Age: 41.0
Sex: M
Vaccine: ANTH
Symptoms: Insomnia, Oedema, Pyrexia
Clinical narrative: After 5th Anthrax vax to the right arm on 5/5/00, PT reacted with redness, swelling, and fever >100 lasting approx 3 days. PT had same reactions for all of four previous Anthrax vax's. Current Problem list: Summer of 2001, PT noticed his ability to run was diminishing. He was running 4.5-5 miles 3-4 times per week. He was becoming increasingly tired after running so he decreased his running time to 1-2 times/wk. He thought maybe he needed to give his body a break or that he was getting old. He found himself needing a lot of rest. After 9-11 he was focused on deployment and was distracted from exercising even further. At this point he did not notice any difficulties falling asleep, staying asleep, or waking up rested. Deployed to another site until April 02. Had difficulty doing the lighter "PT" at this post w/out fatigue. He would go to bed at 20:00 and rise at 05:30. He would wake up rested but would not have the energy to do "PT" at full strength. He broke his finger in Jan 02 and stopped doing "PT" altogether while taking painkillers. When he finished course of painkillers he was not taking any medications. PT deployed to a foreign country in Apr. 02. He was kept very busy with military duty and did not notice fatigue at rest. He returned to a regular exercise prog. during this deployment to include running and lifting weights. He was able to run 4 miles/day and weight lifting as permitted by the injured finger. He would go to bed around 20:30, 21:00 and felt his sleep was restful. In June 02, he injured his neck with a jerking movement while lifting weights. The pain in his neck interfered w/sleeping. He was only able to sleep half the amount of hours compared to pre-injury sleep due to waking up several times / night due to pain. He would wake up unrefreshed and would feel tired throughout the day. He was treated by physical therapy w/out relief. PT left the foreign country in July 02 and returned to his home base for medical evaluation. He was treated with muscle relaxers and sleeping aides but his Sx's did not improve. The sleeping difficulties compounded his fatigue. He returned home to Orlando on 9/30/02. He was extended on active duty for medical purposes (Hand and neck). The orders were retroactive to 10/15/00, lasting 3 mts or until medical care is complete (in sets of 90d). Currently he falls asleep w/out difficulty. He wakes up a few times during the night due to neck pain currently has difficulty walking and does not feel rested. His Sx's have increased over the last 6 mts and have begun interfering w/his daily life. PT experiences lower back pain w/prolonged standing and cramps in his quadriceps and hamstrings. He equates the muscle pain to sore muscles after an intense workout. He was examined by an MD for fibromyalgia pressure points and told to take an anti-depressant and get counseling. He went to counseling appmt. and felt as though he got nothing out of it. He began taking anti-depressant medication 2 wks ago. PT noticed bloating and nausea after eating several mts ago but became more intense in the last month. He feels hungry but even after small meals he feels bloated and nauseas. He needs to force himself to eat to maintain his strength. His primary care MD did blood work. A high Bilirubin prompted a liver scan. Liver scan showed fluid, prompting an abdominal CT scan, which was normal. He is currently experiencing dizziness w/standing. He states that his blood pressure is lower than normal. He has not yet discussed this Sx w/his MD. Over the past few mts, PT has noticed difficulty remembering names and multi-tasking at work. He is still able to perform the tasks required for his job but now needs more time to complete them.