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Write-up: Information has been received from a physician concerning a 12 year old female with a history of infectious mononucleosis, who "about two months ago" (approximately in July 2008) was vaccinated with the first dose of GARDASIL, a dose of MENACTRA and another unspecified vaccine. Concomitant therapy included NEURONTIN, ELAVIL, NEXIUM and CLARITIN. The physician stated that "about one week" after receiving vaccination, the patient developed headache, numbness, extremity tingling and pain on the left side of the body. The patient had been unable to attend school for two months because of the adverse symptoms. The patient sought medical attention with an office visit. At time of reporting, the patient had not recovered. Lab tests included a blood work with unknown results. The physician considered the adverse events to be disabling. Additional information has been requested. 12/08/2008 MR received from PCP. Seen 7/14/08 with c/o sore throat, H/A, congestion x 1 week. DX: Sinusitis-tx abx. Seen in ER 7/15/08 with same sx in addition to joint aches. Thought to be viral etiology. Seen 7/16/08 with additional stomach cramping, body aches, and red bumps on back. Worsening H/A. Worsening pain upper L side. Feels like throat is swelling up, migratory joint pain. Tx-Tylenol #3. Still c/o joint pain and difficulty sleeping. Assessment: Joint Pain/Fatigue. ? Viral Syndrome. By 8/26/08 pt worsening sx-H/A and sensory issues on the L side. Been out of school for long time. Referred to Rheumatology and Neurology. 1/5/09 MR received from Immunology and Neurology consults. 8/19/2008 and 8/26/08. Seen for c/o fatigue, H/A, back pain and joint pain. Also with c/o numbness of jaw and extremities, episodes of joint swelling, SOB, muscle tightness and nausea which began several days after receiving Gardasil vax. Now in home school due to intensity of sx. PE (+) for 8/10 H/a, mild (+) Romberg, point tenderness. Returned 9/16/08 for c/o disturbances of skin sensation. DX: Reflex Symphathetic Dystrophy, GER. Episode 9/18/08 of severe H/A , bilateral arm and leg pain, fever, shaking and vomiting resulting in ER visit. Assessment: Acute viral illness exacerbating chronic pain d/o.
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