Received May 1, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| PNC20 | PNEUMO (PREVNAR20) | PFIZER\WYETH | 1 | — | IM / LA |
Patient came in 5/1/25 due to possible vaccine side effects from pneumonia vaccine that she received 4/28/25. States that since then she has been having nausea, vomiting, chest pain on and off. States that chest pain occasionally radiates to her left arm. She also endorses entire body muscle and joint aches, new onset diaphoresis and lacrimation. States the last time she had chest pain was last night. States the last time she vomited was this morning. Also states she had some shortness of breath. EKG was obtained which showed ST elevation in V1 and V2 and T wave elevation in V4. When compared to EKG from 4/16/2025 there was T wave inversion on V4. Given different EKG findings on today's EKG when compared to 2 weeks ago with ST elevation and T wave elevation recommended patient go immediately to emergency room for further cardiac workup. There was some tenderness and mild erythema on the left deltoid and injection site. In the ER, EKG showed normal sinus tachycardia. There was concern for myositis vs myocarditis given abnormal EKG and heart enzymes with elevated inflammatory markers. There was also concern for potential lupus flare as a result of the vaccine or at least coinciding with the timing of the vaccine.
lupus with previous flares- not currently on medication, resistant hypertension, type 2 diabetes, hx DVT, hx PE, migraines, lupus, history of TIA, GERD, HLD, hepatic steatosis, chronic back pain
amlodipine 5mg, lipitor 80 mg, vitamin D 1000mg, metformin 500mg, protonix 40mg, miralax, percocet 5-325mg, phenergan 12.5mg, zanaflex 4mg, lantus 5mg, eliquis 5 mg bid, aspirin 81 mg
penicillins - hives, gabapentin - "seizures" unverified
5/1/25: Elevated troponin 17 > 16, WBC 13.0, CMP WNL, PT INR WNL, Lactic acid 2.6 > 1.6, procal 0.18, BNP 15, Magnesium 1.8, Sed rate 92, CRP 18, Blood cultures were drawn and pending. CK 49.