephalopathy. BP 170/118, Sensory intact throughout, though she complained of some paresthesia on the extremities. Gait, is somewhat unsteady and unable to perform the linear walking. Treated with Cozaar 50 mg and hydrochlorothiazide. Once blood pressure was controlled her paresthesia, confusion and gait difficulty rapidly improved.  DOS 8/19-8/24/06- DC DX: Probably Miller-Fisher syndrome with ataxia, diplopia and sensory neuropathy.  Labile hypertension Positive antinuclear antibody of uncertain significance. History of cholecystectomy. MRI of brain: normal MRA of neck and head showed some mild irregularities with the distal two thirds of the basilar artery and moderate narrowing at the distal portion of the right posterior cerebral artery probably no related to recurrent symptoms.  Present illness: light sensitivity, blurriness at distance and near in both eyes, eyelids somewhat sore to touch and eyes hurting in up gaze for approximately 1 1/2 weeks. After she reads for a while her vision tends to get blurry.  Review of systems negative except for gastrointestinal significant for gastro esophageal reflux disease.  PE: Applanation tonometry yields pressures of 14 bilaterally. Pupils re 5.5 mm in the dark bilaterally and react to 4mm in light bilaterally slightly sluggish reaction bilaterally. Ocular motility is full. On confrontation visual fields are full. Tear lake appears decreased bilaterally. Optic nerves normal. Attempted visual field testing with a 120 point screening exam, the patient was unable to even complete the right eye because of discomfort, she felt test made her dizzy. What there was of the test basically showed a few nonspecific depressed points, certainly noting to indicate a neurologic vision deficit.  HX of present illness: symptoms began one week ago with increasing numbness, paresthesias in somewhat of glove-stocking distribution in bilateral upper and lower extremities, feeling of great difficulty. Hard time walking, falling towards the wall. After discharge on 8/16/06 symptoms improved until morning of this admission when not only paresthesias but also some visual changes with images on top of one another. Present to a lesser degree yesterday. She apparently had been having a viral infection. Since end of July she had been on antibiotics and that was discontinued. Now having recurrent cough and upper respiratory infection like symptoms. Intermittent palpitations and some atypical chest pain mostly on her right side. Husband noticed some halting thoughts last week.  1/11/2010 Automatic dysfunction and symptonatology visual disturbances. Gait disturbance that make it difficult to even perform daily activities of living due to an excess amount of generalized fatigue. 02/01/2010 Vision remains poor-has autonomic nervous system problems-fatigue continues-not able to work due to GBS-gastro problems-hearing problems-balance problems-unable to drive.