Age: 40.0
Sex: F
Vaccine: HEP, HEPA, IPV, MMR, TYP, VARCEL
Symptoms: Anaemia, Anion gap decreased, Anti-cyclic citrullinated peptide antibody negative, Antinuclear antibody negative, Arthralgia
Clinical narrative: Pt thinks she received all of her vaccinations in her right upper arm. She denies experiencing any unusual or prolonged redness, tenderness or swelling surrounding her vaccination sites, and denies experiencing symptoms consistent with an immediate hypersensitivity reaction, such as angioedema, hives/rashes, swelling of mouth and throat, cardiovascular, respiratory, and GI symptoms within the first 4-8 hours of vaccine administration. Within 24 hours of vaccine receipt, pt noted headache, fatigue, and joint and muscle pain. Joint and muscle pain described as generalized stabbing and shooting pains that increased over the next 48 hours to an intensity level of 8/10, using intensity scale from 0 (= no pain) to 10 (= worst pain ever experienced). Pain described as being "like sharp needles all the time" and sometimes like a "hot poker stabbing". On 16 Apr 2014, patient was taken to Emergency Room (ER) for evaluation of pain, as well as for tingling and numbness and swelling of hands and feet and face. Diagnosed with "paresthesias" and "edema". [No ER records available except discharge instructions and lab results.] Labs included normal CMP, CK, CBC with mild anemia, and elevated ESR. Referred to Neurology. On 6 Jun 2014, patient was evaluated by neurology. Pt reported numbness and tingling in both great toes, and pain in RLE below knee and RUE. She also noted increased clumsiness. No dizziness, changes in bladder/bowel control, hearing, hand coordination, walking and balance noted. No other focal neurological problems noted. Physical exam was normal. Assessment: paresthesias and pain in RLE, RUE. No diagnostics were ordered. [Pt reports she continued to experience intense pain diffusely in her muscles and joints.] On 18 Jul 2014, pt had a follow up appointment with neurology. She continued to report tingling and pains in the backs of her legs and in her feet, as well as pain in her joints. Pain present in joints of bilateral UE (right > left), with some muscle cramps in both hands. Pain primarily in knees, ankles, and elbow. One week prior to appointment, patient noted onset of right-sided neck pain. Pt also reported she was more forgetful and had some trouble thinking clearly. Physical exam assessing the following were normal: extremity strength, motor and gait, coordination, sensory, coordination, DTRs and Babinski Impression: Pain and paresthesias in all extremities (RUE>LUE, LLE>RLE). Plan: ESR, CRP; NCS/EMG of upper and lower extremities to rule out neuropathy, radiculopathy. On 12 Sep 2014, pt was evaluated by neurology for follow up evaluation. She reported diffuse joint and muscle pain, fatigue, hot flashes, and intermittent swelling in the joints, as well as tingling, especially in the feet. Neurological exam was normal. Impression: possible fibromyalgia. Plan: MRI, brain to rule out demyelinating disease. Referral to rheumatology. On 19 Mar 2015, pt had initial consult with rheumatology. She presented for evaluation of chronic pain since Apr 2014 following receipt of immunizations. Pt reported diffuse joint pain and was diagnosed myofascial pain which continues today.