Age: 23.0
Sex: M
Vaccine: ANTH
Symptoms: Dyspepsia, Fatigue, Gait disturbance, Haematuria, Headache
Clinical narrative: This 28 year old member enlisted in the fall of 1993 where he received standard immunizations of Adenovirus 4&7, meningococcal, MMR, oral polio on 18 November 1993 and his yellow fever vaccination on 23 Dec 2003. On 17 December 2003 he reported to recruit sick call for "abnormal labs" and a "one month history of microhematuria". Medical records document a positive family history of renal disease/calculi.  He was referred to Urology 4 January 2004 for an IVP and tomo with a renal ultrasound.  All tests were normal with a diagnosis of resolved microhematuria, possible flex cysts or exercise induced microhematuria.  Further evaluations were completed 25 August 1998 with reoccurrence of hematuria finding normal calcium, TSH and renal ultrasound. A diagnosis of possible genetic related hematuria with a family history of Alport's disease was given.  He was evaluated for Alport's Syndrome 7 Feb 2001 with no evidence of kidney disease however he had a serum blood glucose of 136.  No further documentation of microhematuria was seen with repeated UA as of 2005.  Immunizations continued per military protocol with no reported adverse events in 1995-8. He presented to sick call 04 Mar 1996 with complaints of heartburn.  Review of existing medical records identified "heartburn since high school" which worsened after drinking fruit juices on an empty stomach or eating spicy foods.  Over the counter antacids had little relief and position did not affect this discomfort.  Avoidance of spicy foods did ease the discomfort. He took Advil for occasional muscle-joint aches.  He was placed on Zantac with minimal relief, followed up with gastroenterology 26 Mar 1996 for an EGD which diagnosed him with "Grade I esophagitis".  His medications were changed to Prilosec.  As of 2005, he sporadically takes medications using diet to control his heartburn/GERD.                             He received his first Anthrax vaccination 11 Nov 1998 with his second AVA vaccination on 28 Nov 1998. He reported experiencing soreness at the vaccination site and flu-like symptoms for 1-2 days with spontaneous resolution. He also received his Influenza vaccine 19 Nov 1998 and a prescription refill to restart Prilosec for GERD on 17 Nov 1998. From 2000-2002 he was treated for chronic bilateral ankle pain/strain including physical therapy. He continues to experience periodic pain as of 2005.  He also experienced one episode of substernal chest pressure occurring 3-4 times for <30 seconds on 14 Nov 2002 two months following his first Hepatitis B vaccination (24 Aug 2002). Cardiology evaluation documented his EKG as NSR with sinus arrhythmia, non-specific ST/T wave changes. This EKG was similar to one obtained 7 Feb 2001. His exercise stress test showed "no ischemic changes". He was diagnosed with non-specific chest pain which was "attributed to stress". Repeat evaluation for chest tightness at rest, sleep, lying or standing occurred 08 Oct 2004 and again June 2005. A 48 hour holter monitor was completed 11 July 2005 documenting NSR/ST (39-146 avg 81 bpm) with occasional PAC/PJC/PVC-"Benign holter monitor".  February 2003 he began to complain of headaches. His medical records document a diagnosis of hypertension 07 Feb 2001 with a diagnosis of "pre-hypertension" December 2003 and medically treated January 2005. He was concurrently diagnosed with Type 2 Diabetes Mellitus in August 2003. He described his headaches as a dull-sharp pressured band-like sensation/pain centered in his forehead above both eyes that radiated to both temples.  This pain "inhibited his ability to think straight". He reported feelings of lightheadedness upon awakening that would spontaneously resolve or develop into a headache.  His "mild" headaches occurred 1-2 times a week as a 1-2 out of 10 pain scale with severe headaches (7-8/10) occurring every 2-3 weeks.  He complained of photophobia, 5 minutes of tunnel vision, dizziness with a stumbling gait and increased fatigue prior to and during these headaches. He reported a past history of seasonal URI/allergy headaches since 1997, prior situational migraines in 1992 and 1994 relieved with Advil; and several episodes in 2004 associated with schedule changes, viral illness and medication changes (Zocar, Lopid, Lipitor and Lisinopril dose changes). He was evaluated by neurology 08 Nov 2004 for myalgia, headaches, irritability, fatigue and mental "cloudiness" on Zocar. He reported these symptoms were "less intense to similar symptoms felt while on Lopid". He was diagnosed with an adverse reaction to Zocar and changed to Lipitor with easing of symptoms. He continues to experience headaches as of 2005 with his last headache occurring mid April for 24 hours. His headaches are aggravated with fluctuations in his blood sugars (100-300's), stress, and problems sleeping. He denies problems with his blood pressure, trauma. A full neurological evaluation of his headaches has not been completed.   On 16 Jan 04 he received his Influenza vaccination and his third Hepatitis B vaccine. Then on 28 January 2004 he received his primary Smallpox and third Anthrax vaccination. Over the next few weeks he complained of severe flu-like symptoms with diffuse body aches, fatigue, headaches, and memory-loss. He described his memory loss as difficulty in "qualifying", remembering items, or the ability to learn and retain new items for his job. He was evaluated by medical 31 Jan 04 for "concerns over side effects to vaccines" and diagnosed with "viral illness".  For the next several months he continued to complain of headaches, fatigue, lightheadedness, irritability, myalgia and mental "cloudiness" that were attributed to his diabetes, hypertension, statin medications, Lisinopril dose changes, and situational/stress induced depression (see above HPI and ROS). Approximately December 2004-January 2005 he reports worsening of his short-term memory retention. While on a cruise, he reported increasing pallor and being assigned selective duty assignments due to worsening memory and fatigue. He commented he has very little memory of this cruise. His wife reported phone calls over those six months with him voicing complaints of lightheadedness, dizziness, fatigue and malaise. He reported an irregular sleep pattern most of his life.  Currently he works alternating shifts day/night watches. He retires to bed between 2130 and 2300 rising at 0430 weekdays and between 0830-0930 weekends (average 6-7 hr/night with hs awakening). He complains of sweating in his sleep, heat/cold intolerance with increased thirst and he "stops breathing at night". He has been treated for depression and continues with complaints of sleep initiation and sleep maintenance insomnia. In April 2005, he reported episodes of dizziness at rest and with positional changes that required an emergency room evaluation where he was diagnosed with a viral illness with his blood sugars in the 300's. He described the dizziness as a "spinning sensation" that occurs periodically and upon awakening when he turns his head. He was being treated by his primary physician with Amoxicillin for a nondescript illness.  His medical records from 07 April 2005 address multiple complaints with emphasis on evaluation for obstructive sleep apnea (fatigue, dizzy, malaise, increased weight and stress), palpitations (dizzy, increased blood sugar 100-320's, +SOB/DOE), anxiety/depression (increased stress, new dad, medical illness, decreased sleep, +SOB/DOE, high functioning individual), GERD, and control of DM, HTN, and hyperlipidemia/hypercholesteremia. He was diagnosed with obstructive sleep apnea in July-August 2005 following sleep study evaluation.  Medical record review documents differential diagnosis evaluated include: altered TSH, obstructive sleep apnea (under eval), IgA hyperparathyroidism, iron deficient anemia, hepatitis panels, ADPKD, drug induced (ACE I, Statins), rheumatology, depression and cardiac evaluation.