Age: 45.0
Sex: M
Vaccine: ANTH
Symptoms: Injection site mass, Laboratory test abnormal, Lung disorder, Nervousness, Personality disorder
Clinical narrative: Received anthrax vaccine (1) on 2/14/03 with Hep A vaccine (1), Flu vaccine, Typhoid vaccine, and MGC vaccine    Local: Recalls small area of redness and tenderness and small knot at anthrax vaccine site the first 3 days following vaccine.    Systemic:  Does not recall significant fever, chills, headaches, joint pain, muscle pain, or fatigue within first 1-3 days following vaccines.   Received smallpox vaccine (2) on 2/17/03.    Local: Received 15 jabs on his left arm. Reports usual progression of vaccine site, without significant redness, swelling, streaking, tenderness, or pruritis.     Systemic: Does not recall significant fever, chills, headaches, joint pain, muscle pain, fatigue, chest pain, cough or fatigue within first 3 weeks following the vaccine.   Received anthrax vaccine (2) on 2/28/03    Local: Recalls small area of redness and tenderness and small knot at vaccine site the first 3 days following vaccine.     Systemic:  Does not recall significant fever, chills, headaches, joint pain, muscle pain, or fatigue within first 1-3 days following the vaccine.   Received anthrax vaccine (3) on 3/20/03.    Local: Denies significant redness, swelling, pruritis, or tenderness at vaccine site. Noted a small knot at vaccine site x 2-3 days following vaccine receipt.    Systemic:  Denies systemic symptoms on day of vaccine or following day.      On 3/22, while home on pass, family commented that patient was not himself. He felt sleepy and was confused for most of the day.      On 3/23, recalls "stumbling and bumbling"; those around him, thought he was drunk; continued to be lethargic and went to bed at 1800.      On 3/24, he did not get up for formation. Members from his unit tried to wake him up, but they had difficulty; had to assist him to stand (almost fell); they assisted him to the Emergency Room, where he was then admitted for elevated BP, blood glucose and ECG changes. He was discharged on 27 March, but continued to feel weak, dizzy and fatigued. Has required additional evaluation and treatment over the past year and still does not feel 100%.  See Current Problem List for additional details on problems that patient perceives may be related to his anthrax vaccines.03/22/1996 401    Hypertension - Diagnosed with HTN in 1996, but patient reports being off anti-hypertensive meds between 2000 and his admission in March 2003. After admission, placed back on medication and since then, several different BP medications have been initiated, with dose titrations. His current BP medications include Lotensin 20mg daily, Atenolol 100mg daily, Norvasc 10mg daily and HCTZ 25 mg daily. Follow-up note on 6/17/04, notes BPs normal.    08/02/1999 786.5  Pain, chest - Note from 4/28/03 comments on history of intermittent chest pain "x years", and was "cleared" after a cardiac cath (1999). At visit on 4/28/03, patient complaining of chest discomfort and shortness of breath with exertion. He was referred to Cardiology for further evaluation in 2003, including ECHO, stress test, Thallium stress test and cardiac cath.  Cardiologist's note from 8/21/03 noted description of occasional chest pain on both sides of chest, after exertion, lasting a few minutes before resolving spontaneously (not accompanied by shortness of breath). States that patient continues to have chest pain despite normal cath, and started Norvasc for better BP control, as well as possibility of vasospasm. Assessment includes: 1) s/p cath with normal coronary arteries, 2) chest pain, not cardiac in nature, 3) HTN, well controlled, and 4) History of smoking. During VHC phone interview in June 2004, patient reported continued episodes of chest pain, primarily with exertion, occurring 1-2x/week; notes racing heart but no palpitations; sometimes associated with dyspnea and increased perspiration; has not checked blood glucose level during episodes; usually chest pain resolves with rest within minutes; has never treated with NTG. He is taking ASA 81mg daily, along with his anti-hypertensive medications.   11/02/2003 786.0  Abnormality, dyspnea and respiratory - Patient smoking since age 16. PFTs from October 2003 showed mild restrictive pattern. Follow-up note dated 11/14/03 notes restrictive lung disease consistent with fixed obstruction, and negative CXR. A high resolution CT scan showed no mediastinal adenopathy; no evidence of interstitial changes, nodules or lung masses. A Pulmonary Consult was ordered and completed during January and February 2004; final note discussion "At this time I do not feel that any bronchodilator regimen is necessary.  He needs to quit smoking completely and permanently.  Otherwise, the chances of making his lung disease worse are high.  Compared to previous study, there is no major change in his lung function.  I again told him of the need to quit smoking completely and permanently..."   04/02/2003 780.7  Malaise and fatigue - Patient notes feeling weak, dizzy and tired following discharge from the hospital in March 2003. Dizziness found to be primarily positional, and did improve somewhat with BP medication titration. Patient unable to describe specifics of weakness and fatigue, other than noted a specific incident in late May 2004 during CQ duties when he felt totally exhausted after climbing stairs and walking down hallways in the barracks. Fatigue usually decreases after rest/sleep. Records review shows little mention of fatigue other than note from 6/17/04 that mentions fatigue with "all exertion".   04/01/2003 250    Diabetes mellitus - Patient reports being told his blood glucose level was elevated during his admission in March 2003. The only documentation reviewed by the VHC regarding this admission was the discharge summary, which did not mention an elevated glucose level, but notes "History of ETOH abuse and HTN, complaining of weak feeling, unsteadiness, and near syncope" and says he was admitted for alcohol withdrawal and treatment of HTN. Discharge note also mentioned ECG changes. [A Statement of Medical Exam and Duty Status dated January 28, 2004, states that medical records for hospitalization from 3/24-3/27 were reviewed; it states the nature and extent of the disease as being Diabetes and mentions that no blood alcohol test was made, and the medical opinion states that he was "not under the influence of" and the "injury" was line of duty.] The patient denies being drunk the weekend prior to or the day of his admission, but does admit to a history of drinking 4-6 beers at a time or 30 beers/week on a regular basis prior to March 2003. He denies any symptoms of hyperglycemia the weeks prior to admission (polyuria, polydipsia, blurred vision, fatigue). In records reviewed by the VHC, a note from 9 April 2003 notes a glucose level of 117, which was repeated along with an A1c. A note from 23 April notes a fasting glucose level of 133, with an A1c of 5.7.  A note from 4/28/03 notes an A1c of 7.4 and SBGM readings running 160-200, and initiation of Metformin and Glipizide. (Glipizide was later discontinued secondary to hypoglycemic episodes.) Patient is currently taking Metformin 500mg twice daily. Patient received education on SBGM and nutrition. He checks his blood glucose levels every 3-4 days and reports most readings are around 90-100. He denies experiencing hypoglycemia since glipizide was discontinued. (Felt nervous and drained with BG levels <70.) He does not exercise regularly secondary to not feeling up to exercising since last March. His dilated fundoscopic exam in November 2003 was negative for BDR, but at that time, it was noted that he was a glaucoma suspect.  He reports numbness of his hands and feet over the last several months; this sensation sometimes decreases with increased movement or use of the affected extremity. He also reports severe cramping of his feet and legs. DM risk factors:  BMI  HT.  72"  WT. - 192 (on 6/17/04)  BMI  - 26.1; family history  denies history of diabetes; ethnicity  African American; hx of IGT or IFG  denies previous history of elevated glucose checks with physicals prior to diagnosis, HTN  history of elevated BP since 1996; dyslipidemia  - denies prior history of dyslipidemia; inactivity/sedentary lifestyle  considered self somewhat active prior to diagnosis of DM.     05/28/2004 719.40 Pain in joint, unspecified site - Reports first "bad pain" after pulling CQ in May 2004. Reports severe knee, back and shoulder pain after climbing stairs. Felt like extremities were going to "fall off" and knees felt like they were going to "give out". Patient's Narrative Summary for MEB lists mechanical low back pain as a secondary diagnosis, but records reviewed by VHC do not reflect evaluations of joint pain or low back pain. Patient denies history of previous injuries.    11/13/03, 365  Glaucoma - Patient denies history of increased IOP prior to November 2003. At Ophth. visit on 11/13/03, he was identified as glaucoma suspect, and on 11/20/03, he was diagnosed with glaucoma (COAG ou) and Xalatan eye drops were initiated. Note from January 2004 mentions stable IOP with present meds.  Nurse follow up on 11/02/04 states: "alcohol intoxication; diabetes and glaucoma."   11/1/04 Review of hospital d/c summary indicates diagnoses were alcohol withdrawal and hypertension. Pt was treated with Ativan and Clonidine with no symptoms of withdrawal evident. Discharged on Atenolol. 11/1/04 Reviewed f/u medical board records. Chest pain was diagnosed as non-cardiac. Pt was diagnosed with DM in 8/2003, restrictive lung disease in 10/03, and with glaucoma in 11/03.