Received Nov 30, 2025
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 3 | 30145BA | IM / LA |
In the evening of 10/10/21, patient began developing a pressure-like chest pain. On 10/11/21, patient woke up with no pain, but midday, started noticing gradual intermittent pressure with exertion on the left chest. By evening, the pressure has increased going to the left arm, forearm and pinky finger on the left side. Patient's pain at its worst was a 7 out of 10 in intensity. Patient also noted shortness of breath and mild nausea without vomiting. That evening, patient was taken to freestanding Emergency Department by son and husband. The ED physician completed an evaluation and administered 1 dose of nitroglycerin. After the nitroglycerin, her symptoms improved, and patient stated her pain was now a 2 out of 10 in intensity. Later that evening, patient was transferred from the freestanding ED to Hospital Cardiac Specialty Unit for chest pain and elevated troponin. In the hospital, she felt that her pain was worse with deep breaths, and she experienced heaviness under her left breast. Patient was given a heparin drip and a Nitropaste in place. Work-up included CBC, basic metabolic panel, troponin, D-dimer, chest x-ray, CBC Covid test, and repeat troponin. All within normal limits except CBC, troponin 0.07, repeat troponin 0.19, and D-dimer elevated at 601. EKG showed sinus rhythm with known left bundle branch block. On 10/12/21, patient underwent a left heart catheterization with stent. Left heart cath showed 35% mid lesion LAD, 10% diffuse disease circumflex, 10% diffuse disease RCA. Cardiology evaluated and did not feel CTPA was warranted at this time given that labs are not significantly elevated and symptoms less likely consistent with PE. On 10/13/21, cardiac MRI showed mild segmental LV dysfunction with no evidence of infarct scar, consistent with a non-ischemic cardiomyopathy and evidence of myocardial inflammation, suggestive of myocarditis. In the evening of 10/13/21, patient was discharged from hospital. Patient underwent subsequent cardiac rehabilitation sessions at Health Center on the following dates: 10/25, 10/29, 11/2, 11/5, 11/10, 11/11, 11/15, 11/17, 11/18, 11/22, 12/1, 12/2, and 12/6/21,
none
Patient was a 68-year-old female with PMH significant for cardiomyopathy, hypercholesterolemia, hypothyroidism, hyperparathyroidism, hypothyroidism. sleep apnea, RLS, chronic insomnia, and borderline diabetes.
Prescription: ? Citalopram, 10 mg (once by mouth every morning) ? Gabapentin, 300 mg (once by mouth nightly) ? Levothyroxine, 75 mcg (once by mouth every morning) ? Losartan, 12.5 mg (once by mouth daily) ? Metformin, 500 mg (once by mouth
Medication allergies: ? Valtrex (valacyclovir) causes itching & rash ? Morphine causes itching & rash No known allergies to foods or other products.
See above