Age: 25.0
Sex: M
Vaccine: ANTH, HEP
Symptoms: Photophobia, Postnasal drip, Pyrexia, Red blood cell sedimentation rate normal, Rheumatoid factor
Clinical narrative: 2/17/04 - received ANTHRAX vaccine #1 - no problems 2/27/04 - deployed to foreign country 4/21/04 - received ANTHRAX vaccine #2 and HEP B vaccine #2 4/22/04 - suddenly developed fever of 103, sore throat, body aches, and pulsating/throbbing headaches (5/10) along with photophobia x3 days above sxs worsened 4/27/04 thru 5/4/04 - hospitalized for above sxs - fever of 107 - also developed sob and wheezes - given dx of sinusitis - no response to ZITHRO or ROCEPHIN - LP, head CT, and UA neg - elevated LFTs and RBS - was flown back for further care. 5/18/04 - above viral - like sxs completely dissipated except ha - severity of ha now mild (1/10) but "I have it all day long, everyday" - pain is mostly around the forehead area, bilat temples and "behind my eyes" - "pressure-like" - seen by MD (neurologist at Hospital) - was placed on ZOMIG- BRAIN MRI (7/26) and CXR (7/12) negative. States since receiving above vaccines back in April of last year, noticed having more frequent "sinus infections" - has h/o sinusitis prior to receiving above vaccines but "they were not as frequent and not as bad" - has been on multiple antibiotics for his sxs - ALBUTEROL inh and CLARITIN prn - FLONASE not helpful - sxs "last about a month, then go away for about a week, then gradually come back" - c/o itchiness back of throat, sob, wheezes, PND, chest discomfort, and difficulty taking deep breath when having sinus problems - states has not yet been evaluated by ENT. Last week of December 2004, pt. began to notice joint pain (3/10) "all over my body" - alternating pain mostly felt in knees, wrist, neck, and chest area - "chest area worse, 7/10" - "feels like a growing pain" - "persistent, gradual, throbbing, sharp" pain - joint pain not r/t weather, activities, or time of the day - denies any stiffness - sxs have now worsened - pain now interferes with sleep - able to obtain as little as 1 to 2 hours of sleep at night - c/o fatigue d/t insomnia - "I just have no energy because I feel so tired" - states has not taken any meds to alleviate pain - states has not yet been evaluated by rheumatologist - strong FH (mother) of rheumatoid arthritis. 1/21/04 - pt. seen by his Case Manager - verbalizes his frustrations over his new sxs - states is scheduled to PCS in the next few days - requesting updated clinical summary on his newly developed sxs and an extended exemption for his future ANTHRAX vaccinations - information on ANTHRAX vaccination provided to pt. per pt. request. 1/25/04 - pt. seen by his Case Manager - requesting a copy of his clinical summary written by NP (6/28/04) - above documentation not completed and not signed by NP - a copy of the documentation given to pt. per pt. request - quality of life statement completed by pt. - lab tests (ANA, RF pending at this time) reviewed with pt. - questions answered.  6/23/09 Medical records received DOS 2/17/04 to 7/08/04. Records support previous information received. Assessment: Persistant diffused arthralgia syndrome, frontal sinusitis, chronic recurrent headaches, insomnia, fatigue. No additional coding required. ICD-9 Codes: 719.40, 473.1, 784.0, 780.52, 780.7