Age: 68.0
Sex: F
Vaccine: FLUX
Symptoms: Asthenia, Back pain, Bladder catheterisation, Bladder dysfunction, Blood sodium decreased
Clinical narrative: Started with severe back pain. Patient had a flu shot on October 15th and two weeks to the day she woke with extreme back pain on Saturday, October 29 and that extreme pain lasted at least 4 hours every night along with regular pain and not feeling good. By Tuesday she couldn't take the pain any longer and went to her family doctor who felt she had two pinched nerves and prescribed pain killers but the extreme pain didn't let up with the pain killers so she went back to her doctor on Friday, 11/4. The family doctor switched pain killers which made patient vomit because they were too strong for her system and they weren't helping with the pain. On Monday, 11/7 patient called the doctor again and they set up physical therapy for 3 days that week because they still felt that she had two pinched nerves in her back. Patient started physical therapy the week of 11/7 and was told she would get worse before she got better. Around Friday, 11/11 she started having problems using her right hand, arm and leg and went from walking, to using a cane, to using a walker, to using a wheel chair by 11/16. Patient called her family doctor and said she thought she needed the MRI to make sure she had pinched nerves. On Tuesday, 11/22 patient had an MRI and was told on Wednesday, 11/23 that she had two pinched nerves and to continue physical therapy. The rest of the week she went to physical therapy but really didn't feel well and felt really bad by Sunday, 11/27. On Monday, 11/28 she could only drag her right leg and went to physical therapy to be told that something else was going on and that she needed to go to the hospital, they thought she might have had a stroke. Patient was admitted on Monday, 11/28 and had an MRI to see if she had, had a stroke. By Tuesday, 11/29, they knew that she had not had a stroke. On Tuesday, 11/29 in the afternoon she was seen by a neurologist. Patient's daughter asked Dr. to rule out Guillain Barre Syndrome (GBS). He said he didn't think she had that but would rule it out. He then did the spinal tap as well as scheduled MRI's, CAT Scans, etc. On Wednesday, 11/30, Dr. told patient's daughter that patient did not have GBS but that she did have some type of neuromyopathy, they just didn't know what kind. On Thursday, 12/1, patient's daughter was once again told they didn't know what type of neuromyopathy patient had but it wasn't GBS. Since patient had a spinal tap done, patient's daughter believed what the doctors where telling the family even though everything pointed to GBS but since they couldn't tell us what patient had exactly, patient's daughter kept asking about GBS. Patient's daughter also asked about getting a second opinion and was told that was our families choice but they would no longer provide any help or guidance and that we would be starting over that insurance would not cover us starting over. On Friday, 12/2 the doctors still hadn't figured out what was wrong with patient and stated again that she didn't have GBS and this definitely was not related to the flu shot. Late in the afternoon on Friday, 12/2, patient was taken to Dr's office where the machines were to have the electromyography, ECG and EMG's done. Once these tests were completed Dr. told patient's other daughter after reviewing patient's spinal tap and other tests that patient had GBS and it was from the flu shot. Dr. recommended the following treatment: the method to block the antibodies, using high-dose immunoglobulin therapy (IVIG). Fortunately since they knew patient had some type of neuromyopathy they had already started this treatment on Wednesday, 11/20 or Thursday, 12/1. She completed the 5 days of treatment either on 12/4 or 12/5 and was moved to extensive rehab at the hospital on 12/6. Patient's first full day of rehab was on Wednesday, 12/7. Patient has had Physical Therapy and Occupational Therapy every morning and evening since Wednesday, 12/7 with the exception of 12/24, 12/26, 1/1/12 & 1/2/12 because of the holidays. Patient has had low sodium since she entered the hospital. It was as low as 113 but has now gotten up to 125/126/127. Patient has seizures and takes a dosage of 750 mil of Valproic Acid (see below her list of medications) which Dr. feels is affecting her sodium level but not enough to do anything with patient's seizure medication right now due to everything else that she is going through. Patient's kidneys are working but not her bladder. Patient is catheterized several times a day/night to empty her bladder. Dr. feels that the bladder is not working due to the damage nerve endings and should start working on its own if the nerves get to that point but according to Dr. they may not. The want to release patient on Thursday 1/12/12 but patient still needs total assistance. Patient is able to feed herself if she isn't too tired, she can sit in a chair but isn't strong enough to use a walker or shower by herself. Patient is also having control/coordination problems with both her hands and legs which is also a concern. On Thursday, 1/5/2012 we asked that Dr. reevaluate patient since her progress has been slow. On Friday, 1/16/2011, Dr. performed another EMG to compare to the one done in December. Patient has good strength but the EMG showed that the GBS was worse than originally thought but seemed to have stabilized. Dr. was going to review her case from start to finish and determine if any other tests need to be run. Dr. felt that there might be something else going on that was slowing patient's recovery. On Wednesday, 1/11/12 they needed to take a chest x-ray to be able to release patient to the rehab facility. On Thursday, 1/12/12, Dr. called patient's daughter to let her know they had found a small lump on patient's lung and that it would need to be biopsied. On Friday, 1/13/12, patient is scheduled to have the biopsy done on the lump.