Received Apr 18, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 7+ | NA0738 | IM / LA |
| FLU3 | INFLUENZA (SEASONAL) (FLUCELVAX) | SEQIRUS, INC. | UNK | 948418 | IM / RA |
Initial (11/29/2025): Dizziness, Vertigo, Hearing Loss and Tinnitus Left Ear, Headaches, Seeing Double. Alternating Urgent Care / Physical Therapy / Physician Office Visits (12/26/2025, 01/06/2026, 01/24/2026, 01/28/2026, 01/30/2026, 02/02/2026, 02/11/2026, 02/17/2026, 02/23/2026, 02/25/2026, 02/27/2026) Dizziness and Vertigo, Meclizine Prescribed With No Effect. Physical Therapy For BPPV, No Improvement. Advancing to "Cloudy" mental feeling and unilateral headaches. Progressive memory deficits, language ability decline, and overall cognitive decline. Physician describes: "Acute Intractable Headaches and Dizziness (Vertigo)" Planned MRI After Coordinating With Pacemaker Team. Then, patient's condition declined rapidly resulting in me taking him to the Emergency Room, twice for FBDS/Mentation Decline/Confusion/Incontinence (Bladder and Bowels) (cont.) Phys. Office Visit () Emergency Room (02/28/2026 - Brought There by Person Completing This Form) Nurse: "Pt arrives from urgent care after he reports throat spasms today, intractable headache, muscle spasms on right side of face, vertigo since December, hand spasms, and friend reports pt is having word finding problems for the past week. Today most concerned about throat spasms. " Physician: "Patient presents with multiple complaints including dizziness headache throat spasms that have been intermittent for some time now. He seen his primary doctor he has an MRI ordered ENT appointment. Hemodynamically stable neurovascularly intact here. IV established labs were drawn no gross metabolic derangement troponin and ECG showed no acute abnormality patient not anemic no clinical signs of infection. CT of the head neck shows no acute abnormality. An attempt to get an MRI was informed that we do not have the capabilities to turn off his pacemaker." Discharged home to plan coordination of MRI/Pacemaker. Emergency Room (03/02/2026 - Brought By Reporter) Nurse: "Pt reports having urinary retention with minimal urination since 2/28. Pt reports headache, pain in bladder. No n/v/d." Physician: "presents to the ED with increased weakness, increased dizzy feeling and head pain. Patient is in and out with confusion has a resting and active tremor in B UE, has a positive head thrust with testing, and reports difficulty with word finding. Other testing a screening is negative but patient to follow up with additional imaging. Functionally pt is moving okay but would need guarding and help at home. Anticipate patient will eventually be home health level if making progress and imaging is okay." Second Physician: "This is a mildly abnormal awake and drowsy EEG due to diffuse background slowing. This indicates a mild diffuse encephalopathy which is non specific with regard to etiology. Toxic, metabolic or infectious causes are possibilities." Additional Physician "MRI cervical spine shows multilevel cervical spine degenerative changes most pronounced at C5-6 with moderate to severe canal stenosis and severe bilateral foraminal stenosis. Consider neurosurgery consult or outpatient appt at discharge. Physical and Occupational Therapy evaluation." First Hospital Mar 02, 2026 to Mar 07, 2026 03/07/2026: SIGNIFICANT EVENT Hospitalist Dr Significant event: "Increased confusion and mental status changes, Alert to self only this is far from pt's baseline , Did not know place or date of birth, Could not remember brother in law's name which we have discussed daily , No fever, VSS, blood sugar elevated. Due to MS changes will repeat labs and move pt to the ICU for closer monitoring and consult intensivist for hyponatremia and will re-consult for neurology. Called B-I-L and updated on situation and transfer to the ICU. Discussed case with Dr and NP with neurology. Return to room, after transfer to the ICU, pt started swinging and spitting at staff. Pt has never behaved like this before either. Without pharmaceutical intervention the pt remained calm after some observation. Pt was then transported to radiology for ct head, ct chest/abd/pelvis. NP called back concerned pt may have limbic encephalitis and has spoke to Dr and suggest transfer for in person neurology and available LP. Will start IVIG and high dose steroids." Second Hospital Mar 07, 2026 to Mar 23, 2026 03/08/2026: Dr "The cause of progressive encephalopathy is not yet clear. CSF shows a pleocytosis with elevated neutrophil percentage. An autoimmune encephalitis is currently suspected and IVIG and high-dose corticosteroids have been initiated. Infectious etiologies are also considered. #Suspected autoimmune encephalitis - Recommendations: Follow-up the following labs: MEP, vzv/hsv, glycine, Gaba-A/B, LGI-1, autoimmune encphalitis panel, OCB -- Continue IVIG 2 g/kg over 5 days -- Continue 5 days of methylprednisolone 1000 mg daily --Continuous EEG" 03/15/2026 Neurologist Dr "The patient's MRI brain was interpreted as lacking abnormalities, however the temporal lobes appear hyperintense. EEG interpretation without seizures but has shown R hemispheric slowing. Studies for reversible cause of dementia are unremarkable. Body imaging is also negative. LP performed 3/8 with WBC 49 (lymphocytic predominant) and elevated protein 245. Infectious studies negative. OCBs have returned with positive IgG index of 0.88, elevated IgG synthesis rate, and 7 unique OCBs. Presentation is most consistent with autoimmune encephalitis with inflammatory CSF profile. He is s/p high dose steroids and IVIG with improvement in mental status. " Third Hospital Regional Rehabilitation Hospital March 23 to April 7, 2026, treated by Dr and PA, until pt dramatically relapsed (mentation/cognition decline, language deteriorated dramatically, return of FBDS) Fourth Hospital (Dr again) April 7 to April 13. "He was found to have seronegative autoimmune encephalitis with evidence of temporal lobe abnormalities on MRI, CSF pleocytosis with positive oligoclonal bands. He incompletely improved with IVIG and high dose steroids, however he is now readmitted with worsening aphasia and intermittent abnormal movements. Exacerbation of autoimmune encephalitis is suspected. Toxic-metabolic contributors are unlikely the primary causes of worsening. EEG shows slowing, but no seizures. Will plan to repeat IVIG and high dose steroids, followed by rituximab. " Fifth and Current Hospital Regional Rehabilitation Hospital April 13 - Current: Patient's mental condition and language ability has improved but he still has no bladder or bowel control and very little strength in lower extremities.
Diabetes (became insulin dependent during this event), Hypertension, Pacemaker, Pheochromocytoma (8 yrs ago), Sleep Apnea, Sick Sinus Syndrome, Nasal Polyps, Diabetes Mellitus (Controlled with diet and exercise before this event), Atrial Flutter (occasional), Seasonal allergies.
BRENZAVVY 20 mg tablet (Diabetes), PULMICORT 0.5 mg/2 mL nebulizer BID Nasal Polyps; FLONASE 50 mcg/actuation nasal spray BID (Nasal Polyps). Over the counter multivitamin, Ibuprofen as needed occasional headaches
Acetaminophen (GI Intolerance + "Hives"), Shellfish, Metformin; Metformin - Severe Leg Pain, Milk (nausea), Prednisone (Hypertension and Palpitations Associated Once, But Taken Without Incident During This Event)
Infection Panels (CSF and Serum) Negative (03/07/2026) CSF PARANEOPLASTIC AB PANEL SERUM (Clinic) All negative . (03/08/2026), MRI W/WO Contrast (03/03/2026 and 03/10/2026). Hundreds of other tests performed across numerous urgent care, emergency room, physical therapy, physician office visits, and hospital stays across five different contiguous hospital admissions in the last seven weeks available on request.