Received May 27, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (PFIZER-BIONTECH)) | PFIZER\BIONTECH | 4 | NJ6625 | IM / LA |
5/11: COVID vaccine received - 4th dose On 5/18 patient seen for uUTI and given nitrofurantoin prescription. Starting 05/19 pt reported feeling ill, malaise, loss of appetite, headaches, chills, rhinorrhea, dry cough. Symptoms worsened gradually over time, on 5/23 SOB on exertion and at rest, progressive weakness with inability to get up off of ground. Remaining on the floor for 10 hours until found via a wellness check. Admitted to hospital on 05/24. Pt noted to have a rash on both hands (palmar and dorsal), red pruritic nonblanching rash differing from the rest of the body. Generalized pink morbilliform rash on upper back, left chest, and legs. No pain or pruritus associated with rash. Tachypnea with accessory muscles breathing, no crackles/wheeze, requiring noninvasive O2 supplementation. Received fluid bolus; heparin drip, cefepime, vancomycin initiated 05/24. On 5/26 rash on left hand resolved, right hand rash persisted. 05/26 @ 1345 R/L coronary angiography & PCI 90% mid LAD with stent placement. 5/27 intermittent wide complex tachycardia most consistent with slow VT/AIVR, started on IV amiodarone with resolution back to NSR. This is day 4 of hospitalization and the patient is still admitted to Hospital.
Current illnesses at that time unknown
PAST MEDICAL HISTORY: 1. Gestational diabetes in 1959. 2. Migraines early 20s. 3. CVA with minimal residual in 1992. 4. Lipid therapy in 1992. 5. Diverticulitis in 1995. 6. Many TIAs times 4, the last in 2002. 7. Hypertension in 2019. 8. Lumbar stenosis in 2019. 9. Perforated diverticular abscess, culture positive for pseudomonas, Candida albicans, Enterococcus raffinosus and Parabacteroides johnsonii and merdae on 02/27/2021. 10. Herpes zoster, VRE UTI, VRE localized wound infection and positive Candida serology, 04/28/2021. 11. Incisional hernia with recent repair and admission, 11/11/2021. 12. Abdominal Wall Cellulitis with Enterococcus not VRE, 5/5/2021 PAST SURGICAL HISTORY:1. Appendectomy, age 15. 2. C-sections x2, 1959. 3. Hysterectomy, age 26, 1965. 4. Cataract surgery, 2000. 5. Breast biopsy, 2006. 6. Right inguinal herniorrhaphy using mesh plug technique on 07/05/2007. 7. Cardiac catheterization for atypical chest pain with normal coronary arteries on 08/06/2012. 8. EGD, erosive gastritis, Cameron erosions, hiatal hernia, duodenitis on 08/19/2014. 9. Incomplete colonoscopy secondary to sigmoid diverticulosis on 08/19/2014. 10. L4-L5 left laminotomy and microdiskectomy on 10/31/2019. 11. Sigmoid resection with Hartmann procedure, 03/03/2021. 12. Status post perforated diverticulitis with Hartmann's reversal of Hartmann's procedure for 04/29/2021. 13. Incisional hernia repair with partial component separation and Strattice graft, 11/11/2021. 14. Right knee cortisone injection 10/1/2021 by Dr. 15. Left knee cortisone injection 10/6/2021 by Dr. 16. Right total knee arthroplasty, 03/17/2023. 17. Right and left shoulder steroid injections on 05/05/2026 and 05/12/2026.
Nitrofurantoin 100mg BIID x7d started 05/18, primidone 50mg daily, atorvastatin 40mg daily, hydrochlorothiazide 25mg daily, eliquis 2.5mg BID, lisinopril 5mg daily
NKDA
Admission vitals 05/24/26 @ 1621: Temp 98.7F, HR 123, RR 26, BP 118/71, O2 sat 94% RA. Admission labs 05/24 @ 1648: CBC: WBC 13.0, RBC 4.06, HGB 13.1, HCT 39.6, Plt 271. Diff: Segs 78%, Bands 16%, Lymphs 0%, Monos 16%. CMP: Na 138, K 4.4, cl 101, Co2 21, AG 16, Glucose 249, BUN 45, SCr 2.03, Ca 9.0, Mg 1.7, CrCl 13.4. LFT: Alk Phos 67, AST 95, ALT 35, T bili 0.4. Lactic Acid 7.6, repeat @2219 2.5. CPK 5414. Troponin 8581, repeat @1846 10314. BNP 550. Chest/hip xray unremarkable. CT hip unremarkable. CT A/P denotes large hiatal hernia and subsegmental consolidation in the left lower lobe of the lung likely represents atelectasis. EKG 05/24/26 @ 1900, 05/25 @ 0900 sinus tachycardia with septal infarct. 05/25/26 LVEF 30-35%, severe apical hypokinesis. EKG 05/25 @ 1654 sinus tachy with ST elevation, 05/26 @ 0126 wide complex tachycardia, 05/26 @ 0614 sinus rhythm with occasional premature ventricular complexes and ST elevation.