Age: 87.0
Sex: F
Vaccine: FLU3, FLU3
Symptoms: Brain injury, Catheter placement, Dysstasia, Encephalitis, Fall
Clinical narrative: To whom it may concern, Patient went for her regular office visit on Oct 6th 09. At the visit her complaint was urinary urgency, urinary frequency and urinary burning and diagnosed with a UTI. The doctor prescribed for her seven days Bactrim. She also received the seasonal Flu shot while at the office. After returning home she started her first antibiotic that evening, went to bed. The next morning (Oct 7th 09) patients husband had fixed some breakfast and called her to come eat. When she did not get up, her husband called a second time and she came into the kitchen to eat. When she tried to sit at the table she missed the chair and fell back against the refrigerator. Her husband helped her up and got her on the chair. She ate a little and did not feel well and her husband helped her back to bed. That evening  (Oct 7th 09) her husband noticed something wrong. He called someone in the family. She was in the bed in a fetal position with a never seen before fear, could not get up on her own. Family had to put her in a wheelchair to take her in the kitchen to eat. When you touched or moved her she would scream out in fear. If you bumped her bed; not even touching her, she would react in fear and pain. A family member called the office to tell them what had happened. A nurse said she probably had a reaction to the flu shot, and the UTI had her very weak. The family helped her for a week or so while her antibiotics waiting for the infection to clear. She did not seem to be getting over this so (also while home she had to use diapers) on 10-19-09 the family admitted her to the hospital and on the second day there 10-20-09 the doctor told a family member that the test reports were looking good and they should see a big difference in a patient in a few days. When she entered the hospital she had a white blood cell count of over 400 (normal 0-5) the nurses could not believe it and said they had never seen one that high. When she was cathed when she went to hospital the nurse noticed a huge discharge of creamy fluid (very abnormal). She was released to skilled nursing on 10-29-09. That AM the doctor told her husband there was no more the hospital could do for his wife. While at skilled nursing (in the same hospital) the nurses did not understand why she was sent there. They could not do a thing with her as far as rehab. They had never seen anything like it. No luck in skilled nursing so the family had her transferred to another hospital 11-6-09 > 11-13-09 the doctor in the neurology dept said when she first arrived it could be the UTI or the flu shot. After the hospital transferred to another healthcare facility 11-13-09. That day the head Neurologist called a family member and during conversation told the family member I can tell you one thing for sure/ A UTI did not do this to the patient/ and the family member reacted and said so what did do this? And he said possibly the Flu shot. On 12-9-09 she was back to the hospital with a strep bacteria for antibiotics and back to the Healthcare facility 12-21-09 where she is at this time. In the records from the hospital the new doctor seen they had mentioned Brain damage and encephalitis. The doctor at the time 10-6-09 never reported the adverse reaction, so I have elected to do this myself. I got records from the office but I don't think I got all of them. The doctors visit on 10-6-09 his notes were sketch so I am not sure the lot #. The doctors office should have the correct info. Let me know if I need to do anything.