Sex: F
Vaccine: HPV4
Symptoms: Pain, Presyncope, Proctalgia, Rectal tenesmus, Retching
Clinical narrative: She needs a wheelchair for any long distances like going shopping, going on vacations; amplified musculoskeletal syndrome/Joint pain; Eczema; Over weight; She presents significant intoeing; frustrated; goiter; brain MRI which showed a small thalamic focus; Hypermobility syndrome; Ehlers Danlos syndrome (EDS); Fibromyalgia; Hirsutism; autonomic dysfunction/migraines, nausea, and dizziness/irregular periods/Hemiplegic migraine/neurocardiogenic syncope; Information has been received regarding a case in litigation referring to a currently 19 year old female patient (pt). No information regarding the patient's pertinent medical history, concomitant therapy and drug reactions or allergies were provided.  On 13-APR-2018, the pt was vaccinated with the first dose of Quadrivalent Human Papillomavirus (Types 6,11,16,18) Recomb. Vaccine (GARDASIL) (strength, dose, route, anatomical location, lot# and expiration date were not provided) for prophylaxis.On 28-JAN-2019, the patient received the second dose of Quadrivalent Human Papillomavirus (Types 6,11,16,18) Recomb. Vaccine (GARDASIL) (strength, dose, route, anatomical location, lot# and expiration date were not provided) as a cure for cancer.  In February 2019, she started to experience constant dizziness and nausea. She was having balance issues, visual disturbances, daily headaches, and fatigue. Eventually, her whole body was in pain and her entire left side was numb from head to toc. She started having episodes of presyncope whenever she was standing, walking, or even sitting upright for too long. She experienced constant GI issues. After a while, her nervous system started to get even worse. The high amounts of constant pain caused neuropathy and the lack of signals caused muscle wastage in her knee. She even struggled daily just to brush her teeth and comb her hair. Started to get sent home from school a lot or she missed school altogether. Her grades dropped. Due to her constant absences, she was lacking continuity in her learning so the school tried to accommodate her by letting her leave school early if she had flex periods at the end of the day or come in late if she had flex periods at the beginning of the day. This did not't really help though. Ultimately, she was moved to online learning. She could not't really do the things she loved to do anymore. Her friendships faded. Her wrist hurt so much that she stopped writing poems and drawing. Walking long distances is still not easy for Pt. She needs a wheelchair for any long distances like going shopping, going on vacations, and navigating a large place like an airport (Gait disturbance). Her friend group is a lot smaller now. She spends most of her time in her room these days. She no longer plans to go to college. She is on daily pain and GI medicines and has weekly Doctor appointments. Also it was reported that shortly after her vaccination, in March, 2019, patient began to manifest symptoms of autonomic dysfunction, including migraines, nausea, and dizziness. therefore the pt was ultimately diagnosed with amplified musculoskeletal syndrome, neurocardiogenic syncope, hemiplegic migraines and irregular periods (Amplified musculoskeletal pain síndrome and autonomic nervous system imbalance); those symptoms have persisted for greater than six months. Her dysautonomia was unrelenting. At the time of the report, the outcome of amplified musculoskeletal pain síndrome, autonomic nervous system imbalance and gait disturbance was not reported. The causal relationship between amplified musculoskeletal pain síndrome, autonomic nervous system imbalance and gait disturbance and therapy with Quadrivalent Human Papillomavirus (Types 6,11,16,18) Recomb. Vaccine (GARDASIL)  was reported as related.  Upon internal review, the gait disturbance as  considered to be medical significant due to medical condition.   Follow up information has been received on 08-APR-2024 from medical records regarding a case in litigation. The patient's concurrent conditions included  Dermatitis contact, constipation, gastroenteritis, Influenza A virus infection, Ligament sprain, Urinary tract infection, Sulfonamide allergy. The pt's historical conditions included arthropod bite. The pt's historical vaccines included diphtheria vaccine toxoid pertussis vaccine acellular (dtap), hepatitis b vaccine, hib vaccine, influenza vaccine, meningococcal vaccine, measles vaccine mumps vaccine, pneumococcal vaccine, polio vaccine and varicella zoster vaccine.  During the pt's office visit on 27-SEP-2019, as part of the interdisciplinary team approach, the pt was seen by colleagues in psychology and physical therapy during her appointment; additionally the assessment for amplified musculoskeletal pain síndrome was: The pain team reviewed the origin of amplified pain in detail with pt and her parents. Pt's pain system had likely become sensitized over a prolonged period of time triggered by her hypermobility and autonomic sensitivity which has led to persistent discomfort. Orthostatic reassuring. It was recommended direct physical therapy: Intervention strategies would include therapeutic exercise, therapeutic activities, posture training, balance, agility training, taping, patient/family education, home exercise program and modalities including TENS, Frequency: 1x/week and Duration: 12 weeks. The pt's current medications included methylprednisolone. During the pt's office visit on 17-APR-2020, the pt noted that she had some increased "atypical migraine" pain this week. However, she did complete 2 Detective thinking worksheet and a third time in her head. Reviewed the 2 examples she completed on paper, Including two regarding interactions with her family when she initially felt frustrated but felt much calmer after using detective thinking to understand what the other people may have been thinking or feeling. The additional time was when she had some all or nothing thinking regarding participating in PT during bad weather/increased pain. For homework, she will practice another 3 times; she would like to write them down on a post it note to help keep track of the skill. Reviewed recent TMJ pain. Discussed this pain In the context of amplified musculoskeletal pain syndrome, including how CBT skills can be useful, even though it is a somewhat different area of pain. She noted that this is helpful to do as it allows her to focus on pain in general as opposed to focusing on specific aspects of pain, including potential worries/thoughts about sources of pain. Pt's mother joined for the end of session and Pt reviewed session content with her. The assessment included psychological factors affecting medical condition [F54] as evidenced by: Significant Influence of stress, anxiety, and other emotions on experience of pain. Since the last session, pt has improved with regard to treatment goals. She continues to use a variety of pain coping strategies and practice new ones each week. During the pt's office visit on 01-MAY-2020, the pt was attended via tele health due to for nausea and abdominal discomfort. The pt reported having persistent nausea and constipation. She and mom report that she has always gastrointestinal (GI) issues and she was changed to Celecoxib and has tried Elavil in the past, but 10 mg made her too tired and didn't improve her pain. Her abdominal pain has worsened over the past 1.5 months and is worsened by meals and was located in the epigastrium, non-radiating. Pain was crampy and burning in nature. Softer and smaller meals were better than harder and larger meals. She reported associated feeling full and nausea and has had an episode of non-bilious and non-bloody emesis in the past but vomiting [s not a persistent symptom. She also reported having persistent acid reflux. She was on 20 mg of Prilosec for 14 days which seemed to improve her abdominal pain and reflux. Zofran helps the nausea. Carafate was prescribed but has not helped. She also reported having difficulty with swallowing, both solids and water cause issues, She reported that she had difficulty with initiating swallows and has to try to gulp 10-12 times before if feels like liquids and/or solids pass through her throat. Liquids and solids feel like the get stuck in her throat and she occasionally had associated choking and gagging. She has not had any reported respiratory infections and does not report having the sensation of food getting stuck In have not been effective. her esophagus. She also reported that her bowel movements have worsened as well. She does take Culturelle which had seemed to help. She reported passing a bowel movement twice every week that is consistent with Type 1 on the Bristol stool chart. She does have excessive straining and occasional rectal pain while passing stool. There was bright red blood of small streaks in the stool once per week. She reported having the urge to defecate and does endorse the sensation of incomplete evacuation. She has tried 6 ounces of Mag citrate and Senna in the past which effective. There was no reported history of fevers, rashes, mouth ulcers, respiratory or urinary symptoms. The causal relationship between Amplified musculoskeletal pain síndrome and autonomic nervous system imbalance and therapy with Quadrivalent Human Papillomavirus (Types 6,11,16,18) Recomb. Vaccine (GARDASIL) was updated to unknown, also the causal relationship of all other AEs was not provided.  Information received on 08-APR-2024, contained the following adverse events: Overweight, eczema, foot deformity, frustration tolerance decreased, goitre, magnetic resonance imaging head abnormal, hypermobility síndrome, ehlers-danlos síndrome, fibromyalgia, hirsutism, (onset date, treatment, outcome, causality and further details not provided).  All available medical records will be provided upon request.