Patient received AVA #1 with primary SPV on 2/21/2011. She was in good health with no remembered adverse events to AVA vaccine other than a sore arm "as if someone punched me" for about 1 week with full resolution. Her TBI mental health screening (ANAM) was "average" on 2/21/2012. She left late Feb 2011. On 3/8/2011 (day 15) she presented to medical with scattered pruritic bumps described as small red bumps with white centers. Her exam documented multiple skin lesions, papules, vesicles with some papules to upper/lower extremities shoulders and trunk. She denied any fever, nausea, vomiting, shortness of breath, chest pain, or other systemic symptoms. Her SPV site was forming a scab. Providers diagnosed "generalized vaccinia or reaction to the mites noted at JBB(?)". She was treated with ATARAX, Z-pak, and BACITRACIN. She reported resolution of all symptoms approximately 4 weeks later. While this skin reaction was resolving, she also reported injuring her left knee (3/22/2011-dx patella contusion, abrasion) falling off bike and was given MOTRIN and sent for physical therapy (PT). On 4/9/2011 she was unable to attend PT due to being "sick". She advised clinic provider she experienced nausea, vomiting, diarrhea, inability to eat x 3 days, and had shortness of breath, chest pain and difficulty sleeping (due to work schedule). She reported presenting to a field ER and was treated for "dehydration with 4 liters of fluid". (Unable to locate this visit, however on 6/21/2011 visit she reported she had E. Coli and on 8/3/2011 she advised provider she had cramping and diarrhea from antibiotics for 7/2/2011 pharyngitis). In July 2011 she felt "trapped" and "enclosed". She was not eating, sleeping poorly, and was highly irritable and had tremors to her right hand. She first noted right hand tremors in high school but never sought medical treatment for. Patient is left handed. She was seen by psych providers and diagnosed with "panic attacks/anxiety" and treated with AMBIEN and later PROZAC. However PROZAC made her feel like a zombie with lack of energy and she had problems concentrating. She was medevac'ed in July 2011 for further outpatient therapy. From 8/2011 to 2/2012 she completed evaluations for GERD (on PRILOSEC w/relief), sleep apnea-restless leg syndrome (not demonstrated), and PTSD/depression (meds helping). Patient reported increase in tremors when anxious and when on PROZAC (changed to CELEXA and B6). On 2/25/2012 she received her second AVA vaccination. Within 24 hours she advised her husband reported increased irritability and that she tossed around at night kicking in her sleep. Patient reported she was unsure of her surroundings and had problems concentrating. Her providers reportedly increased her psych meds by 1/2 dose which did help and made her feel better. Neurology evaluation 2/28/2012 documented tremors began in high school and increased with travel, when nervous or doing PT, eating, and holding objects. She was given a diagnosis of essential tremors that worsen with stress, fatigue and anxiety. She was placed on INDERAL for tremors and common migraines without aura since age 4 years. As of May 2012 she continues to complain of generalized muscle fatigue on left side of body, being tired and had recurrent left knee pain. Patient reported having increased tremors to right hand that are now episodically interfering with ADL. She also advised she is experiencing some visual blurriness. She describes problems focusing at distance but can see up close. She had LASIK surgery in 2010 with 20/20 vision but now says vision is "so/so". She has not f/u with ophthalmologist. She is also being evaluated for "allergies due to 3 week chronic cough". In 2012 she was started in vitamin B6 for symptoms of chronic fatigue (2012 thyroid studies and iron/iron binding normal and hCG negative).