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Life Threatening? No
Write-up: Initial and follow-up information has been received from a physician concerning a 14 year old female with unspecified mental health issues who on 28-AUG-2009 was vaccinated with a dose of GARDASIL (dose, route and LOT# not reported). On 22-SEP-2009 the patient started complaining of abdominal pain and weakness. The patient was admitted to hospital and felt fine when she discharged on 25-SEP-2009. On 27-SEP-2009 the patient went to emergency room and was admitted again for headache, weakness and being unable to walk. The labs CT of head and CT of spine were performed and no outcome provided, the GUILLAIN-BARRE Syndrome test was negative. The patient had been discharged on an unspecified date but she was still unable to walk and had weakness. No further information was available at this time of the report. The patient was hospitalized. The reporter considered the abdominal pain, weakness, headache and being unable to walk to be an incapacity or significant disability. Additional information has been requested. 11/9/09 medical records and discharge summary received for DOS 9/22-9/25 and subsequent admission 9/27/09-10/02/09. Final DX: 9/22 admission- Hiatal hernia. FInak DX 9/27 admission -Migraine Headaches, Somataform Disorder, Diabetes, Obesity Patient initially admitted for stabbing epigastric/abd pain and pain in shuoulders and back, tingling in back. CT abd and pelvis neg. diagnosed w/small hiatal hernia by endoscopy. D/C to home. Returned to ED with c/o LE weakness and back pain. Also c/o severe HA. Unable to bear weight and walks with walker. DTRs 1/4. Normal sensation. Strength 5/5. All diags neg. Somataform disorder. Refer to psych and possible rehab/PT. Homehealth. D/C using walker. HA resolving.
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