Age: 1.5
Sex: F
Vaccine: FLU4
Symptoms: Facial pain, Fatigue, Gait disturbance, Headache, Herpes simplex
Clinical narrative: Patient was given the Flu vaccine on 26 Oct 2018. Patient was seen on 01 Nov 2018 and the subjective portion of the note was as followed: "9MO female pt presents to clinic for ER follow up. Pt accompanied by mother and father. Pt was given her flu vaccine last week 26Oct2018. MOP noted that on that day she began gripping her head intermittently and rubbing her face. Mom denies fever but reports chills that cause her teeth to chatter. 2 days after the vaccine - she started being less active, having worsening chills, and a loa - barely eating any food. Drinking some fluids when forced. 1-2 # wet diapers in past 24 hours and normally makes 8+ per day. MOP denies any n/v/d. BM yesterday that smelled worse than usual but no blood or mucous in the stool. Pt was taken to urgent care on 30Oct2018 and they 'really didn't do to much' and transported patient to regional ER. There the provider 'examined her' but did not do anything else. Dad states he was told to come to the PCM to 'get a diagnosis.' No labs were done. No imaging was done. No meds given. Over past day patient has not eaten with rare fluid intake and seems more tired than usual. A new symptom is that she is having trouble with her balance. Stumbling when she walks (usually walks well and runs without difficulty). Mom denies fever or known sick contacts. No recent travel. No daycare." Dr. stated the following: "9 MO f new to clinic here for eval of worsening fatigue, poor intake, and balance issues. Concern about infectious etiology, although no focal findings of bacterial source on clinical exam. No meningeal signs although that is not uncommon in this age group. Afebrile. Could be new onset DM (mom has t1dm). Recommend labs and possible imaging given her progressive findings as well as fluid hydration. Parents will drive patient to PED ER. In case of emergency advised to pull over and call 911. Parents feel comfortable driving her together." 01 Nov 2018 Patient went to hospital and was initially diagnosed with: "Acute ataxia" and "Disposition: Admit: To Inpatient Unit, admitted to neuro, Patient care transitioned to: Time: 11/01/18 17:15:00, PA-C." 06 Nov 2018 Patient was discharged with the following summary statement: "Patient is a 19mo F with 1 prior unprovoked seizure who presented with unstable gait, fatigue, and decreased PO Intake found to have abnormal head CT. Was admitted for continuous EEG, MRI and sedated LP. EEG was normal sleep and awake, while LP was negative for signs of infection. MRI findings concerning for HSV encephalitis vs sequelae from possible seizure, so patient started on acyclovir, now improving with negative HSV PCR s/p acyclovir, and stable for discharge home with neurology follow-up." with a discharge diagnosis of: "General medical, Encephalitis due to human herpes simplex virus (HSV), Acute ataxia, Acute ataxia, Atypical seizure. " 08 Nov 2018 Patient followed up with Dr. with the following HPI: The Patient is a 1 year 7 month old female. Source of patient information was mother and father. "19mo yo f ambulates to the clinic with her parents for an ER follow-up via instructions of the ER. Pt was seen with Dr. last Thursday, 01 NOV 2018 for symptoms of increased fatigue and loss of appetite. Parents stated they were instructed to go to hospital per Dr. Parents states that pt was admitted to hospital the same day and MRI, blood work, CAT Scan, Lumbar Puncture, and EEG was completed. Parents states that pt was given antiviral and antibiotics with the result of improved symptoms. Father states that the antiviral medications was discontinued the day prior to her discharge as well as the antibiotics were discontinued the day the test results came back negative for bacterial related illness. Pt has improved since being discharged from hospital and the pt's parents have no concerns at this time." and a A/P stating: "19 mo F here for F/U after 5 days inpatient stay on 01NOV18 -06NOV18 for potential infectious etiology. Parents reports pt tx w/ abx. Pt inpatient medical record requested today. Last seen on the clinic on 01NOV18  for worsening fatigue, poor food intake and balance issues. Pt sent to ER same day. Today, pt seems to feel better. Parents reports pt playing, eating well, and gait have improved. Denies fever, n/v/d, constipation. Benign exam today. Vitals WNL. Normal pulm exam. No signs of infections or dehydration on exam. Advised parent on  importance of proper nutrition and hydration. Counseled parents on clinic f/u if symptoms flared up such as fever, poor appetite, lethargy or confusion. Parent verbalized understanding." 21 Nov 2018 Patient referred to Neurology by Dr.