Age: 39.0
Sex: M
Vaccine: FLU3
Symptoms: Dysstasia, Enuresis, Gait disturbance, Guillain-Barre syndrome, Incontinence
Clinical narrative: Date reported 122009 to Pharm D about 1:30 pm from patient. Pt. got seasonal flu shot- 09/29/2009. Started with tingling in the Back 10/06/09 - loss of lower trunk muscle and temperature sensation. First seen - ER at hospital 10/10/09 - was treated for possible flu - "they did a swab for flu" pt wanted to clear up symptoms as he was going to a cruise the following day. October 11th through the 13th (saw M.D. every day) was seen by the Dr. working for the Cruise line. M.D. treated him for dehydration with secondary enuresis. On the 12th he had Bladder Pain and was treated with CIPRO for possible UTI. The patient became incontinent on the 13th and had trouble standing and walking, dragging the left foot. Test performed none, 13th, pt admitted to Hospital until the 17th. Pt was Catheterized. Test performed: Paralysis progressed in the trunk area. The Doctors did a Cat Scan and MRI which did not show anything. Upon returning the pt sent to another Hospital, from 10/17 - 10/29/09 (multiple M.D.s) - was getting rehab. Began IVIG infusions for 5 days on 10/17. On the 21st feeling started to return to the lower extremities. Drs. started calling the Diagnosis Guillain Barre syndrome. note: although possibly linked, M.D.'s did not say the Flu shot was the cause. Pt. transferred to another hospital on 10/29 - 11/08/09. Today, the pt. has kept improving, still does not have much strength and still experiencing loss of temperature sensation although the Dr's say "that might be the last to return" VAR form showed Treated with Allergens the past 4 weeks and B 12 shots - (pt said he was receiving allergy shots every other week to every third week (has been getting app. 3 years)). Pt had a Pen allergy in childhood resulting in respiratory arrest.  12/23/09 ED records received. Service date 10/10/2009. Assessment: Sinusitis. Patient presents with flu like symptoms, major complaint is eye pain. Fever, chills. Nasal congestion. Sinus pain.  12/31/09 Neurology consult. Service date 10/15/09.  Additional hospital labs and diagnostics service dates 10/18/09 to 10/27/09.  Assessment: Dorso-lateral medular syndrome T5-T6. Patient presents with acute urinary retention. Progressive numbness and weakness of legs. Transfered to higher level institution. Post transfer, patient also presents with pulmonary infarct. Bibasilar atelectasis.  12/31/09 Hospital records, discharge summary received. Service dates 10/17/09 to 10/29/09. Assessment: Guillain-Barre syndrome. Massive bilateral pulmonary embolism. Pulmonary infarction. Aseptic meningitis viral.   Patient developed urinary retention, lower extremity weakness and numbness. Paresthesias and dimished sensation lower extremities. Ptosis. IVIG administration. Physical and occupational therapy. Developed acute shortness of breath with associated tachycardia and pulmonary embolisms. Acute pulmonary hypertension. Oral thrush.  Methicillin-resistant Staphylococcus aureus nares colonization.  Discharged to rehabiliatation. Paresthesias right arm. Leg spasms. Intermittant chest pain. Abnormal gait.  12/28/09 Hospital records received. Rehabilitation services discharge conference summary. Service date 11/12/09. Assessment: Guillain-Barre syndrome, bladder retention, pulmonary embolus. Wheelchair use. Discharged - continued outpatient PT/OT.