Age: 15.0
Sex: F
Vaccine: HEPA, MNQ, TDAP
Symptoms: Dizziness, Dysphonia, Headache, Lumbar puncture normal, Pain
Clinical narrative: Pt received shots 10/6/09. In early AM hours pt developed severe HA and parathesia to extremities. Pt seen in ER x 3 with CT scan of brain and seen in office x 1 with ref to neurology and ophthalmologist for continued pain. (See attached dictation). No known drug allergies. Headache. This is a 15-year-old female who presents to the office complaining a constant headache. The patient received her MENACTRA, VAQTA, and ADACEL vaccine on Tuesday. On Tuesday night, she began having a severe headache and began to feel tingling sensations in her extremities. The patient went to the ER on Wednesday night and was released without any treatment and was told that she had a viral infection. On Thursday, the headache continued to worsen, especially when the patient was upright to the point that the patient could not talk without severe trembling affecting her voice. She returned to the ER where a CT showed a possible bleed. On Friday, this office recommended that she go to the ER where the CT was reevaluated and the patient's parents were told that it was normal. A spinal tap was negative and the patient was sent home with a diagnosis of sinusitis and treated with erythromycin and VICODIN. On Monday, the patient had no significant relief but with the diagnosis of sinusitis, the patient was prescribed an antihistamine and decongestant combination called NOREL by this office. The patient returns to the office today saying that her headache is lessening but she still has a constant headache. When she lies down, it remains at 2 out of 10 and when sitting up, it is about a 5 out of 10. The patient is no longer having any additional complaints of parathesias of extremities and is having no difficulty communicating. Vital signs: weight 108 pounds, temperature 98.1, respirations 20, pulse 60, blood pressure 98/62. Well-developed, well nourished female in no acute distress. Neuro: cranial nerves II-XII are intact. The patient has a negative Romberg but does complain of dizziness but does not falter while standing. The patient is able to perform rapid alternating movements without difficulty. Pupils are equal, round, and reactive to light and accomodation. Extraocular muscles are intact without nystagmus. HEENT: benign. The patient denies pain with palpation over frontal, ethmoid, and maxillary sinuses. Neck: supple without lymphadenopathy. Lungs: clear to auscultation. Heart: regular rate and rhythm without audible murmur, rub, click, or gallop. Headache. The patient will be referred to an ophthalmologist for retinoid examination to rule out any intraocular pressure which may help us determine the cause of the headaches. The patient will be referred to a neurologist for further evaluation and treatment. The patient is prescribed MIDRIN 1 capsule q 4h prn headache. The patient is to contact the office if no improvement or symptoms worsen. 10/28/2009 records for ED visit 10/9/2009 and PCP visit 10/14/2009. Dx sinusitis and headaches Patient c/o's numbness/tingling in extremities and a constant H/A. Patient evaluated in ER and dc'd with dx of sinusitis. Patient was referred to opthalmogist and to neurologist to evaluate constant H/A c/o's.  11/24/09 Medical records recieved for DOS 10/14/09. Final DX: Headaches, tension,  Migraine variant (visual or cluster), Headaches NOS, Myopia, Astigmatism, regular Eye exam. C/O HA x1week.  Frontal-temporal. Severe. Effects vision. W/nausea, dizziness,vertigo, light snesitivity, throbbing. Blurry vision, problem w/distance vision.  Vision 20/200 OD, OS & OU. Did not RTO for VF 30-2 SITA STD for OU.  ICD9 Codes: 307.81, 346.20, 784.0, 367.1, 367.21