Received Apr 16, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 3 | — | — |
Patient is a Veteran of a war. Has history of chronic fatigue syndrome dating back 20+ years with negative workup. Patient claims his fatigue worsened following COVID19 vaccines. He received 3 Moderna vaccines, the latest being 01/07/2022. Patient reports worsening in pre-existing fatigue, and now mental fog, memory impairment, and increased chronic pain. Pt has been evaluated by neuropsych, mental health, endocrinology, speech pathology to help with symptom management. Patient given modafinil to help with fatigue.
Chronic Fatigue, unspecified (ICD-10-CM R53.82) (Primary) Essential (Primary) Hypertension (ICD-10-CM I10.) Hyperlipidemia, unspecified (ICD-10-CM E78.5) Prediabetes (ICD-10-CM R73.03) Chronic Obstructive Pulmonary Disease, unspecified (ICD-10-CM J44.9) Solitary Pulmonary Nodule (ICD-10-CM R91.1) Fatty (Change of) Liver, not elsewhere classified (ICD-10-CM K76.0) Cholesterolosis of gallbladder (ICD-10-CM K82.4) Aneurysm of iliac artery (ICD-10-CM I72.3) Nicotine Dependence, Cigarettes, Uncomplicated (ICD-10-CM F17.210) Allergic Rhinitis, unspecified (ICD-10-CM J30.9) Benign prostatic hyperplasia without lower urinary tract symptoms (ICD-10-CM N40.0) Prurigo Nodularis (ICD-10-CM L28.1)