Age: 38.0
Sex: M
Vaccine: ANTH, IPV, MMR, SMALL, TYP
Symptoms: Influenza, Iron binding capacity total, Lymphocyte count decreased, Malaise, Myalgia
Clinical narrative: Patient is a 41 year old male who profession is a dentist. He stated he was in good health until he began to notice problems with his health in late summer/fall of 03. On 21 July 03 he received AVA #1, MMR, IPV, SPV and typhoid. Then on 7 Aug 03 he received AVA #2. Both #1 and #2 were administered in his right arm. He stated that with each shot his arm would swell with swelling extending below the elbow and would turn red. The swelling and redness would persist for 7-10 days. He also reported that he felt feverish and would have flu like symptoms. He stated that after the 7-10 days he would feel fine again. In Nov 03 he returned after a 90-day abroad. He stated that he did not have the usual screening. Upon his return he noticed a constant ringing in ears and stated he was exposed to generators and air compressors. He reports that the symptoms progressed from a ring to a hum and both ears affected equally. He had and evaluation by an audiologist and was told he had cilia damage. He stated that the ringing is constant 90% of the time and is worse at night. He had no head imaging or an ENT evaluation. Also since his return that he has been having problem with diarrhea. He initially thought the diarrhea during his abroad was stress related. He notes this every day to every other day. Prior to deployment he use to have 2 BM's per day but now has 4 with 1-2 diarrhea episodes. He denied abdominal pain or blood. He denied IBS symptoms and had negative cultures. He had a negative colonoscopy in 2004 and was treated with Flagyl x 30 days with no change in bowel habits. He was recently diagnosed with bilateral ulnar nerve compression. He stated that since his return he would note numbness and tingling his middle, ring and little finger of both hands. He stated that this is currently worsening, especially at night. He now notes that the feeling in the anterior area of both arms and some in his legs. He began to notice this feeling in his legs early 06 with numbness across his legs and groin. He reported that his rt arm is worse than his left with his rt arm being his dominant arm. In early 04 he began to notice problems with generalized muscle and joint pain across his back, neck and all over. Initially thought it was due to aging so he did not follow up. He also noted that he felt more timed and worn down than usual. The pain and worn down feeling continue to worsen gradually so he started to see the VA in spring 06. He denies swelling. In May 05 he began to notice problems with his balance. He also noticed some tremors in his hands. He denied dizziness or spinning sensation such as himself or the room spinning. He describes it as a feeling that he "can't gets his legs to go - like orthostatic hypotension". He has not had tilt testing done. In Mar-Apr 06 he began to notice problems with low back and flank pain. He reported that this is different than his usual muscle pain and that this is a deep soreness across his lower back and sacral area. He also reported and intermittent burning sensation across this area of soreness. Symptom: Diarrhea Start: 11/2003. Symptom: Fatigue, Malaise > 60 Days Start: 11/2003. Symptom: Numbness Start: 2003 Comment: Hands and legs. Symptom: Muscle Pain Start: 2004. Symptom: Gait abnormality Start: 05/2005 Comment: Balance problems, no dizziness.