Age: 61.0
Sex: M
Vaccine: ANTH
Symptoms: Joint range of motion decreased, Laboratory test abnormal, Musculoskeletal stiffness, Myositis, Oedema
Clinical narrative: This is a 61-year-old who had been in his usual health until 26 March 2003. The client states that he received his primary anthrax and non-primary smallpox on 01/30/03. He subsequently received anthrax number 2 and 3 on 02/13 and 03/07/03 respectively. He developed a "viral infection" on 03/26/03 a felt the tendons thickening in the back of his right knee.  On 12 May 2003 he began feeling pain that he associated with tendonitis. On 27 May 2003 experienced difficulty sleeping secondary to right leg pain. He reported for evaluation. He reportedly was experiencing a dull/achy pain that was usually worse after running. He was diagnosed with a leg strain right gastrocnemius and provided Motrin 800mg TID. He was also instructed to ice the affected area and to do stretching exercises.  On 06/06/03, the ligaments behind his bilateral knees felt "strained" and his bilateral knees began to swell. He reported to for evaluation again. He was found to have pain with palpation of the medial bursa region, right knee and pain with palpation of the ITB bilaterally. He also demonstrated 1+ - 2+ pitting edema with decreased ROM secondary to the edema. He also reportedly had a mass in the posterior aspect of the right knee. He was diagnosed with pre-patellar bursitis and tendonitis, possible Baker's cyst and lower leg localized swelling bilaterally. He was instructed to decrease ladder climbing, no running, and to keep feet elevated when not actually working.  He was prescribed Lasix® 40mg daily for 7 days and Naproxen® 550mg daily for 14 days.  The client reports that he continued to have pain in bilateral knees and could not sleep secondary to the pain. On 15 June 2003, he reported again to the clinic because he could no longer bend his knees in the morning and had difficulty performing his job. He reportedly had pain in the popiteal area bilaterally; negative Homan's sign, no calf tenderness, mildly unstable gait and hamstrings with 10° contraction. There was no edema in bilateral knees and pretibial area. At that time he was found to be unfit for duty but fit for travel. It was recommended that he be put in the business class area of the plane so he could do stretching exercises every hour to prevent clotting problems.  According to the client, on 19 June 2003, the client saw the doctor. After evaluation he prescribed Bromelain, papain and Darvocet-N-100®. The records from the doctor's office visit dated 06/23/03, states that the "patient is still having pain and stiffness in legs, especially knees and adductor areas. Most of the grossly edematous areas - now free of edema - inflammation still present". The record also states "Koch test 70% - 60.5 sec". The client received "FAKSS" therapy, which according to the patient is a type of osteopathic manipulation therapy. A note recording a telephone conversation on 06/24/03, that appears in the client's medical record, indicates that the client was "still having pain on movement". The record also indicates that his WBCs were elevated and was his C-reactive protein level.  On 27 June 2003, the doctor saw the client again. The records indicate the client experienced pain on elevation of thigh or straightening of knee while in a sitting position which was felt at "the insert of the biceps femoris at pelvis". He indicates that the pain was only with activation of the muscle and even deep palpation does not duplicate the pain. At this time the client expressed his concern regarding muscle weakness that had been present for "the last 5 weeks, since the problem began". He was treated with "strain-counter strain for the relief of pain".  The doctor again evaluated the client on 30 June 2003. At that time the record indicates that the client was still  experiencing pain with muscle stretching. However doctor notes that the client "generally has begun the recovery phase".  A letter dated 10 September 2003 from the patient's personal trainer and massage therapist indicates that the client was seeing him for an "exercise/wellness routine".  The letter states that the client was receiving "1. stretching routine (improve range of motion), 2. Trigger point massage (relax muscle spasm to maintain structural homeostasis) and 3. Resistance training (increase strength). The doctor agreed to this therapy. The client continued to see this therapist through 13 March 2004.  On 27 February 2004 the client presented to the doctor for final evaluation.  The records from this visit indicate that he was continuing to have pain in popliteal fossa on squatting, which is relieved immediately by standing up. He was also experiencing "pain in the trapezius when the arms move upward and scapular rotate; side bending downward stretch with right shoulder produces pain in left long ____ of biceps; to clasps hands behind lumbar spine . . .pain in shoulders". The physician's impression for this visit was shoulder pain; knee pain; and slow recovery from disability myositis-weakness and fatigue. He felt that at this point a second opinion was warranted to fully evaluate his abilities.