Age: 38.0
Sex: F
Vaccine: FLUX
Symptoms: Vitamin B12, White blood cell count increased
Clinical narrative: This adverse event is being reported by MD. I am the neurologist who saw this patient in clinic.  Below is a copy of my clinic note from the office visit on 11/12/2013:  Chief Complaint parasthesias in the UE and LEs  Problems  Reviewed Problems  No known problems oNeuropathy  Medications  Reviewed Medications Name  Date  Source  Crestor 10 mg tablet Take 1 tablet(s) every day by oral route. 11/12/13    Nexium 40 mg capsule, delayed release Take 1 capsule(s) every day by oral route. 11/12/13    Allergies  Reviewed Allergies PENICILLINS  narcotics  Vaccines  Reviewed Vaccines the patient recently received the influenza vaccination at hospital in 10/2013.  Past Medical History  Reviewed Past Medical History  Notes: high cholesterol.  Surgical History  Reviewed Surgical History Family History  Reviewed Family History Mother  - Diabetes mellitus   Father  - Congestive heart failure   Social History  Reviewed Social History General IM  Smoking Status: Never smoker.  Non-smoker.  Alcohol intake: None.  Caffeine intake: Moderate 2 cups a day.  Illicit drugs: none.  Marital status: Married.  Number of children: 1.  Education: 4 Year College.  Occupation: nuclear Med technologist.  Pt is married and lives with her husband.  Vitals  11/12/2013 11:14 am Ht:  5 ft 5 in  Wt:  140 lbs   BMI:  23.3  BP:  115/90 sitting L arm  Pulse:  95 bpm   RR:  18  HPI  38 yo female w/ pMHx for hypercholestremia. New patient visit.  The patient is an employee at Hospital and received the influenza vaccination on October 4th. 2 days after receiving the influenza vaccination, the patient experienced burning/tingling in a patchy distribution, bilateral UE and LE throughout, distal > proximal. Per her account, 2 weeks afterwards, her WBC count was elevated at 14, but then came back down to 7. She now also complains of episodic weakness in the distal UE and LEs (proximal as well as distal), "on and off" after the flu shot. Sx of parasthesias have also slightly worsened since initial onset. The patient was given a rx for a steroid taper and also started on Neurontin. Prednisone resulted in a new bout of a burning pain in the right side of the calf. The patient also experienced weakness, calf pain, and blurry vision soon after she was started on Neurontin. These symptoms resolved after she discontinued Neurontin.  Sciatic pain has been ongoing for many years is localized only to the legs and not the arms. This pain is of an entirely different character and intensity compared to the sx constellation that is currently being experienced soon after receiving the influenza vaccination. New bout of increased fatigue. Per her account she had a recent brain, C-spine, and T-spine MRI, all of which were wnl. Denies HAs, fevers, chills. Denies dysarthria, dysphagia, diplopia, tinnitus, or changes in hearing. Per her account her HgA1c is 5.8%. The patient has been undergoing nerve block injections for sciatica.    ROS  Patient reports weakness and numbness but reports no loss of consciousness, no seizures, no dizziness, and no headaches. She reports no fever, no night sweats, no significant weight gain, no significant weight loss, and no exercise intolerance. She reports no dry eyes, no irritation, and no vision change. She reports no difficulty hearing and no ear pain. She reports no frequent nosebleeds and no nose/sinus problems. She reports no sore throat, no bleeding gums, no snoring, no dry mouth, no mouth ulcers, no oral abnormalities, and no teeth problems. She reports no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortness of breath when lying down, no palpitations, and no known heart murmur. She reports no cough, no wheezing, no shortness of breath, and no coughing up blood. She reports no abdominal pain, no vomiting, normal appetite, no diarrhea, and not vomiting blood. She reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. She reports no muscle aches, no muscle weakness, no arthralgias/joint pain, no back pain, and no swelling in the extremities. She reports no abnormal mole, no jaundice, and no rashes. She reports no depression, no sleep disturbances, feeling safe in relationship, and no alcohol abuse. She reports no fatigue. She reports no swollen glands and no bruising. She reports no runny nose, no sinus pressure, no itching, no hives, and no frequent sneezing.  Physical Exam  Patient is a 38-year-old female.  Constitutional: Weight: well-nourished. Ambulation: ambulates independently.   Head: Size/Trauma: (normal) oropharynx and oropharynx: tonsils: enlargement and normocephalic and atraumatic.   Neck: Appearance/Palpation/Auscultation: supple and no carotid bruits.   Lungs: Auscultation: normal breath sounds.   Heart: Rate And Rhythm: RRR. Murmurs: none.   Skin: Inspection: no cyanosis, lesions, or rashes. Extremity Edema Right none. Extremity Edema Left none.   Mental Status: Orientation oriented to person, place, problem, and time. Language: can appropriately name objects, does not repeat phrases, and has spontaneous speech. Memory: recent memory intact and remote memory intact. Fund of Knowledge: current events and past history. Mood/Affect: appropriate mood and affect and (normal) thought processes. Frontal Release Signs: snout absent, glabellar absent, right palmomental absent, and left palmomental absent.   Cranial Nerves: CN II Right: pupil normal size and reactive to light and dark; visual acuity 20/20 without correction and intact to confrontation; and fundoscopic exam grossly normal, optic nerve normal appearance, normal optic vessels, and no cataracts. CN II Left: pupil normal size and reactive to light and dark; visual acuity 20/20 without correction and intact to confrontation; and fundoscopic exam grossly normal, optic nerve normal appearance, normal optic vessels, and no cataracts. CN III, IV, VI: no nystagmus, extraocular muscle strength normal, and normal ocular motility pursuits. CN V Right: normal sensation. CN V Left: normal sensation. CN VII Right: normal facial expression. CN VII Left: normal facial expression. CN VIII Right: normal hearing to finger rub. CN VIII Left: normal hearing to finger rub. CN IX, X: normal swallowing and palatal movement. CN XI Right: normal sternocleidomastoid and trapezii. CN XI Left: normal sternocleidomastoid and trapezii. CN XII: no tremors of the tongue and tongue protrudes midline.   Motor, Sensory, Coordination, Gait and Reflex Exam: Right Upper Extremity: normal bulk and tone. Left Upper Extremity: normal bulk and tone. Right Shoulder Strength: FROM, abduction 5/5, internal rotation 5/5, and external rotation 5/5. Left Shoulder Strength: FROM, abduction 5/5, internal rotation 5/5, and external rotation 5/5. Right Elbow Strength: FROM, flexion 5/5, extension 5/5, and pronation 5/5. Left Elbow Strength: FROM, flexion 5/5, extension 5/5, and pronation 5/5. Right Wrist: FROM, flexion 5/5, and extension 5/5. Left Wrist: FROM, flexion 5/5, and extension 5/5. Right Hand: FROM and hand grip 5/5. Left Hand: FROM and hand grip 5/5. Right Lower Extremity: normal bulk. Left Lower Extremity: normal bulk. Right Hip: FROM, flexion 5/5, abduction 5/5, and adduction 5/5. Left Hip: FROM, flexion 5/5, abduction 5/5, and adduction 5/5. Right Knee: FROM, flexion 5/5, and extension 5/5. Left Knee: FROM, flexion 5/5, and extension 5/5. Right Ankle: FROM, plantar flexion 5/5, and dorsiflexion 5/5. Left Ankle: FROM, plantar flexion 5/5, and dorsiflexion 5/5. Right Great Toe Strength: extension 5/5. Left Great Toe Strength: extension 5/5.   Reflexes: Reflexes Right: biceps 2/4, triceps 2/4, brachial radialis 2/4, patellar 2/4, and achilles 2/4. Reflexes Left: biceps 2/4, triceps 2/4, brachial radialis 2/4, patellar 2/4, and achilles 2/4. Plantar Reflex Right: response downgoing. Plantar Reflex Left: response downgoing. Coordination: normal finger-to-nose and rapid alternating movements normal. Sensation: decreased pinprick, vibration, and light touch and normal position; distal UE and LEs. Gait/Posture: tandem gait normal, gait normal, and station normal.   Assessment / Plan  38 yo female w/ pMHx significant for hypercholestremia.  The patient presents with parasthesias in a patchy distribution in the bilateral UE and LE, distal > proximal.  Sx constellation began 2 days after she received the influenza vaccination.  Etiology of sx constellation is most likely a direct complication of the influenza vaccination.  Neurological exam findings significant for decreased pin prick, light touch, and vibration sensation in the distal UE and LEs.  Condition stable.   1. EMG/NCS to be preformed by Dr.  2. Laboratory testing for evaluation of neuropathy: Urine 24 hour heavy metal, urine/serum electrophoresis, urine/serum immunofixation, HIV, RPR, TSH, B12/folate panel, HgA1c, ANA, ENA, ANCA, RF, ESR, cryoglobulin (to be sent at 37 degrees), hepatitis panel, ACE level, quantitative IgG/IgM/IgA.  3. Lyrica 50 mg PO BID for neuropathic pain.  If the patient is still symptomatic in 1 month, we will consider increasing the dose.  Side effect profile of Lyrica was explained to the patient.  4. Return to clinic in 1 month.  With the next clinic visit the patient was advised to bring the CD of her brain and c-spine MRI with her so that both studies could be personally reviewed.   5. This case will be reported to the Vaccine Adverse Event Reporting System. The total amount of time spent with the patient was 80 minutes with >50% of the time spent counseling the patient regarding diagnosis and plan of care.  1. Neuropathy  349.9: Unspecified disorders of nervous system  oANA, RA, CRP, ESR  oHEAVY METALS 24 HOUR URINE WITH CADMIUM  oIMMUNOFIXATION, SERUM  oIMMUNOFIXATION, URINE  oPROTEIN ELECTROPHORESIS, SERUM AND URINE  oTHYROID STIMULATING HORMONE (TSH)  oIMMUNOGLOBULIN IGA, IGG & IGM, QUANTITATIVE  oCRYOGLOBULIN - Note to Lab: send at 37 degrees   oVIT B12 AND SERUM FOLATE PANEL  oACE  oANCA SCREEN  oRHEUMATOID FACTOR  oENA  oHEPATITIS PANEL  oHIV  oRPR  Return to Office MD for FOLLOW UP on 12/10/2013  oto see on or around 12/12/2013  QM  Programs: Meaningful Use Medicare - Year 1 - 2013   Last updated 11/12/2013   Measure  Status   Active allergy list  Satisfied   Active medication list  Satisfied   Adult weight screening and followup (18-64)  Satisfied   Medication reconciliation  Satisfied   Provide clinical summaries for office visits  Needs Data (1/1)   Provide patient information  Needs Data   Record demographics  Satisfied   Record smoking status  Satisfied   Record vital signs  Satisfied   Tobacco Use Inquiry  Satisfied   Up-to-date problem list  Satisfied   Encounter Sign-Off