Received Mar 19, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 4 | LM2221 | IM / RA |
| FLU3 | INFLUENZA (SEASONAL) (FLUZONE HIGH-DOSE) | SANOFI PASTEUR | UNK | U8499BA | IM / RA |
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | 235D2 | IM / LA |
| VARZOS | ZOSTER (SHINGRIX) | GLAXOSMITHKLINE BIOLOGICALS | 1 | N547S | IM / LA |
This is a 70 year old male with past medical history of dementia, heart failure, osteoarthritis, chronic neuropathic pain, insomnia, chronic bilateral knee pain, lipomas, migraine, PTSD, urinary/bowel incontinence, adjustment disorder with depressed mood, GERD, and dyslipidemia. He received 4 vaccines on 12/18/24 (influenza, COVID-19, Tdap, and Zoster) at his primary care visit. On 12/27/24 his wife reported that he had been experiencing severe whole body pain since the PCP visit, his mobility decreased significantly to the point he was bedbound. Of note was previously on pregabalin 300mg BID and celecoxib 200mg daily for pain, orders were expired at that visit, pregabalin was not renewed until 12/31/24 by the resident physician due to difficulties with controlled substance ordering through system per addendum 12/31/24. The patient presented to ED on 2/27/25 with complaint of chronic fatigue and weakness which his wife attributed to the vaccines he received in December 2024. Per ED provider notes, patient reported lower extremity weakness for the past 3 months however no acute symptoms were reported and CT head scan was negative for acute abnormalities. Provider recommended follow-up with outpatient neurology, per records does not appear Patient was seen by neurology provider. Patient continues to be bedbound at baseline as of March 2026.
None
past medical history of dementia, heart failure, osteoarthritis, chronic neuropathic pain, insomnia, chronic bilateral knee pain, lipomas, migraine, PTSD, urinary/bowel incontinence, adjustment disorder with depressed mood, GERD, and dyslipidemia.
1) ATORVASTATIN CALCIUM 20MG TAB TAKE ONE TABLET BY MOUTH ONCE A DAY - AVOID TAKING WITH GRAPEFRUIT JUICE ; Indication: FOR CHOLESTEROL 2) BUPROPION HCL 75MG TAB TAKE TWO TABLETS BY MOUTH ONCE A DAY - LAST DOSE O
penicillin - nausea/vomiting, gabapentin - drowsiness and lower extremity edema
IMAGING: CT Head WO IV Cont Result Date: 2/27/2025 (medical facility) 1. No acute intracranial abnormality. 2. Moderate hypodensities of the periventricular white matter and subcortical white matter bilaterally are nonspecific but most commonly related to chronic small vessel ischemic changes. 3. Moderate generalized cerebral and loss Electronically Signed by: Provider 2/27/2025 1:29 PM