Received Feb 9, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 3 | 020F21A | IM / AR |
Behavioral changes began 08/26/201, Altered mentation began 08/28/2021, Cerebral edema, blurry/ double vision, memory loss began 08/30/2021
None
Rheumatoid Arthritis, Psoriatic Arthritis, Osteoarthritis, Fibromyalgia, Sjogrens disease, Major Depressive Disorders, Anxiety, Chronic wide spread pain, non- alcoholic fatty liver, IBS, Barrett's Esophagus/ GERD
Trintellix, Pantoprazole, Bijuva, Zanaflex, Trazodone, Alprazolam, Orencia, Vitamin D3
Penicillin
08/30/2021: PT: 13.0 seconds (normal), Alcohol Serum <10 (Normal), TSH 1.57 (Normal), Troponin I <0.012 (Normal), Comprehensive Panel Glu 123 all other values within normal limits, Sars Cov 2 Rapid test - Negative, Ammonia <9 (Low), CT Scan - No acute intracranial process, Periapical lucency surrounding the rooths of the most posterior left maxillary molar concerning for odontogenic abscess. AFB Stain/ Culture: No acid fast bacilli seen or isolated, Mycology Culture/ Stain: No fungal or yeast elements seen or isolated at 4 weeks. Meningitis/ Encephalitis PCR (CSF): Negative for all organisms tested, West Nile Virus PCR (CSF): Negative, JC Virus PCR (CSF): Negative, Epstein-Barr Virus (CSF)- Negative, VDRL (CSF): Negative, CSF Culture + Grain Stain: No organisms seen, no WBC on stain, no growth at 3 days for culture, Oligoclonal Bands (IGG, CSF): Negative, Cell count w/ diff if indicated CSF: Colorless, Clear, RBC 1, WBC 3, Glucose CSF: 68, Protein (CSF): 67 (high), Urinalysis w/ C&S if indicated: Yellow, clear, USG 1.010, pH 6.0, glu neg, pro neg, ketones neg, bilirubin neg, blood neg, nitrate neg, urobilinigin <2, Leukocyte esterase neg, Urine drug screen Positive for Benzodiazepine, THC, and Opiates, other values negative, Lumbar Puncture, procalcitonin serum 0.05 (normal), CRP (non cardiac)- 1.2 (high), Sed rate <1, Magnesium 1.6 (normal), Blood culture: no growth at 5 days, CXR: Normal. 08/31/21: Magnesium 1.6 (normal), RPR - Non-reactive, Comprehensive Glu 137, BUN 6, potassium 3.1, other values WNL, CBC RBC 5.24, MCV 77.9, all others WNL 09/01/2021: Procalcitonin serum - 0.052 (normal), Magnesium 1.6, Comprehensive Glu 118, BUN 6, Postassium 3.3, AST 56, ALT 38, other values WNL, CBC: MCV 79.6, all other values WNL, CXR: within normal limits 09/02/2021: Potassium 3.1, Magnesium 1.8, EEG diffuse slowing, generalized disturbance of cortical function, MRI- T2 hyper-intensity in parieto occipital lobes with cortical restricted diffusion extending into the left parietal lobe. Consistent with posterior reversible encephalopathy syndrome (PRES) 09/03/2021: Basic Metabolic Panel - Glu 106, Potassium 3.3, other values WNL, CBC - MCV 79.5, other values WNL, MRI w/out contrast: no hemodynamically stenoses or proximal occlusion, no findings of venous sinus thrombosis, XR Panorex: no acute abnormality. 09/04/2021: Magnesium 1.5, Potassium 3.3 09/05/2021: Magnesium 1.7, Basic Metabolic Panel Glu 121, BUN 23, BUN/Cre Ratio 26.4, other values WNL. MRA Head w/o contrast: Patent intracranial arterial vasculature. MRI head w/o contrast: Interval improved bilateral occipital lobe subcortical white matter signal abnormality and edema persistent cortical restricted diffusion in keeping with PRES 09/06/2021: Magnesium 1.7, Potassium 3.7
1961 ~2-3months of age, high fever, eyes rolled behind head, scar from vaccination site