Age: 33.0
Sex: F
Vaccine: FLUX, HEPA, PPV, TD
Symptoms: Headache, Hypotonia, Laboratory test abnormal, Musculoskeletal stiffness, Myalgia
Clinical narrative: Patient contacted with a concern that her current health problems (Fibromyalgia, Depression, Chronic Pain, History of Alopecia, Dizziness) may be due to vaccinations she received in 1998. HPI:  This patient reports a "complete physical break-down" that occurred from January-April 1999.  She was medically discharged from in July 1999.  She reports that she had a good career from 1986-1999.  In November 1998, she recalls receiving 2 sets of vaccinations.  (Her immunization records indicate receipt of Tetanus-diphtheria, pneumococcal, influenza, and Hep A vaccinations in December 1998.) In January 1999, she was routinely running 15-25 miles each week when she noticed that her muscles seemed to be losing their tone.  She began experiencing pain with running, particularly in her left leg.  She was diagnosed with a stress fracture.  Towards the end of January 1999, she started having pain with daily activity in her hips and shoulder area.  She saw a rheumatologist and was diagnosed with fibromyalgia.   In February 1999, the pain became more intense, and now she started having pain in her right wrist.  In April 1999, she developed "bald patches the size of 50 cent pieces."  To work up the alopecia, she reports that hormonal levels were checked and were reportedly normal.  She was seen by a primary care PA and was referred to rheumatology.  She was reportedly told that she could be pre-menopausal.  (She was 33 years old at the time.)  Of note, she has a history of a partial hysterectomy due to uterine fibroids.  She was not satisfied with her evaluation and saw a civilian OB/GYN.  There, she was diagnosed with depression and started on Celexa 20 mg (later was increased to 40 mg).  She reports that she did notice some improvement in her pain. In July 1999, she requested a medical hardship.  She went to a nearby Hospital and was seen by rheumatology.  She had a series of X-rays and a CBC panel that was normal.  She also reports that her ESR has always been normal.  She was later referred to physical therapy, and her physical therapist requested a work-up for multiple sclerosis.  She was seen by a neurologist and had an MRI done, which was normal.  She was then referred to Neuropsychiatry where she was diagnosed with Somatoform Disorder.  Subsequently, she reports that she was seen by a psychiatrist who diagnosed her with Depression/Anxiety and not Somatoform disorder. She continues to receive follow-up treatment.  She is currently being treated for Fibromyalgia.  She continues to experience pain in bilateral shoulders, hands, back and neck.  The pain is worse when she is tired and after about 2 hours of physical activity.  She reports stiffness after periods of inactivity.  She has recently been switched from Celexa to Wellbutrin and is tolerating this medication well so far.  She reports no further alopecia.  She is seeking assistance to review her case and offer any further clinical suggestions.  She also questions whether or not her condition could be related to the vaccines she received in 1998.  She states that she still has daily symptoms and is unable to work.  She comments, "I just want my life back." The medical records received on 2/24/04 states fatigue, joint aching, muscle ache, tendonitis, shin splints, decreased memory, decreased concentration, weight gain, dysthymia, anemia and headache. 60 day follow up 4/12/04: She continues to experience fibromyaglia and depression. The HC referred her to the specialized care program, but she denied. Her primary care physicain has referred her to a rheumatologist. After our summary is finalized, I will send a copy. Per annual report diagnosis of fibromyalgia and adjustment disorder are unchanged, managed by specialists 02/15/2005.