Received Jun 15, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 1 | 016B21A | SC |
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 3 | 012521A | SC |
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 2 | 03B21A | — |
Patient developed numbness and tingling in his extremities starting February 2022. This progressed to arthralgias that were severe and associated with labored breathing, fatigue, generalized swelling including of the prostate, brain fog and moments of deep insight over the summer and fall of 2022. He dealt with these symptoms for over 2 years. He also had an episode of severe diarrhea and acute kidney injury March 2024.
None
Hypertension
Losartan, HCTZ
Cat Dander
MRI Shoulder 9/9/2022 1. Moderate tendinosis and low-grade partial-thickness intrasubstance tears at the supraspinatus tendon with no full-thickness tear identified. 2. Mild to moderate tendinosis without tear at the infraspinatus tendon. 3. Moderate subacromial/subdeltoid and mild subcoracoid bursitis. 4. Full-thickness longitudinal tear of the distal superior subscapularis tendon. 5. Mild tendinosis and mild tenosynovitis at a medially subluxed proximal long head of the biceps tendon. 6. Small effusion and mild synovitis at the glenohumeral joint. 7. Moderate DJD and very small effusion at the AC joint. MRI Cervical spine 1. Moderate to severe left foraminal stenosis at the C3-4 level. 2. Severe left foraminal stenosis at the C4-5 level. 3. Severe right and moderate to severe left foraminal stenosis with moderate to severe central stenosis at the C5-6 level. 4. Severe right and moderate to severe left foraminal stenosis with moderate central stenosis at the C6-7 level. 5. Moderate left foraminal stenosis at the C7-T1 level.CT abdomen 1. Fluid throughout the large bowel without evidence of distention. Minimal subjective wall thickening in the distal descending colon and sigmoid colon may represent low-grade enteritis or colitis. No adjacent inflammatory change 2. Tiny intrahepatic low-attenuation structures statistically most likely to represent benign cysts or hemangiomas and not requiring follow-up unless this patient has high risk factors for hepatic malignancy in which case the patient would require follow-up MRI with and without contrast within 3-6 months. (For example: Cirrhosis, malignancy with propensity for metastasis to the liver, non alcoholic steatohepatitis, hepatitis, anabolic steroid use, hemochromatosis and/or other hereditary liver disease, alcoholism, sclerosing cholangitis, choledochal cysts or primary biliary cirrhosis) GFR on 3/12/2024 was 26.