Age: 69.0
Sex: F
Vaccine: SMALL
Symptoms: Head injury, Heart rate increased, Impaired driving ability, Infarction, Loss of personal independence in daily activities
Clinical narrative: She got her vaccine, she got diarrhea, wasn't feeling good and on 11/10/23 her heart rate went up while she was walking in the park.  She then started having more nerve pain.  She resumed Lipitor on 11/6/23.  She was sitting in a meeting on 11/9/23 and felt just horrible all over and then went home.  She has been getting acupuncture every 2 weeks, but then started having more trigeminal pain and started having it every week.  On 11/16/23 she got RSV and  flu vaccines by the 11/18/23 the trigeminal pain was too intense.  Someone had come to the door to ask if they could get her trash and stuff, and she was too sick to do anything from this.  She started to open her mouth and had electrical shooting pain and the pain kept getting worse.  She was started on Valtrex as she was having problems and had biopsies done and she had asked for Tegretol and was told now and the Valtrex was giving her some results with the nerve pain.  She was standing at the sink at her husbands for Thanksgiving had increased heart rate, which was 110.  She laid down and had some water as she felt she was dehydrated and she felt better.   She started Gabapentin and got into see her PA and he told her instead of Tegretol to take the Valtrex which he gave her 10 mg for 10 days.  She took her last pill this morning and it still has not settled down and is going to see if she can get a new refill.  They do not know what has caused the trigeminal nerve pain.  She has a referral for an Appointment in March with an endocrinologist.  She does see pain management, has heart issues, joint problems and looked at her symptoms and suggested a brain MRI with contrast, and in March she had multiple infarcts.  She tripped in the yard and fell, hit her head and hit head really hard.  Later got concussion symptoms.  Pain management told her if she went to the ER.  She went several trips to ER to find a neurologist and does not know if a lot was stress related.  Was stuttering, could not control body temperature, cold, muscle tension and could not tell if she had to pee and knew she had to for several hours and then if she went to the bathroom would urinate a lot.  She did have a appointment with one neurologist who read the report, and the report said no findings for trigeminal nerve pain and that got pushed aside to see what was going on .  Then she had a cardiac work up done which took months.  She never got to address it.  The few times she saw a neurologist and he never put them in her notes on Chart.  She is doing better with balance and all, had no sense of proprioception, and felt like she could walk if she was close to something, and if not otherwise could not walk.  She kept plugging along with it, had some myofascial relief and is still not right.  Then this happened, and knows that there was stress involved even the year before as she had to have a breast biopsy and felt she was pretty calm around it.  She lives where they had so many wildfires in the area, and has had breathing issues.  She was supposed to have a sleep study and could not go due to tech having COVID.  She wears a mask as she does not want to challenge her respiratory anymore.  She is more forgetful.   She is very stressed trying to get her records but the neuralgia is aggravated by stress.  She made a FU appointment to see a neurologist too but not until March.   all of her tests prior she was told her visits were fine, and now she has been put on all these medication and she cannot get the records to see what information is in her Chart.   She eats healthy and she is not able to drink a cup of tea and other things due to the nerve pain.  She is still trying to figure out what is causing the nerve pain and why she is loosing so much weight.   She got an aura one day of zig zags and it was so unusual that she thought was she having a stroke.  If it was she cannot see, cannot drive and felt that if she drove to the local ER they could not do anything.  She had a concussion and multiple strokes were not mentioned in her Chart, and never referred her to a neurologist as they were very very busy.