Received Apr 2, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| TDAP | TDAP (BOOSTRIX) | GLAXOSMITHKLINE BIOLOGICALS | UNK | 3ZH27 | IM / RA |
Patient presented 8 months to the the student health center with these concerns. We had not seen him in our clinic until 4/2. Vaccine was on 7/10/2025. He had seen an outside clinic. Three to four days after the Tdap vaccine, he reports acute onset of extreme exhaustion and fatigue. He developed severe right shoulder pain and tightness/pain of the left paraspinal cervical muscles. He was having palpitations and felt like he was having chest pain. He thought he might be having a stroke and "anginal symptoms"---did not seek ER care or medical attention. He has since developed involuntary twitches (greater in the UE >LE) and muscle spasms. He reports severe lightheadedness with change in position. He believes something was "attacking his immune or nervous" system. He also endorses brain fog and frequently gets dates/times up. With onset of symptoms, he states that his legs initially felt like "cinder blocks" and he had weakness in his legs and pain in his arms. He reports that he was bedridden for 1.5 days. He felt that if he moved that "he would have a heart attack." He has had frequent episodes of heart palpitations and chest tightness since his symptoms started. He had headaches initially with symptom onset but these have mostly resolved. Neck pain has persisted. He denies any fever. He denies pain, swelling, or redness of the injection site. Patient states that he did take an OTC home COVID test given his symptoms which was positive within days of receiving the Tdap vaccine; however, he said the text was expired and there was no fluid left. He instead used tap water to run the test which he read could cause a false positive---he never received confirmatory COVID testing. He initially had blurry vision with symptoms that lasted for several weeks. He currently denies any eye muscle weakness or vision. He does endorse some globus sensation with swallowing, nausea, and decreased PO intake (does endorse some hx of GERD). Within the first couple of weeks, he reports that his hands and feet were numb. The numbness has significantly improved but he has "pins and needles" return intermittently. He feels that he is unsteady and has coordination problems. He reports that his balance is "messed up" and feels like he will just tip over sometimes. He will occasionally will drop things on accident. He feels slightly weaker on the left with walking compared to the right since onset of symptoms months ago. He also states that his HR has been elevated in the 110s-130s consistently. He also notes that his BP has been elevated. He reports frequent urination but this is not new. He endorses one episode of urinary incontinence awhile back. He feels slightly constipated now but no fecal incontinence. He notes a weight gain with onset of his symptoms but does acknowledge he wasn't eating well. He has since tried to eat "clean" and has had some intentional weight loss. No night sweats. He will sometimes feel that one extremity is more sweaty than the other. He has brain fog and has performed poorly in school since symptoms started.
He had a positive home COVID test that he took within a week after he received the Tdap shot due to his symptoms. He is unsure if the COVID test was valid as it was expired and he used tap water for the test instead (reports the fluid had dried up.)
GERD, possible generalized anxiety disorder (chart review of outside records diagnosed him in 4/2025), palpitations
Denies any supplements or meds within a month of the vaccine. He had taken tumeric powder, cinnamon powder, beet root, and Ashwagandja within a year of the vaccine.
None known.
Per chart review, he was evaluated at Urgent Care and Family Practice on 10/31 for his symptoms. This is his first encounter with the healthcare system that I'm aware after the onset of his initial symptoms in July. He had an unremarkable CBC and TSH. CMP with elevated Cr 1.35/BUN 21, low CO2 19. Labs collected on 11/1/2025. EKG at outside clinic with normal sinus rhythm on 10/31/2025 and a negative CXR. At his 4/2 visit in our clinic, an EKG showed sinus tachycardia with HR 106 and T wave abnormalities. Glucose was 68. Labs sent and are pending at time of submission of form with CBC, CMP, lipase, mg/phos, TSH, vitamin D, b12/folate, syphilis, ESR, CRP, lipid panel, HBA1C, HIV, Mg/PHos, and CK. He was referred to neurology and cardiology to further evaluate his symptoms. Of note, patient had provided childhood immunizations that he had the DTP shots as a child in 1991 and 1989--no adverse reactions to these.