Age: 59.0
Sex: F
Vaccine: FLU4
Symptoms: Stomatitis, Streptococcus test negative, Tonsillar hypertrophy, Tonsillitis, Toothache
Clinical narrative: 10-4-19 1PM Headache, Fatigue. 3P went home early + went to bed. 10P woke up sweating, Temp, Chills, body aches, severe HA, palpitations, SOB. Over course of 4-5 day fever increased, sores in mouth, lips swollen. Tonsils huge + infected. ER - fluids only, sent home. Next night ER by ambulance. Sent home. On following Fri went to urgent care. Misdiagnosed. Treated for tonsilitis. Called family. Went home. Treated by family Dr. Details attached. October 2. Feeling good. Work 8am. Received Flu vaccine this morning. October 3. Went to work. Afternoon mild headache. Woke up during the night sweating. October 4. Went to work. Mild headache. Very tired. No energy. Went home early from work around 3:30. Went to room. Took ibuprofen and went to bed. During the night I got chills, severe headache from neck up, waking up hot and soaking wet. October 5 Woke up that morning in bed soaking wet. Chills and severe headache. Mild diarrhea. Very weak. During the day I had episode of diarrhea. Crawled to bathroom. Turned on shower and laid in tub. Too weak to stand. At this point no food since Friday afternoon. Trying to drink water. Mouth getting sore. Nasal congestion. Can't breathe through nose at all. Slept all day and night. Trying to alternate Tylenol and ibuprofen. During the day and night ran temp of 100-104. Sleeping with ice packs on forehead and neck. October 6. Still have severe headache. Very weak. Hard to keep eyes open. Had friend from hotel take me to ER. Temp 100. 4 attempts before IV started. NP asked if I'm usually that difficult to start an IV on. I said only when I'm dehydrated. EKG, BW, swab for strep. Mouth very sore. Teeth hurt. Sores in mouth. NP said throat red and huge pus pockets on tonsils. I could feel the tonsils rubbing my throat. IV positional. Took a long time to urn. Was told all test came back neg. I was told have a virus and body rejected flu vaccine. Go home sleep it off. Had to remove EKG leads myself. Get dressed, find way through ER to lobby. Called friend to pick me up. Went back to room, slept the entire time. Still have headache, chills, fever, sweating, severe fatigue and weakness. Mouth so sore lips are cracking. Hard to close mouth. Even water hurts to swallow. Hard to take pills. October 7 No change. Friend brought me some Gatorade and mucinex. Still can't breath through nose. Still not eating anything. Nausea starting. Slept all day. Symptoms still the same. Later that night woke up. Gasping for breath. Very hard to breath. Lymph nodes on neck very swollen. Called EMS. Walked to front door of hotel for ambulance. Took me to ER. IV started. Small bag and toradol. Swabbed for flu. Negative. CXR negative. Laid in ER for hours with chills, sweating, severe headache, extreme weakness. Told by ER dr virus. Go home and sleep it off. Again by myself had to get off stretcher, find way through ER to lobby. This is 3:30 am. No ride. Came by ambulance. Somehow found number. At 3:30 am in a thin gown, flip flops, and light jacket I make my way outside to street corner in 36 degree weather. Wait on ride. Remember staggering and then seeing small light in a car dash. It pulled up to me and I got in. Remember seeing a deer on side of road and then being let off at front door of hotel. Went to room and bed. October 8. Still weak, chills, fever, sweating, headache, nausea. .Still no food. Still trying to take Ibuprofen and Tylenol. Sips of drinks. Sleep all day and night. Exhausted. No strength. Still using ice packs for neck and head. Friend arrives in town. Brings me popsicles, crackers, bananas. Friend from hotel brings me popsicles, and Gatorade. Able to eat popsicles. Hurts mouth to eat or drink. Lips still cracking and swollen. Sores in mouth and nostrils. Only blowing bright red blood from nose. October 9. No change. Sleep all day and night. October 10. No change. Text family for help. Cousin flying out to drive me home. October 11 No change. Less fatigue. Taking Excedrin Migraine during day. Drove self to walk in clinic. Dr said I have tonsillitis and hand foot and mouth disease even if I only have sores in mouth. Gave me mouthwash and Amoxicillin 500 one everyday for 10 days. Back to room and bed. Cousin arrives and packs up room while I sleep. Unable to help. Sleep all night. No change in symptoms October 12. Leave for home. Sleep most of way home in care. Stay at hotel that night. No change in symptoms. October 13. Start drive home. Sleep most of time. No chills at this time. Arrive home that night. Get in bed. October 14. Cousin home. My mom keeping eye on me. Continue with Tylenol, etc and Amoxicillin and mouth wash. Temp staying around 100. Unable to eat. Mouth too sore and nausea. October 15. No change. October 16. No change. Call my Dr. appt tomorrow. October 17. Go to Dr. He says this has gone on too long. BW, mouth still has pus pockets and red. No getting cough. B/p elevated. Gave me shot of steroids and script for zofran and cefdinir. He thinks now bacterial. Home to bed. Lost 17 lbs. October 18. BW shows bacterial infection. Continue with fluids. Still can't eat. October 19-30. Slowly symptoms decreasing. No temp. Mild headache, severe fatigue and weakness still. October 31-Nov 3. Headache slight, no chills, still have times of sweating during sleep. Building strength back up. Eating very light. Total of 20 lbs lost. Able to move around house. Wear out easily. Refill on cough med. November 4. Feeling better. Still have moderate weakness, fatigue, cough. Able to move around more. 2/19/2020 UPDATE ON PHYSICAL CONDITION  Still have cough. Productive. Small amounts light yellow phlegm Mild temp off and on of 99.9-100.8 Severe Fatigue Dizziness Able to work but go to bed as soon as get home. Days off spent sleeping Muscle weakness No energy Get SOB easily Not able to get back to normal feeling of wanting to get up and do things.