Age: 28.0
Sex: F
Vaccine: ANTH
Symptoms: Injection site oedema, Injection site pain, Malaise, Memory impairment, Menorrhagia
Clinical narrative: Pt received AVA #1, 2 and 3 slight arm soreness and swelling, nausea and feeling achy. April resolution of her symptoms. August 2000 diagnosed with endometriosis. During her treatment for endometriosis from Aug00-Jul02 she had problems with extreme fatigue, body aches, muscle and joint pain, headaches, bloating and weight gain. In Jul02 hysterectomy, felt better. AVA 4 on 3Dec02 arm soreness, slight swelling and flu like symptoms for a couple of weeks. 3Aug03 AVA 5 slight swelling, arm soreness and flu like symptoms. AVA 6 on 04Apr04. She stated that her reaction was like that of her fifth vaccination. In Sep04 she was deployed. Within one week she developed diarrhea, felt feverish, total body pains, headaches and the return of her fatigue. Had not felt this bad since hysterectomy in Jul02. Deployed for 4 months and felt bad in varying degrees throughout. Flu vaccine 29Oct04 pain and swelling at the site and reported a large black are with her smallpox vaccine on 28Oct04. Towards the end of her deployment she became violently ill with diarrhea, vomiting, chills, sweats, and bodyaches. She sought medical attention and the doctor thought that she had a GI infection. Returned to the states in Feb05. The diarrhea and vomiting subsided but the body aches, fatigue, continued chills and sweats. She denied any association of activity with symptoms and reports tiring easily after activity. Problems thinking she stated that for the past 6 months she has felt scattered brained. She is unsure if it is related to the medication of some other process. She admits to forgetfulness, problems finding the words to say and expressing her thoughts. Depression has a prior history of depression and admits to situational depression. Headaches-notes headaches daily. They may last hours to days. She stated that she has seen a neurologist and does not have a diagnosis. He did not think they were migraines even though she gets migraines on occasion. In describing the pain she stated that the pain varies. The pain is usually in the back of her head above her neck and is sometimes behind her eyes. She stated it is an annoying pain or a dull throb; it is just there and may worsen to a borderline migraine. The pain varies from a 3-7 on the pain scale. Nothing makes it better or worse only that rest sometimes helps. She denies nausea, vomiting and visual problems. She stated that she has photosensitivity when the pain is bad, but overall she stated that she is more sensitive to the light. Fatigue notes problems sleeping and staying asleep, does not feel rested. Has no energy and feels more tired after any activity. Menorrhagia (excessive menstrual bleeding). Start: 08/2000 End: 07/2002. Comment: also dyspareunia. Symptom: Flu-like symptoms 96hrs. Start: 02/27/00 End: 03/03/2000. Symptom: Flu like symptoms 96hrs Start: 3/12/00 End: 04/2000; symptom: fatigue, malaise <60 days start: 02/27/00 End: 04/2000. Symptom: Joint pain, multiple joints start: 08/2000 End: 07/2002. Symptom: muscle pain start: 08/2000 End 07/2002. Symptom: Flu like symptoms >96hrs Start: 12/04/02 End: 12/24/02 Symptom: flu like symptoms<96hrs Start:08/04/2003 End: 08/07/2003 Symptom flu like symptoms 96hrs Start 04/05/2004 End 04/08/2004. Symptom: Joint Pain, multiple joints Start: 09/2004 symptom: muscle pain start: 09/2004 Symptom: headache, general start: 09/2004; symptom: paresthesia start: 09/2004; symptom swelling start: 09/2004 comment: intermittent hands and feet. Symptom: fatigue, malaise >60 days start: 09/2004; symptom: depression start: 09/2004 comment: prior hx with current worsening. Symptom: cognitive deficiency start: 09/2005; symptom: constipation start: 06/2005.