Received May 18, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 1 | 3053479 | IM / RA |
Patient has complicated medical history including chronic aspiration, asthma. She was treated with augmentin for respiratory issues and possible aspiration from 4/2/26-4/8/26. She has required extra oxygen at times, including 4/21/26 (the day prior to the vaccine). The day after the vaccine was given, patient was found to have wheezing and increased work of breathing, Sent to hospital for evaluation 4/23/26. They treated her for pleural effusion, heart failure. Discharged from hospital 5/4/26 in stable condition. Provider states they do not feel the hospitalization is related to the vaccine, but due to the timing of administration the day before hospitalization we are sending this report.
Reactive Airway Disease secondary silent aspiration/Aspiration PNA hx, possible heart failure with preserved EF, osteoporosis, GERD, hx of seizures, frequent UTI, spastic hemiplegia, allergic rhinitis
Principal Problem: Profound intellectual disabilities Active Problems: Blindness Seizure disorder (HCC) Asthma History of aspiration pneumonia Reactive airway disease Hx of congestive heart failure Hyperlipidemia Venous insufficiency of both lower extremities HTN (hypertension) Hiatal hernia GERD (gastroesophageal reflux disease) Gastroparesis Aerophagia Constipation Hx of colonic polyps S/P laparoscopic cholecystectomy Rectal prolapse Hypothyroidism Chronic hyponatremia Acquired absence of globe of eye with orbital implant Phthisis bulbi of right eye Dry eyes, bilateral Allergic rhinitis Chronic cough Osteoporosis CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min (HCC) Neurogenic bladder Recurrent UTI Seborrheic keratosis Stereotypic movement disorder with self-injurious behavior Sleep disorder Hx of fracture Contractures involving both knees Scalp lesion
acetaminophen, 650 mg, oral, TID albuterol, 2.5 mg, nebulization, BID ascorbic acid, 500 mg, oral, BID bisacodyl, 10 mg, rectal, Daily budesonide, 0.5 mg, nebulization, BID calcium citrate, 400 mg, oral, Daily cholecalciferol, 25 mcg, oral,
Hydrochlorothiazide