Age: 14.0
Sex: F
Vaccine: HEP, TD
Symptoms: Abasia, Anorexia, Aphasia, Movement disorder, Weight decreased
Clinical narrative: Severe movement disorder unable to eat, drink, walk, or talk, massive weight loss many hospital stays. Fight for life Aug 2005. PG tube placed for nutrients.  01/11/2007 MR received from local hospital.  Multiple visits from 04/12/2005 to 09/01/2005. Visit 4/12/05-presents to ER 4 days s/p Td and Hep B vax with c/o being shaky and thrashing in her sleep.  She progressed to having a twitch in her right shoulder, and fingers and feet noted to be stiff and awkward.  Walking strangely. Picking at her face. Treated with Benadryl and discharged on Cogentin. DX: Dystonic Reaction. Visit 4/13/2005- return visit to ER on discharge day with c/o of worsening symptoms of stiffness and shaking. Tx'd with Benadryl. Risperdal stopped. DX: Dystonic Reaction. Visit 4/17/05-O/N ER admit for increasing extrapyramidal symptoms-jerking, shaking, picking, itching. chills and c/o left forearm and leg pain, as well as difficulty remembering names. PE: WNL except sustained clonus of ankles, downgoing toes, oral and lingual dyskinesias, Toewheeling, Cogwheeling, and antalgic gait. Treated with benadryl and transfered to another hospital. Fianl DX: Extrapyramidal symptoms. Visit 08/14/05- ER visit for worsening tremors and dystonia. Patient now presenting in a wheelchair. Unable to eat, drink, or sleep much x2days.  Weight loss of 50# since 04/05. Txd with Valium to enable rest. DX: Neurological disorder with tremors. Visit 08/19/05-Evaluation for PEG tube insertion. Doing well with feeding tube place the day before.  No PEG at this time. DX:  "Primary diagnosis is not yet established", prognosis unknown. Visit 08/20/05- Visit to replace feeding tube which was accidentally pulled out. Visit 08/21/05-ER visit for c/o fever and continuing gross motor movements of the arms, legs, trunk, and head which prevent the child from sleeping. Transported to another hospital via Air transport. Assessment: 1)Severe Dystonia of idiopathic origin. 2) Fever R/O aspiration pneumonia  3)severe malnutrition and dehydration. Visit 09/01/05 Visit for medication administration: Prednisone and Valproate./pc 01/16/2007 MR received from PCP including multiple consults and hospital reports. Extensive report from admission after transfer to a hospital on 4/17/2005.  Initially a medical admission for rapid onset left-sided muscle spasms with multiple neck and extremity movements several weeks following her Td and HepB vax.  She was transfered to the inpatient psychiatric special care unit to be followed by her treating psychiatrist.  She was noted on PE to have jerkiness of all extremities and body and speech articulation problems which were a deviation from her baseline.  Medication adjustments were made and she was dicharged somewhat improved but still having persisitant involuntary movements. Discharge DX: Likely medication induced movement disorder, NOS, characterized by akinesia and a hx. of choeoathetoid movements. Admission on 5/23/05 for worsening movement disorder which has rendered the pt. without any significant quality of life. Final DX: dystonia Neurology consult of 7/14/2005  with Impression: Generalized dystonia possibly related to long-term phenothiazine use. Of note in the Impression: " The temporal relationship of tetanus booster quickly followed by fever, malaise,  and the onset of her symptoms seems difficult to ignore".  Multiple office visits to PCP between 8/17/2005 and 2/22/06 for various problems associated with severe dystonia and athetoid movements of Sydenham's Chorea. 01/22/2007 MR received from treating hospital for several admissions and treatment protocols.  Admission of 08/22/2005-09/01/2005 is a continuation of above admission, but was transferred via Air Flight to a PICU. Pt. admitted for a severe choreiform movement disorder and 53# weight loss in 4 months. A G-tube was placed for nutrition and several medication changes made. High dose steroids given with significant improvement. Discharge Diagnosis: Sydenham's Chorea. Admission of  12/28/2006-12/31/2006 for worsening of movement disorder. Discharge DX: Chorea and URI. Treatment reports for IVIG tx. on 3/20/2006 state DX: Chorea, etiology unknown-suspected to be autoimmune. 01/30/2007 Records received from hospital for several office visits for her choreaform movement disorder dated 3/16/2006, 6/15/2006, and 9/28/2006. Assessment:  Bipolar mood disorder with psychotic features in partial remission, OCD, ADHD, Atypical Nevi of tongue, Choreaform movement disorder.