Age: 17.0
Sex: F
Vaccine: HEP, MNQ, TDAP
Symptoms: Intervertebral disc protrusion, Laboratory test normal, Loss of consciousness, Movement disorder, Paraesthesia
Clinical narrative: About 1 month after vaccination developed fever to 101 degrees for 1 week. This was followed by "black out spells". Within several days a facial tic started along with her head jerking toward the left. After medical work up, the diagnosis was "movement disorder". Takes NEURONTIN 600mg tid for symptoms.  3/30/09 MR received for DOS 12/22-26/2008 with D/C DX:  Spells.  Paresthesias.  Other Dx:  Lyme Arthritis.  Asthma.  Pt presented with 10 day hx of L sided twitching. Pt reports loss of time and orientation but not full LOC. Feels like "spacing out". PE (+) for L sided head twitching x1. Admitted for video EEG. 5/18/09 PCP records received from 12/4/08-4/16/09 which include neuro consults. First presented with c/o confusion and loss of time which have been worsening over recent months. Sent for EEG and labs. TC from parent on 12/19/08 reporting onset of tics-involuntary movements of the head to the left x several days. Seen 12/22/08 where arm jerks were also reported. Sent for video EEG. started on gabepentin with improvement in head jerking, sleep and neck pain.  Still having episodes where pt spaces out. Assessment:  Head twitches suggestive of tics. Follow-up received 03/11/2010. She has no improvement in her facial and head tics. In October 2009, she was having difficulty sleeping at night due to the tics, and as a result was falling asleep in her classes. She has been followed by the college health services. Dr increased patient's dosage of NEURONTIN to 900 mg in the am, 600 mg at noon, and 900 mg in the evening. She also takes trazadone in the evening and that has been helping her sleep. Patient's mother was asked if Dr has determined any cause for the tics, the mother states the etiology is unknown, but that patient's Lyme disease in 2004 may have contributed to the problem as well. The Lyme disease went undiagnosed for a while before she was treated. The mother is not necessarily blaming the vaccines, but wonders if they may have been a contributing factor due to the past history of Lyme disease. Patient's mother also reports that patient has had increased asthma symptoms since moving to another city. She does not necessary feel that it is due to the vaccines, but the facial and head tics have been significant in changing her quality of life, and the asthma symptoms are now limiting her even more in her activities. Follow-up: 6/4/10 Call received from pt's mother. Pt has had increased head twitching, and has now been diagnosed with vocal chord dysfunction which causes spasms of the vocal chord and aggravates her asthma, and potentially could block her airway. She has been referred to Neurology and has an appt on August 5th, 2010. In additional she is seeing a neuro/psych physician in July at clinic. Pt still attends college. Her mother states the neurological problem is affecting her cognition and attention span. She was a 3.9 grade average student at High School and now she struggles to maintain a 2.6 in college. She is also seeing Dr. who is an allergist.