Age: 28.0
Sex: F
Vaccine: ANTH
Symptoms: Fatigue, Headache, Hypoaesthesia, Influenza like illness, Joint stiffness
Clinical narrative: Multiple vaccinations during Feb 2003 in preparation for deployment. See immunization history. Last vaccines received prior to symptoms onset were her 3rd anthrax vaccine on 3/7/03 and MMR vaccine on 3/20/03. Experienced generalized body aches, headaches and fatigue that were self treated with Tylenol and lasted about 1 week. These symptoms recurred intermittently over the next 2 months. by the end of the year, she was teaching a civilian job. She recalls felling tired all the time, her weight was going up and down and her muscles and joints ached all the time. She had felt bad for almost a year before she sought medical evaluation. By the time she sought evaluation, her symptoms had gotten progressively worse. She recalls really feeling bad by the beginning of winter of 2003/04. Diagnosed with thyroid disease around March 2004. At the time of diagnosis, her symptoms included fatigue, weight gain, cold intolerance, changes in her menstrual cycle, changes in pattern of bowel habits, weak nails, loss of hair, dry skin, and muscle and joint pains. She denies any palpitation or significant changes in heart rate or tremors. Her Synthroid dose was gradually increased over the past year to 0.75 mcg daily. Following her most recent medication adjustment, few of her symptoms have resolved. She continues to experience muscle and joint pains, cramps, numbness, sleep impairment, weight gain, cold intolerance, changes in bowel habits, painful menstrual cycles, weak nails, increased acne, loss of hair, and fatigue. Describes muscle pains as aching and cramping type pains. Notes spasms and fasciculations. The muscles in her hands and arms become sore if she holds anything for too long. (Fingers and hands hurt after holding the phone). Her calves and thighs cramp and twitch following any weight bearing exercise. She experienced pain an stiffness in her knees, hands, neck, back (like getting the flu), and sometimes her wrists. She described this pain as sharp, like a pinch and notes that it is migratory. She experienced increased pain and stiffness in her legs if she bends down too long. Her hands and shoulders are usually stiff and her other joints are often stiff for about 1/2 hour after she gets up in the am. She denies any swelling, increased warmth or redness over her joints. Described a restless feeling and kind of numbness in her legs, especially at night. She described this like a pressure, like someone pressing on my bone. If she wakes up to use the bathroom at night, she reports her legs hurt like I just stopped running. Sometimes experienced tingling in her toes and a sharp pain through the arches. This Sensation interferes with her ability to fall asleep and she now suffers from sleep impairment. The intensity level of her joint and muscle pain varies significantly using a pain scale of 0 (no pain) to 10 (worst pain ever experienced). Fatigue when she first noted being tired, she feels her energy level was around 70% using a scale of 0 (bedridden due to no energy) to 100% (baseline energy level prior to spring 2003). Now she feels her energy level is about 50%. She reports rarely having days where she is bedridden due to feeling totally exhausted. (Cannot relate these episodes to any precipitation event). Swims on a regular basis and reports feeling exhausted after swimming, but able to work and function the next day. Denies feeling depressed. Denies swollen glands or sore throat, fevers, or memory changes or significant problems with concentration. Experienced tension headaches that vary in frequency. (Anywhere from once per week to weeks without any headaches. Pressure type pain is usually located around eyes and forehead, but mainly around the neck.