Received Oct 20, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA MNEXSPIKE)) | MODERNA | N/A | 3052133 | UN / UN |
| FLU3 | INFLUENZA (SEASONAL) (FLUAD) | SEQIRUS, INC. | N/A | 407257 | UN / UN |
09/16/25 Provider Encounter Note. Patient presents today for evaluation of a recent 3 day history of paresthesia complaints. Patient reports that he received his influenza and COVID immunizations one-week ago. Following his immunization, he did feel achy and feverish. He is unsure if these are the symptoms to better explain his below paresthesia symptoms. 09/19/25 Presented in the Emergency Department. The patient reports that he got his Influenza and COVID vaccinations last week, specifically on 09/10/2025. The next day (09/11), the patient states that he noticed some tingling all over his body. He states it was most prominent to his lateral hips, lateral bilateral ribs, and lateral shoulders. Patient states the pain started as "dull and achy" but then progressed to feeling "like my body was on fire." He was taking ibuprofen and aspirin which was helping his symptoms and after several days, he states that his symptoms resolved. During this time, he also felt unsteady. He states that he typically walks approximately 3 miles per day. He was unable to complete his morning walks secondary to feeling of instability. He denies any falls, syncopal episodes, or injuries. Patient made an appointment with his outpatient PCP who saw him on 09/16. Patient had a thorough laboratory workup performed which was largely noncontributory. After shared decision-making, spinal imaging and EMG was deferred. Patient states that 2 days ago, he was restraining his deck and yesterday he stood for a long period of time. By yesterday evening, patient states that his pain and numbness returned. He called his outpatient PCP back to let him know that his symptoms had again worsened and was advised to present to the ED for further evaluation and management of his symptoms. Patient denies speech changes, trouble swallowing, or breathing. Upon ROS, he states that yesterday he felt feverish and had chills but denies having a temperature per his thermometer reading. He denies headaches, changes in vision or hearing, sore throat, congestion, rhinorrhea, chest pain, shortness of breath, abdominal pain, nausea, vomiting, changes in bowel movements, and urinary symptoms. No urinary or bowel incontinence. No known sick contacts. No recent travel. 10/03/25 Provider Office Visit. 10/10/25 Presented to ED and admitted. Discharged 10/18/25 to in-patient rehab.
None
Actinic keratosis, acne, arthritis, eczema, hyperlipidemia, hypertension, IBS
aspirin, atorvastatin
cortisone, erythromycin, ivermectin, loratadine, mometasone, penicillin
09/19/25 CT cervical/thoracic/lumbar spine - no acute bony abnormality in the cervical, thoracic, lumbar spine. 10/06/25 MRI spine - multilevel degenerative changes of the lumbar spine. At L4-L5 degenerative changes cause severe thecal sac narrowing. 10/01/25 EMG - no evidence of AIDP but indicated a right chronic L5 and S1 radiculopathy with superimposed right severe median mononeuropathy at the wrist. The exam during EMG showed 4 out of 5 weakness in bilateral hip flexion, knee flexion, and ankle dorsiflexion. Sensation was decreased to vibration in a length-dependent pattern, and reflexes were 1+ in the arms and absent in the legs. 10/11/25 Lumbar Puncture - differential: lymphocytes 40-80%, histiocytes 15-45%, neutrophils 0-6%, glucose 79, protein 68, CSF IgG 4.3, IgG 494, IgG Index, CSF 0.84, albumin 39.6.