Age: 13.0
Sex: F
Vaccine: FLU(H1N1), FLU(H1N1)
Symptoms: Muscular weakness, Neurological examination abnormal, Nuclear magnetic resonance imaging normal, Paraesthesia, Reading disorder
Clinical narrative: 11-24-09. All reported by mother. Per pt's mother: 11-15-09 difficult/slurred speech, facial weakness mouth pulled to Rt, could correct when reminded -(Hx. Headaches) symptoms continued. Confused. 11-17-09 O.V. pediatrician Dr med. center did basic neuro check, "per MD probably migraine)". 11-19-09 went to school - difficulty breathing, Rt hand numb tingling unable to use Rt. hand weakness. Entire body "Shaking" went to her next class symptoms continues. She was assisted to the health room- walking slowly - confused, difficulty breathing increase, sitting on chair when mom arrived @ Health Room, pt was sitting on a chair leaning forward Lt hand clenched visibly shaking, entire body, - ambulance was called she was transported to med. center - mom told them she had H1N1 vaccine on 11/14, a Basic Neuro check was done (per mom) possible Dx Hyperventilation, released home had headache not feeling well. 11-20-09 feeling better - still unable to move hands but pt wanted to go to school(mom reported), around 12 noon - pt was taking a quiz she was unable to read; hand writing wasn't legible, and she had body tremor, mom reports she came to school took her home and called the MD - pt was again seen by MD lab work done UA normal, blood test. Not sure what was done but was told the results are normal. She was given a paper to write her name and numbness - both hand weak and tremor unable to write name and recall numbers, the ambulance was called she was taken to hosp., neurological assessment done; CT Scan WNL, mom asked to be tested for lyme disease, no results @ this time. MD will call her today with results. 11-2309 MRI was done also waiting for the results, mother also told RN pt can't remember how to do things ex. hold pencil, hold spoon, she must be told how to do this and then says I can't after she tries and is unsuccessful in accomplishing task. Will cont. as more info is received. 11-26-09 TC to pt home, RN spoke with her father regarding update of pt condition, he reports she is able to use her hands and some of the numbness has subsided, she is still unable to write due to cognitive problem cannot recall numbers, she had to be reminded to to continue to write and then she says she can't do the task. Father said she is a different child, father and his wife will continue to follow up with medical evaluation per pt MD and Neurologist. 12-9-09 RN spoke with pt father. He reports they did not have a diagnosis for pt condition, she is able to use her hands without difficulty, but that she is not the same child - he states, "we had a 13 year old girl and now we have a 9 year old." He asked RN to contact his wife Re. testing that was done @ the MD office, RN will contact his wife. 12/10/09 TC to wife, pt mother. She told RN pt had 2 MRI's she is not sure of the date of the 2nd MRI but reports the results were negative, she had a spinal tap and 12/4 with negative results, neg for lyme disease, she told RN this morning she had a meeting with the school principal and pt teacher pt is unable to comprehend and follow through, with tasks and studies, the Neurologist is also consulting with the school to decide what to do with her education, wife reports, "pt" was on the honor roll prior to her illness/receiving the H1N1, RN will complete VAERS report and will cont to follow with the family. RN will fax and send report.