Age: 29.0
Sex: M
Vaccine: TDAP
Symptoms: Borrelia test negative, Computerised tomogram head normal, Confusional state, Decreased appetite, Dizziness
Clinical narrative: Please see continuation page for description of timeline 6-18-24 Tuesday  Woke up with pain in right hand/thumb, looked red and swollen, painful to touch or close fist. Went to Urgent care in the morning they prescribed a Bactrim antibiotic and since we did not know they approximate date of the last tetanus shot (sure within 10 years but unsure if within 5) urgent care recommended we go ahead and we get one. Went to pharmacy at 6pm and got tetanus shot and prescription. Started prescription on Wednesday morning.  6-19-24 Wednesday  No Change  6-20-24 through 6-23-24 Thursday-Sunday Woke up Thursday and days following with persisting symptoms. Severe fatigue, no appetite, not feeling right, slight vertigo (hard to focus/tunnel/blurry vision, tingling in hands and feet, dizziness, limb weakness, pain in arm near shot, feeling of elevated heartrate/blood pressure) Called urgent care on Sunday 6-23 and explained issues asked if we should continue antibiotic. They recommended if his hand was better (it was completely healed) that we should stop the antibiotic. Did that, no change in symptoms. 6-24-24 Monday Symptoms persist, went to work was really tired, symptoms getting worse 6-25-24 Tuesday Went to work symptoms persist. Eating dinner, halfway through patient stated he really wasn't feeling right and didn't know what to do. Had eaten half a sandwich and some chips with some soda. Complained of fatigue, tingling in hands and feet, headache and blurred/tunnel vision. I suggested maybe blood sugar issue due to family history and lack of recent A1C levels. Went to parents and tested blood sugar and blood pressure. Blood sugar was 68 (tested mine as well and it was the same so unsure of reliability of tester) and blood pressure was elevated 150s over 80s. Decided due to no changes and recent events in the family decided would be best to go to the ER. Blood pressure remained elevated at the ER 154/85 up and down slightly with each reading. BP 70s and 80s. All blood work came back normal except for TSH at 5.9 (range varies but shouldn't be above 4.5) Diagnosis of hypothyroidism given and they stated he needs a thyroid ultrasound. No medication given. Skeptical of that diagnosis. Awaited scheduling call for ultrasound. Went home. Testing for LYME and other tick borne illnesses came back qualitative, blot testing preformed and all listed as NEG in the chart 6-26-24 Wednesday Patient stayed home from work, went to chiropractic appointment in afternoon around 430pm. Came home still same symptoms and worsening headache overtime, stated adjustment was rough as it had been months since the last appointment. By 1130pm he had a full blown migraine (he has never had one like this, I have chronic migraines so I know when I need to medicate or when I need to go to the ER for more serious symptoms.) Light sensitive horrible pain, tingling up and down right arm and into face. I checked for facial drooping and a few other cognitive things and didn't suspect a stroke but due to ongoing problems went ahead and took him to ER. Blood work and head CT was all clean and normal. That Dr stated he did not think we needed the thyroid ultrasound due to one level increase, suggested we wait a few weeks and re check. Gave him medication tramadol for headache/pain. Went home. Both of us stayed home Thursday to recoup. 6-27-24 through 6-30-24 Thursday-Sunday Stayed home mostly slept or relaxed, back/neck pain beginning and quickly to worsen. 7-1-24 and 7-2-24 Monday-Tuesday Went to work, still struggling with all persisting symptoms. Went to same chiropractor, seemed to help with neck pain 7-3-24 Wednesday Called me at 10am was working and began to feel light headed and sick, felt like blood pressure was high or blood rate elevated shaking in hands/arms tingling in limbs. Met him at urgent care. She reviewed everything with us, mentioned Guillan-Barre syndrome in relation to the tetanus shot but quickly let us know that was likely not it. Did an xray it was normal. Physically examined him, prescribed Prednisone for inflammation reduction and Muscle relaxer for pain and spasm relief.  7-4-24 through 7-7-24 Thursday-Sunday Stayed at home minimal activity to rest back and all symptoms persist on and off.  7-8-24 Monday  Went to work had a decent day, later on in the night symptoms reared up stomach pain began, abdominal muscle beneath ribs tighten and hurt all the time, had a bad night. 7-9-24 Tuesday Stayed home, I got him an appointment with another chiropractor went at 530, adjusted him and when he got up from the table he could stand up straight and felt really good. By the evening everything began to come back. Stomach acid build up, terrible bathroom visits and still no appetite. Worries about gallbladder/pancreatic issues. 7-10-24 Wednesday Went to urgent care due to horrible stomach pain and back pain. She stated prednisone can cause stomach issues, removed that and gave us protonix to help. Helped at first then had no affect after 2 days. Muscle relaxer helps at times.  7-11-24 through 7-12-24 Thursday and Friday Stayed home seemed to be getting better kind of felt like eating thought we were through the worst planned more visits to new chiropractor.  7-13-24 Saturday Woke up in pain and confused felt really bad and wanted to go to the ER, worried about blood pressure and heart rate, tingling in arms and face worried about stroke or heart attack ( I did not think this was happening but at this point we cant figure anything out) Went to the ER, Dr there said everything is caused by Anxiety and Depression, without outright saying it, asked us not to return to the ER unless it was life threatening and to take Valium as needed until we can get a F/U with primary care on long term anti anxiety medication. Took the valium to sleep, helps with anxiety from not knowing what is wrong but all symptoms persist. At this visit they checked all levels to determine gallbladder and pancreatic issue and they were normal. TSH normal 7-14-24 through 7-16-24 Sunday-Tuesday We had a trip planned for this week with my parents and stayed behind as the trip would have been to taxing for him he cant sit or stand for long periods, pain in back causes nausea, pain in neck causing headache. Stomach tightness all the time. Comes and goes good moments and bad all day and night. Shaking hands and arms back and forth slight to mild no clear trigger. 7-17-24 Wednesday Went to Clinic to discuss what is happening. She thinks autoimmune disease such as MS or Hashimodo-thyroiditis. Wants thyroid ultrasound still. Did more extensive blood work for thyroid ended up completely normal. She only felt his neck for his thyroid and he stated she mainly felt where his neck muscle as been spasming. All thyroid testing came back normal as well as auto immune panel, she still wants the ultrasound so that is scheduled for 7-23-24. We called urgent care and requested they submit an order for MRI cervical and thoracic so we can see if there is something there. He visited chiropractor on 15th, 17th and 19th his determination is that he does not have a herniated disc or bulging disc. All chiropractic visits help but symptoms come back eventually. MRI Scheduled for 7-24-24 we are hoping this shows the issue and he can get a pain injection or cortisone shot.  7-18-24 through 7-21-24 Thursday - Sunday Symptoms persist on and off Neck and upper middle back hurt, hoping MRI will show something to go off of.  7-22-24 Monday Urgent care Dr follow up, just spoke to her about still not being able to figure anything out.  7-23-24 Tuesday Thyroid ultrasound completed. Thyroid ultrasound came back normal referred to local neurologist. Lower back pain begins. 7-24-24 Wednesday Low back pain flares up as day goes on, shaking, standing helped reduce pain at times but would eventually being to worsen. Had MRI no contrast on cervical and thoracic spine. No pinched nerve indicated, no herniated or bulging disc indicated, MS not indicated no lesions present. Needed muscle relaxer as soon as possible horrible lower back pain nausea and abdominal muscles tense. Finally relaxed and was able to eat dinner and go to sleep. At this point he is only taking medications such as muscle relaxer, diazepam, Advill and topicals as needed but as minimal as possible as to not rely on them. Has good days and bad days. Blood pressure has been stable in the 130s over 80s over the last several days.