Age: 22.0
Sex: M
Vaccine: ANTH, HEP, HEPA
Symptoms: Grip strength decreased, Haematuria, Haemoptysis, Headache, Laboratory test
Clinical narrative: Anthrax vaccine #1, #2, #3- no problems. 10/06/03- received anthrax #4- along with Hep A #2 and Hep B #2- few weeks later ("by the end of October"), pt. noticed following symptoms. 1. Lack of energy- "I couldn't run as far- because I had hard time catching my breath"- still persists. 2. Felt not rested- "I always wanted to sleep"- still persists. 3. Weight loss (unsure how much)- sx now resolved. 4. "Pressure-like" headaches (8/10)- "back of my head and behind my eyes"- intermittent- often lasting up to a week- no meds taken for sxs- still persists. 5. Myalgias of upper and lower extremities (2/10)-constant- worsens with activity- states seems to be stress related- lessens but do not completely dissipates- now occurs intermittently- 8/10- was given NAPROXEN- med not helpful. 6. Arthralgias of fingers (7/10)- worsens with gripping- sx now resolved. 7. "Coughing up blood"- dark red clot- tablespoon size- intermittent- well controlled under steroid therapy- reappears if steroid d/c. 8. Dizziness- worsens with position change- sx now resolved. 9. Chest discomfort (6/10)- sharp- center- not r/t coughing- sx now resolved. Patient states in mid Nov '03, he was seen for his sxs (no change in intensity of sxs since first appeared)- was given a referral to pulmonologist- CXR, chest CT and Bronchoscopy done- was admitted to medical center- prednisone therapy initiated- after 3 days, was transferred to hospital- was admitted for 10 days for pulmonary hemorrhage- was seen by multiple specialists-CXR revealed "infiltrate in the right middle lobe which was consistent with pulmonary hemorrhage"- his UA revealed hematuria with 3+ blood and trace protein (no gross hematuria)- serologies showed positive P- ANCA- subsequently underwent a renal biopsy, and the dx was microscopic polyangitis- pt. was given plasmaphoresis treatment times three- was treated with CYTOXAN and Prednisone with good success- hemoptysis slowly tapered off with prednisone- by discharge, hemoptysis resolved and his kidney functions became stable. Since discharge from the hospital, pt. was placed on two doses of q monthly CYTOXAN- was d/c'ed in 04/04 d/t low blood count- started on CELLCEPT (since 4/04) instead- Prednisone dc'ed 9/04- hemoptysis reappeared after prednisone d/c'ed- was placed back on Prednisone- states had gained 50 lbs from chronic prednisone use- states has now slowly been losing excess weight with diet and exercise. Also, since discharge from the hospital, pt. has had periodic f/u with nephrologists and rheumatologist once a month- has been told his medical problems are stable. ("staying the same")- states had been on profile for 1 year- received extension for 5 mos d/t CELLCEPT use (will be on CELLCEPT for 6 more months)- states has permanent exemptions to all vaccines- non deployable x1 year- MEB scheduled for 12/04- pt. does not want medical retirement.   6/23/09 Medical records received DOS 10/6/03 to 11/17/04. Assessment: Microscopic polyangitis. Patient presented with lack of energy, felt not rested, weight loss, headaches, myalgia extremities, arthralgia of fingers, coughing up blood, dizziness, chest discomfort. Tx with prednisone. Weight gain.   ICD-9 Codes: 786, 783.2, 719.40, 786.3, 786.2 780.4, 501.9, 780.7, 784.0, 729.1