Age: 38.0
Sex: F
Vaccine: HEPA, TYP, YF, HEPA, TYP, YF
Symptoms: Headache, Hypoaesthesia, Injection site pain, Muscular weakness, Nuclear magnetic resonance imaging
Clinical narrative: The following was reported by the client: Vaccines given on 03-09-2009 in the morning with complaints of soreness at the injection site and a mild headache that evening.  Recalls first injection was typhoid and made her heart feel like it was racing.  On 03-13-2009 had soreness in the lower back that extended up her spine.  Did not think this was due to injury. Used local heat and took Motrin.  Soreness continued through the night. On 03-14-2009 back hurt so much that she was unable to participate in a ski trip. Pain was improved on 03-15-2009.  On 03-16-2009 was able to ski.  Had some headache on and off.  Was hit by a snow board on the left arm on this date.  On 03-21-2009 muscles did not feel as strong.  On 03-22-2009 remained in bed.  Hands and feet felt numb.  Felt tingling in these extremities. Had chills and no fever.  Felt like she had the hives.  Skin was red. On 03-23-2009 went to work and experienced numbness and weakness in the left arm.  Right hand was numb.  Experienced burning and tingling.  Went to Medical Center.  Was told that symptoms were from the vaccines she had received and not the snow board injury.  Had a "huge sore" on the inside aspect of left upper arm.  Asked for referral to neurologist.  Symptoms became worse that night. Seemed better the morning of 03-24-2009 and became worse that night. Continued through 03-25-2009.  Saw physician on 03-25-2009. Soles of feet and palms of hands were red with numbness and tingling. Took Tylenol PM prior to bed on 03-25. Appointment with neurologist on 03-27-2009 who told client symptoms were likely vaccine related.  Had burning under the skin and redness on the left ear. States passed tests for reflexes, strength, and "pokes." Pain in back was severe.  Physician told her she could not travel on 03-29-2009 as planned.  The morning of 03-28-2009 felt better, but that evening developed severe back and neck pain.  Continued to 03-29-2009.  Called neurologist.  Saw Dr. on 03-31-2009.  Blood drawn.  Neurological tests passed.  Has appointment for MRI of head on 04-01-2009. Denies any problems with breathing, speaking, thinking during the course of events.  Husband hasn't noticed any change in gait although client states legs and ankles have felt weak. 4/6/09-records received for DOS 3/23/09-C/O numbness in left upper arm for past few days. On 3/9/09 received hepatitis A vaccine and then had a contact inury while skiing when arm struck while extended over head by snowboarder. At that time had a significant bruise to inner aspect of left upper arm.  Office visit 3/27/09-C/O numbness and buring dysethesias that affects both upper extremities and both distal lower extremtieis. Intermitten musculoskeletal mid to low back pain. After skiing injury more diffuse nubmness and paresthesias of left upper extremity but gradually improving. Office visit 4/3/09-evaluated for numbness and burning dysesthesias. Now only intermittent burning dyesthesias at night with occasional numbness. Fluctuating insomnia and fatigue. DX: Paresthesias. 4/20/09-records received-office note for C/O chronic constipation, abdominal pain, sinusitis. Back pain is fleeting, no radicular pain down legs, ergonomic evaluation at work for suspected carpal tunnel. DX: muscular back pain. 8/19/08-C/O feeling unwell for past couple of months, hives, thick in tongue, fatigued and anxious. Menstrual periods now have a greater interval, 3/25/09-immediately after receiving vaccine on 3/13/09 noticed achiness in back, tingling in arms and legs and burning sensation in thighs. 3/31/09-numbness in left arm and burning sensation of upper body, anxious.