Age: 10.0
Sex: F
Vaccine: HPV9
Symptoms: Mobility decreased, Musculoskeletal stiffness, Nasopharyngitis, Neck pain, Nuclear magnetic resonance imaging spinal normal
Clinical narrative: 6/2016 - started having stomach pain and menstrual like cramps almost reoccurring daily (has not started menstrual cycle yet). 8/8/16 - developed rash on body from shoulders to thighs, doctor could not give any explanation. 8/9/16 - had nosebleed at night. 8/10/16 - had nosebleed, rash still present on body. 8/15/16 - still has rash with a few new ones popping up. 8/30/16 - Severe ankle and leg pain on right leg, from knee down, unable to put any pressure on right leg, but doctor says it is CRPS (Complex Regional Pain Syndrome) caused from her breaking her ankle back in March 2016. No physical therapy (because we could not afford it) but has to desensitize the area herself. 9/22/16 - for a couple of weeks, complains of chest hurting her, if I have my arm around her and she is laying on her side, it hurts, very deep breaths hurt sometimes. Still getting rash like bumps. 9/26/16 - chest pain at school, not during an activity, also hurting on left side under arm, rib cage area running up and around to chest. 9/30/16 - doctor appointment to discuss issues, joint pain and a lot of pain when touched in chest area and upper back. Blood work checking CBC, thyroid, ANA (used to detect Auto-Immune Diseases), rheumatoid arthritis. All came back normal, except ANA came back borderline but told not to worry. Referred to allergist/immunologist for more tests, and pulmonary function test on 10/19. 10/4/16 - noticed that her legs (shin) had small white spots/areas, like skin lost the pigmentation. 10/10/16 - chest pain and back pain still present. 10/19/16 - Pulmonary Function Test and Allergy tests. Only allergies that showed up positive were common allergies (mold, etc.). Diagnosed with Asthma and prescribed two different inhalers. More blood work again, checking her ANA levels, they came back elevated, but again told not to worry yet. 11/9/16 - a lot of pain on her spine in the middle of her back. 11/17/16 - complaining of pain in pelvic area. 2/1/17 - dry patches on face and body started and dry skin, maybe hormone changes. 2/16/17 - top of spine, base of neck, swelling and stiffness around bone. Can't turn her head or bend it without extreme pain, painful to touch, cries when jolted. 1/18/18 - went to doctor for flu symptoms but only a cold, doctor had trouble listening to left lung, so he checked her back and noticed that she had was showing signs of scoliosis, referred to Orthopedic Clinic. Reason for referral - scoliosis, 10 degree tilt on scoliometer, premenarchal. (Well-Check/Physical in June 2017 was normal, no signs of scoliosis). 2/19/18 - Appointment for x-rays of spine. Diagnosed with Adolescent idiopathic scoliosis of thoracolumbar region. Doctor wants to follow-up in 4 months. 4/23/18 - has been complaining of back pain for a few weeks, no injury or trauma, thought it had to do with her asthma, then yesterday the pain got worse and by this morning she could barely move. Had to help dress her and put her shoes on because she could not bend over. Took her to clinic and doctor could not finish exam because she was in so much pain. Sending her for an MRI to rule out a cyst on her spine. 4/24/18 - back pain is still the same as day before. 4/28/18 - back pain has lessened some and she is able to play volleyball and attend cheerleading practice. Complains of pain but pushes through it. Also, since the vaccination, she has complained off and on with joint pain, specifically starting with her ankles, then to her knees, and then to her hips. Also had pain in left elbow and left wrist. The pain comes and goes. As of 1/15/2019 - Back pain and neck pain continues to get worse. More so at night.