Age: 27.0
Sex: F
Vaccine: TDAP
Symptoms: Sneezing
Clinical narrative: 4/27/07-Sore throat, body ache, headache, cough, sneezing, runny nose, fever, pain at injection site. 4/30/07-Symptoms progress, and now included difficulty breathing, dizziness, weakness, chest pain, uncontrollable cough along with gagging, and swollen lymph gland in under arm of injection site. Went to the doctor breathing treatment given, steroids, Albuterol inhaler, and cough medication prescribed. 5/4/07-No improvement in symptoms. Called doctor. Antibiotics prescribed. 5/7/07 - Runny nose, sneezing, and swollen lymph node improve, other symptoms persist. Severe coughing and difficulty breathing, dizziness, and weakness. Went to urgent care clinic. Chest x-ray done. New antibiotic and cough medication started. Also ordered to continue Albuterol inhaler. 5/14/07 - Shortness of breath, chest pain with exertion, headache, generalized weakness, dizziness, and cough continue. Went to doctor. Blood test and drawn chest x-ray done. Ordered to continue antibiotic. Flovent inhaler, and Albuterol inhaler. 5/18/07 - Symptoms from 5/14/07 persist along with shortness of breath, sharp chest and back pain in lung areas with each breath, any movement, and especially exertion. Went to doctor. Steroids started for 10 days. Instructed to take Flovent inhaler indefinitely. Pain meds as needed for chest and back pain and rest ordered. 5/26/07 - Headache, dizziness, weakness, sharp chest and back pain with exertion and shortness of breath continue. Still taking steroids. Albuterol, and Flovent as ordered along with pain medication. 5/30/07 - Headache, weakness, chest and back pain with exertion and shortness of breath continue. Went to doctor, chest CT done. Still taking Albuterol, and Flovent as ordered along with pain medication. 6/4/07 - Headache, weakness, chest and back pain with exertion and shortness of breath continue. Went to Pulmonary doctor, pulmonary function test done. Informed that I may be having an adverse reaction to the Tdap vaccine and that I should inform my employee health department at work since that is where I received the vaccine. Ordered to continue taking Albuterol and Flovent. During the past 5 weeks since having the vaccine I have only been able to work for 13 hours total due to the severity of my symptoms. I have been unable to engage in any activity that requires any type of substantial effort without experiencing respiratory distress and dizziness.  6/8/09 Received ER medical records of 1/19/2008. FINAL DX: asthma exacerbation Records reveal patient experienced recurrent URIs since 1/5/09 w/SOB, chest tightness, nonproductive cough, ear pain, sore throat, nasal congestion.  Had been seen by PCP for asthma attack & tx w/steroids which were completed but symptoms worsened when steroids d/c.  Tx w/nebs & improved.  D/C to home on continued oral antibiotic & prednisone taper.  6/18/09 Received consultant medical records DOS 1/22/08 to 5/26/09. Assessessment: Chronic obstructive asthma, shortness of breath, cough, chronic bronchitis. Patient presents with  erthema of posterior oropharynx, coarse breath sounds, drainage and inflammation of turbinates, chest tight, hoarseness, pleuritic chest pain, wheezing. Dyspnea, cough, headaches, nocturia, limb weakness. Thrush