Age: 19.0
Sex: M
Vaccine: FLU3
Symptoms: Antinuclear antibody negative, Arthralgia, Asthenia, C-reactive protein normal, Epstein-Barr virus test positive
Clinical narrative: Patient reported receipt of routine vaccinations on 5/29/2014. He reported getting 2 (two) shots to his left deltoid with immunization records documenting one influenza vaccination given (Lot # U4693CA; SP). After vaccination he ate lunch then sat in class until 9pm. He stated his left deltoid was sore. Approximately 24 hours later this dull achy constant soreness radiated into his bicep with sensation of numbness and tingling described as a prickly sensation with subjective weakness to his arm secondary to site soreness. He admitted to episodic stabbing pains down left arm to entire hand 2-5 times (nothing provoked - occurred at rest or carrying books). He denied any physical activity, training or injury to left arm. Day 2 he awoke stating this tingling numb like pain now included his left lateral chest and side. He stated it hurt to take a deep breath otherwise no breathing difficulty or chest pains. On day 3 this sensation progressed down to top of his left foot with anterior hip/thigh pain and tingling. He is currently completing classroom training sitting most days. He advised during classroom training since 5/30/2014, he was required to stand leaning over a table all day as they completed assigned chart tasks. This standing worsened his leg pain. He presented to ER 6/3/2014 complaining of nausea, LUE, LLE, left neck and side pain (4/10) x4 days. He advised symptoms "keep moving all around his left side". Providers documented he was afebrile (98.2F) with left paraspinal muscle tenderness otherwise normal exam, muscle tone, DTR's, and no muscle atrophy. Lab studies were normal (UA and BMP). He was diagnosed with left sided body pain and released home on FLEXERIL and NORCO. He presented to medical 6/4/2014 (day 4) where providers also documented spasms to left paraspinous muscles-trapezius and cervical spine, otherwise normal strength upper/lower extremities, normal DTR and limping to LLE due to pain (5/10). He presented to neurology and VHC on 6/5/2014. Neurologist documented some focal tenderness to left deltoid, trapezius and axilla with normal neurologic exam (DTR, sensory and vibratory, etc). He advised VHC provider he had no grip issues (is right hand dominant), could hold light objects up to 20 lbs and holds 5-6 lbs for up to 8 minutes before left arm begins to hurt and had to put down. He advised standing causes increased pian to left leg-thigh which now makes him guard (limping). He points to the pain as more in anterior upper mid-quadriceps region on left leg and to left mid-deltoid. He stated when his leg extended back it stretched/pulled his thigh/knee eliciting pain (5/10). He denies any problems with balance, bowel or bladder control. He was released with neurology instructing him he had "no evidence of a peripheral or central nervous system process and diagnosed with joint pain". He was instructed to use his Ibuprofen for one week with food and FLEXERIL as needed. Over next few days, he continued to guard left arm/leg complaining of "persistent weakness" (problems with holding objects as above), stiffness and soreness to left deltoid, arm, neck, torso and leg returning to neurology on 6/12/2014 still concerned about "atypical GBS". Provider noted he guarded his left arm and leg from most movement due to pain (was prescribed Ibuprofen 800mg and FLEXERIL for pain/spasms- unknown if utilizing meds). During his exam, providers observed he could dress himself buttoning his shirt, tucking shirt into pants without restrictions which were incongruent with effort seen on formal exam and there were some fluctuations in areas of numbness. Provider documented "subjective sensorimotor symptoms that did not appear to follow a consistent dermatome pattern. Provider's impression was "progressive subjective left arm/leg pain shifting to subjective sensorimotor symptoms....including give way and non-anatomic distribution of sensory loss with no evidence of GBS, myelitis or plexitis".