Age: 46.0
Sex: M
Vaccine: ANTH
Symptoms: Fatigue, Gait disturbance, Hypoaesthesia, Joint range of motion decreased, Laboratory test abnormal
Clinical narrative: Left elbow pain with onset within 1-2 days following anthrax vaccine (3). Described as a sharp pain. Rates level of intensity as 4-10 initially. Left elbow pain is not associated with swelling, redness, warmth, or paresthesias. Reports weakness of his left upper extremity and decreased range of motion due to pain. Around January 20, 2006, he experienced pain (sharp, burning). These pains decreased for a couple days following his first acupuncture treatment, but returned at an intensity level of 5-5/10. The pain resolved after 2nd acupuncture. Fatigue onset in August 2003 shortly after AVA (3). Describes as an inability to perform normal activities due to inadequate energy. Compares to a battery being drained, like trying to make a 3 hour battery last for 6 hours. Currently rated his energy level as 30-40% of baseline using a scale of 0-100%. Denies accompanying symptoms of headaches, depression (feels frustrated that he cannot do the things he use and generally does not feel like himself, but feels he is coping with his frustrations), fever, sore throats or swollen glands. No migrating arthralgias other than the episode of multi joint pain in January 2006. Describes some muscle weakness affection his left upper extremity, and more recently has experienced his legs giving out...rubber legs. Paresthesias affecting lower extremities. Around December 2005, he stated experiencing tingling sensation in both feet, parts of his legs, and sometimes his hips. Describes as a burning type sensation and similar to numbness after novocaine at the dentist or like when your foot goes to sleep. Sensation in intermittent and last a couple of hours. Episodes have occurred several times since December 2005. Sensation comes on suddenly and seems to occur more often after he has been on his fee more or when he had been more engaged mentally. Sensation does not seem to be precipitated by positioning or stress. Dizziness/unsteadiness. Onset around March 2006. Began noting a feeling of dizziness or unsteadiness where he feels out of balance. He experienced 3 or 4 episodes while visiting this year. Describes like walking in a bouncy castle...not on a solid surface. Also describes like staggering drunk but denies sensation of head spinning or objects spinning around him. Onset can occur while sitting, at rest. Sensation of imbalance is usually accompanied by sensation of legs going to give out or rubber legs. Feels like he is staggering if he attempts to walk. Often uses wall for support. Has fallen on more than one occasion. Longest episode was about 8-10 hours, but usually only last 1-3 hours. Has never felt like he was going to faint or black out. Denies any hearing loss, sensation of pressure or fullness in ears, or tinnitus. Some episodes may have been associated with position changes, but other episodes have occurred while sitting still. Denies any associated visual changes, headaches, slurred speech or nausea and vomiting. No numbness or weakness. Service member feels his unsteadiness has affected his agility and his ability to do detailed work with his hands (use to make jewelry pieces). Tremors-had a few episodes of notable hand tremors over the past 1-2 years. Most notable with writing (right hand dominant) and when working with rocks to make jewelry (ruined piece of jade). No episodes noted when eating. Describes like Parkinson's shaking. Episodes usually only last 5-10 minutes. Service member feels episodes are associated with increased stress (when under pressure).