Received Feb 20, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | UNK | — | — |
HPI patient is a 55-year-old male with a known history of hypertension, hyperlipidemia, previous tobacco use, family history of heart disease, who has recently developed intermittent episodes of chest discomfort, palpitations and shortness of breath. The patient describes the chest discomfort as a aching and painful sensation that can occur anytime during either rest or with exertion. The palpitations also occur at a time but more frequently in the evening. Is also noticed dyspnea on exertion and occasional mild shortness of breath at rest. The symptoms have occurred since his COVID-19 vaccination, Moderna vaccine. The patient denies near syncope or syncope. He does have a family history of heart disease. This is prompted him to have a more thorough evaluation. 55-year-old male presents to the emergency department for evaluation of chest pain. The patient describes several days to week of left-sided chest pressure, tightness and heaviness. He describes 2 days of exertional dyspnea and worsening of his pain with exertion. He states that his symptoms started shortly after receiving a COVID-19 vaccine. No fevers, chills, sweats, nauseousness although he had these symptoms at the onset. No vomiting or diarrhea. No rashes or skin changes. No prior history of coronary artery disease or stroke or acute coronary syndrome. Patient does have a history of hypertension, hyperlipidemia and chronic back pain status post 3 surgeries.