Age: 16.0
Sex: F
Vaccine: HEP, MMR
Symptoms: Muscular weakness, Musculoskeletal stiffness, Ocular hyperaemia, Pain, Photophobia
Clinical narrative: Female  2/27/2020 Boostrix TDAP at Pharmacy NDC: 58160-0842-52 A little tired than usual over the weekend 3/9/2020 MMR II Inj Merc at Pharmacy (3 prior to this did not have it) NDC: 00006-4681-00 Engerix-B 20 MCG/ml Inj Glax NDC: 58160-0821-52 3/11/2020 After taking Vitamin D liquid drops, abdominal pain and diarrhea Spinal manipulation in evening 3/12/2020 Tired, complained of aching all over, emotional and weepy, anxiety, diarrhea continued 3/14/2020 Completed 3 hours of taekwondo advanced belt testing, including breaking wood boards Entire body shaky and weak Knees began to feel hot and painful Spinal manipulation in evening 3/18/2020 Entire body sweaty, complained of aching body ? especially of legs and back Had her take small dose of magnesium supplement, thinking it was related to physical exertion.   3/19/2020 Sleepy at all times, malaise, red and swollen eyes (blood vessels in eyes), feverish (warm and sweaty) inability to concentrate.  We had a language lesson and she could not remember words after everyone repeated them several times, and was misspelling words she knew.  Complained of a headache.   3/20/2020 ? 3/23/2020 Body and forehead very hot to touch (no thermometer, deep muscle and ?close to bone? pain in legs and lumbar region, feet numb.  Complained of inability (too much pain and weakness) to get out of bed to use the bathroom on 3/20/2020. Slept most of the time, waking for 30 minutes to drink water, very sensitive to sound and light (she stayed in bed in a dark room), could not complete tasks requiring thought or remembering sequence of actions, and needed prompting to follow them. Not hungry, but ate some fruit cooked in water, and one fruit and spinach/plain yogurt smoothie.  Complained of diarrhea and abdominal pain. Drank fresh ginger and turmeric tea with cinnamon and cardamom and honey. Took Vitamin B, D, and Vitamin C supplements Rubbed Arnica gel and menthol rub on legs and low back to help relieve pain. 3/22/2020 Began menstrual cycle Body and forehead very hot to touch (no thermometer, deep muscle and ?close to bone? pain in legs and lumbar region, feet numb.  Hallucinations of people walking on the roof.  Weepy and concerned she was going to get everyone sick. 3/23/2020 Broke out in rash over entire back, buttocks, shoulders, and upper back.  (see Figure 1). Was hungry for the first time in a week, and ate some pasta and baked apple (just apple and water).  Complained of diarrhea and headache. That evening, used photography darkroom thermometer to document lowered temperature (forehead warm and body slightly warmer): 100 degrees F. Needed assistance to compose coherent email to instructors, and turn in one past assignment. Took a small dose of Thuja occidentalis 30c and a mix of the following herbs: Xiao Feng San, Huo Xiang Zheng Qi San, Huang Qin Along with ginger, turmeric, cardamom, and cinnamon with honey              3/24/2020 After sleeping 11 hours, eyes were clear and could handle slightly more sunlight in room.  Hearing sensitivity.  Temperature dropped to 98.9 degrees F.  Rash on body trunk and chest reduced (see Figure 2), but bright red rash spread to extremities. Does not recall events or conversations from the past week. Was hungry and ate some fresh fruit, vegetable broth, and bread. Administered dose of Thuja occidentalis 30c and Chinese herbs of: Xiao Feng San, Huo Xiang Zheng Qi San, Huang Qin Drank ginger, turmeric, cardamom, and cinnamon with honey.      12/23/2020 She has recovered from the rash without noticeable scarring, and has not complained of pain, however she has complained of stiffness. There has been a marked personality change since the event.