Received Feb 18, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | 1 | UT8873NA | IM / RA |
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE) | SANOFI PASTEUR | UNK | UT8873NA | IM / RA |
1/25/26-1pm- pt messages PCP with back pain from playing pickle ball 1/21/26 with very tight hamstrings/shoulders, numbness in fingers/toes. 10:45pm- pt messages again with loss of coordination; weakness to arms/legs. (pt had consulted a teledoc this eve and was prescribed cyclobenzaprine/prednisone, which he had not started yet. 1/26/26 11am- office visit-pt shared numbness also to mid back with pressure to scapular areas lying down, limited ROM at ov to shoulders/upper extremities; tightness to lower extremities. 5:17pm- wife messaged PCP again that pt tried to go up2 stairs and collapsed due to lower extremity weakness-thought maybe the muscle relaxer was doing this, and Dr. said no, that should not be causing that reaction. Concern for Guillan Barre and suggested going to the ER. Patient chose to go to [withheld] ER in [withheld town].
12/18/2025- at Physical appt shared he had a dry cough for a month, but worsened over last 2 days; has has nasal congestion; no fever, no chills, no SOB, no chest congestion, no chest pain, no sinus pain or pressure, and no rashes.
Hypertension, hyperlipidemia, anxiety disorder, seasonal allergies, mild sleep apnea
Amlodipine 5mg daily, Losartan Potassium 100mg daily, Lexapro 5mg daily, zyrtec otc prn, vit c daily, vit d3 2000U BID.
NKDA
Pt has physical exam at his ov visit on 1/26/26: MSS: no cervical , thoracic or lumbar spinous process tenderness. no cervical, thoracic or lumbar paraspinal muscle tenderness NS: CN II-XII intact. 4- abduction of the arms b/l, 4+ adduction of the arms b/l, 5/5 strength with forearm flexion and extension b/l. 5/5 grip strength and intrinsic hand muscle strength b/l 4+ hip flexion b/l 5/5 leg extension and flexion b/l. 5/5 plantar flexion b/l negative seated flexion test +antalgic gait, +difficulty with balance pt demonstrated difficulty standing from a seated position w/o assistance of using his arms sensation intact b/l UE's and b/l LE's +absent bicep and patellar DTR B/L