Received Feb 20, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | UNK | — | — |
Dose: 0.5 mL Route: Intramuscular Site: Left arm Manufacturer: Pfizer-BioNTech Lot#: EN6201 Location: Referring Provider: ID: 76 y.o. female with past medical history of hypertension, hyperlipidemia, arthritis present for follow up visit for new complaint of right upper quadrant pain starting mid February. She just had labs with her primary care provider February 16 and the following week noted several episodes of intermittent upper right pain which also radiated to the back. Symptoms seem to occur more at bedtime and does not identify if these were specifically postprandial or any relation to food intake or type. The pain was of a burning quality and the area felt somewhat swollen. It was 5-6 out of 10 in severity she did not note any associated heartburn, nausea, vomiting or other digestive symptoms and her bowel pattern was unchanged. She has Bristol consistency 3-4 bowel movements occurring 3-4 times a day which has been since her COVID shot. She had prior treatment for collagenous colitis but not noting any diarrhea. Weight is stable good intake. No urinary symptoms. The pain actually has resolved in the last week or so and no symptoms at this time. She saw her primary care provider for low back pain October 23 and was treated with Macrobid for UTI. Last office visit Dr. 7/21/21: Patient is a 73 y.o. female presenting for follow-up of collagenous colitis. Patient has a history of uncontrollable diarrhea that initially started in February 2021 a few days following her COVID-19 vaccine. Her subsequent colonoscopy on 5/11/21 showed changes on random colon biopsies consistent with collagenous colitis. She was subsequently started on budesonide 3mg TID which she gradually tapered over a six-week period. She has not taken any budesonide over the last three-weeks. She is also no longer on miralax. She notes significant improvement in symptoms with resolved diarrhea. She feels well and denies bowel irregularity, anorexia, abd pain, nausea, vomiting, weight loss, or rectal bleeding. She maintains a relatively healthy diet. No colon polyps on last 2 colonoscopy 2018 and 2021 and was advised no further screening colonoscopies are needed. S/p CCY 2013 GI Problem list: collagenous colitis