Received Mar 24, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 4 | LP1780 | IM / AR |
Patient experienced new onset diagnosis, "it looks like viral myocarditis" and was hospitalized in the ICU for this. The timing is related to receipt of his COVID vaccine on 3/14/2025, but onset of symptoms started before the vaccine. It is unknown whether there is any causality since patient has had respiratory symptoms for approximately 2 weeks, and received the vaccine during his worsening respiratory symptoms. The cough and SOB may have been related to myocarditis prior to receiving the vaccine, due to recent suspected viral illness. The timing of the vaccine vs. viral exposure with sick contact clouds the picture. Patient also has longstanding 40py history of smoking and was diagnosed with a COPD exacerbation, and likely OSA. The heart failure with EF 11% is NYHA Class IV, Stage C, new onset. More details from H&P: "63 y.o. year-old male with unknown past medical history who presented with shortness of breath. Patient has not seen a physician in many years and has not been on any medications at home. Patient states that he was in his usual state of health up until 2 weeks ago when he developed had a cough. He states that his granddaughter was also sick with similar symptoms around the same time. He states that he received COVID-19 vaccine on 3/16 and since then has been having symptoms of cough and shortness of breath. He states that shortness of breath has been getting progressively worse and so he came to the ED for further evaluation. In the ED, patient was noted to be tachycardic, tachypneic and hypoxic with SpO2 of 53 on room air. He was subsequently started on 5 L of oxygen via nasal cannula. Electrolytes showed elevated CO2 consistent with chronic CO2 retention. ABG showed pH 7.26, pCO2 85.7, HCO3 38.5, lactate 0.7. Patient was started on breathing treatments. She was called due to respiratory distress and patient was transferred to the ICU. In ICU patient was started on BiPAP. Further evaluation with echocardiogram showed patient has EF of 11% with global LV hypokinesis and grade 2 diastolic dysfunction. Cardiology has been consulted for management of heart failure with severely reduced EF. Patient denies any family history of cardiac events. Brother, mother and Sister all died from lung cancer. He does state he gets chest pain and shortness of breath with any physical exertion fro the last 3 months. He also endorses snoring and feeling not well rested after sleeping."
Cough, likely viral illness
Unknown - has not seen a primary care doctor in over 40 years per patient
None
None
EF 11%, BNP 575