Age: 35.0
Sex: M
Vaccine: ANTH, ANTH
Symptoms: Pain in extremity, Photophobia, Pruritus, Rash, Rectal tenesmus
Clinical narrative: This healthy 35 year-old began his Anthrax series on 22 February 2003.  He reports the site was red, sore with a large pruritic lump at the injection site and had feelings of irritability that lasted approximately one week.  He reports vaccinations two and three (8 March 03 & 22 March 03) resulted in an increase in the vaccine site nodules with itching and non-specific feelings of malaise that lasted for 1-2 weeks. His fourth dose was administered 29 November 2003 with this vaccine causing the worst feelings of malaise, fatigue, flu-like symptoms, nodular formation at the injection site, and "delay in cuts healing" lasting one month following injury.  His fifth dose was administered 26 June 2004.  He received his FluMist nasal vaccination in February 2005 with complaints of flu-like symptoms. During his deployment he sought medical care on 19 July 2004 for complaints of "not handling the heat well". He stated the heat from the pavement and engine was causing headaches, sinus drainage, "woozy & weakness" with fatigue, difficulty breathing in hot air, diarrhea and he had no-low energy.  The temperature was 120-140 degree's Fahrenheit.  He wore a cooling vest over a shirt soaked in cool water. He was diagnosed with heat exhaustion and evaluated for thyroid disease (no labs available), treated with intravenous fluids (LR), ibuprofen and placed in a cool environment. A follow up exam on 21 July 2004 reports symptoms of exercise induced asthma, insomnia, and resolution of heat exhaustion (see consults below).  On 01 August 2004 he presented with complaints of nose, eyes and ears burning, drying sinus and trouble breathing-"air hunger" when in heat with headaches and "shaking" with three episodes of diarrhea.  He was diagnosed with questionable allergy reaction and placed on Allegra and possible anxiety related to stress. On 08 August 2004 he complained of a sudden onset stomach pains, cramping, and feeling funny in head with questionable fever, vomiting once.  He was diagnosed with gastroenteritis questionably medication induced (Niaspam stopped for 3 days). He reports going to sick call 13 times in three months for heat related problems.  Upon his return on 14 September 2004 he was evaluated for "medical problems " to include rash diagnosed as tinea crusis-resolved, hemorrhoids-resolved, urinary tenesmus-urinary referral (unavailable), mild dehydration with headaches, dizziness, low heat tolerance, and feelings of being "zoned out"-resolved with rest and fluids. He reports drinking 7-8 liters of water/fluids a day otherwise drinks 4-5 liters. During this interview, he reported difficulty with bilateral joint pain in his feet with mild leg pain that intensified over time during his deployment (Jun-Aug 2003) which persists today (June 2005).  He was evaluated several times at a Hospital between October-November 2004 (see consults) for a one year history of worsening foot pain with the onset of knee and hip pain after prolonged standing and increased activity. His initial injury was reported "while he was walking in an area in a walking part that was covered with rough rocks that are used to prevent members from sinking into the sand.  In the later part of July 2004 he injured the tendon or ligament in the bottom of his feet bilaterally.  He had burning sensation in the heels." He described the foot pain as painful arches, burning heels, tenderness to the balls of his feet, and intermittent toe numbness after being up on his feet for several hours.  This pain eventually would awaken him from his sleep in October 2004. He was diagnosed with bilateral Plantar Fasciitis +/- fat-pad atrophy and placed in physical therapy. He was fitted for orthotics for high arches and used aspirin, NSAIDs, Tylenol, soaked his feet and stretched with minimal relief.  His exam on 20 October 2004 documents continued foot discomfort and abdominal pain for 1 ½ months with a history of GERD. NSAIDS were discontinued; he was started on Prevacid 30 mg daily and given a GI and podiatry referrals (GI tests unavailable). As of June 2005 he continues with intermittent nausea. His appetite is unchanged with no gross weight loss.  He continues to take Nexium or Prevacid for GERD. Other joints such as his ankles, knees, legs, hips and lower back began to hurt over the following year (2004) described as if his knee's and hip's were "locked in place" or strained due to increased walking.  He complained of sensitive "trigger points" bilaterally to the hips/buttock region following the sciatic nerve with associated lower back pain at 2-9/10 scale.  This pain would vary in duration up to half a day depending on activity performed. Physical therapy and medications varied in degree of relief depending upon the day.  He was placed on profile (P4) with no prolonged standing/walking/sitting in October 2004. In Jan-Feb 05 both his shoulders began to ache similar to discomfort felt in his hips. His physician advised him his muscles were tense and placed him on a muscle relaxant Flexeril for 10 days and it relieved the shoulder pains and eased his back/foot pain.  However, Flexeril makes "him loopy" so he currently uses it at night and the pain in his hips-feet persists.  He reported one episode of severe muscle spasms to left leg in Nov 04 while at a retirement party while sitting down.  He reports his legs ached and he walked about restaurant. He suddenly gasped as a cramp occurred, went pale and red with problems breathing due to pain. The initial cramp lasted 2 minutes with intermittent flare-ups described as piercing, pinching, tearing sensations with warm intermittent pulsating electric impulses from knee to hip.  These electrical charges finally resolved and leg got cold. The spasms occurred on and off for 5-6 hours.  He used Ibuprofen for discomfort, rested and attempted to stretch (hurt too much). He had never had cramps like this before but stated 50% of the spasm felt is the dull ache in both IT bands felt currently every other day since off Flexeril (3rd wk march). He describes his back spasms located to the lower lumbar-sacral region as a "knife in lower back" that occur while bending, kneeling or attempting to stand halting activity. The pain lasted 45 minutes with subsequent ones since lasting 20 minutes. His pain is worse after working. He has been working with Physical Therapy (30 sessions) for back leg and foot discomforts over last 6 months with reported easing of pain, less fatigue and soreness. As of 21 October 2005 he reports being released from podiatry and his psythrist with improved but persistent knee, hip, lower back and leg pain. He describes his knees "load up when bending as if air gets pushed into them" causing pain. His ileotibial bands have periodic spasms causing hip and back pain with the right >left.  He has intermittent paresthesia with spasms only to his toes. His diagnoses include Bilateral Plantar Fasciitis, Right Iliotibial Band Syndrome, Bilateral Pes Planus, and Verruca Plantaris, ball right foot.  He can wear tennis shoes without discomfort however his combat boots continue to bother his feet the most. Concurrently he reports the onset of headaches July 2004. He reports childhood headaches approximately age 10-12 occurring once every three months as a dull ache in the crown of his head lasting a few hours that resolved spontaneously.  These headaches progressed into adulthood averaging once every third day varying in intensity.  He would awaken with or go to sleep with.  Aspirin, Motrin or Tylenol resolved these headaches. The headaches were similar to past headaches but were more intense encompassing the entire head described as a "pressure sensation with tension".  He would awaken with as if "someone was standing on my eyeballs pushing them in and hit me in the forehead with a 2 by 4."  The pain went through his eyes to the back of his head down into both trapizus muscles.  He complained of photophobia, dizziness, chills, and nausea with 2-3 episodes of vomiting. His medical records document diagnosis of heat fatigue-exhaustion 19-21 July 2004 with allergy reaction and stress anxiety in August 2004.  His headaches persist today lasting from ½-1 day varying in intensity from dull to severe (2-9/10). He describes these as a band-like squeeze to from his head, down the neck into the trapizus. The last severe headache occurred once a week for two weeks in March 2005 otherwise occurs every few months. Over the counter migraine medications have variable results. He has commented on the headaches to all his current care provides but has not had them evaluated. Problems sleeping through the night began in July 2004.  He slept in a large tent with others, his duty shifts fluctuated and the temperature of the tent ranged 64-85 degrees Fahrenheit with outside temperatures 120-140 degrees.  He stated he could fall asleep easily but awoke early, sometimes every 2-4 hour through the night.  He averaged 2-4 hours of sleep at a time.  He denied any changes in activities, physical training exercises, caffeine intake consisted of 1-2 sodas per week, no coffee or tea, undo stress despite deployment, or excessive concerns over family responsibilities or health problems. He was given 50 mg Benadryl for sleep that did help. He states he worked nights while in the desert and now is working days.  He has not addressed this issue with his primary care physician.