Age: 78.0
Sex: F
Vaccine: COVID19
Symptoms: Condition aggravated, Fatigue, Immune thrombocytopenia, Lymphocyte count decreased, Lymphopenia
Clinical narrative: Hematology/Oncology History: 1.  10/2021: Admitted to hospital with febrile illness, myalgias, petechial rash, acute thrombocytopenia, lymphopenia.  She had received her Covid booster 9/29.  It was approximately 2 weeks later when she began having fatigue.  The rash presented a few days prior to admission. On admission her platelet count was 11, absolute lymphocyte count 0.55.  Unclear if her acute events were related to the Covid vaccine or a separate viral illness.  She did receive dexamethasone 40 mg x 4 days as treatment for her presumed ITP.  Platelet count quickly recovered. 2.  Current plan: Weekly CBC.   Interval Events The patient presents to the clinic today with her husband for hospital follow-up regarding her recent febrile illness, petechial rash, acute thrombocytopenia/lymphopenia.  I have reviewed inpatient notes, labs for the visit today.  I also reviewed and updated her past medical, surgical, family, and social histories and discussed her case with the admission hematologist.  She reports resolution of all previous symptoms since hospital discharge.  She feels back to her normal health.  Her rash is resolved.  She has no further myalgias or significant fatigue.  She tolerated the dexamethasone without difficulty.   History Patient has a past medical history of Arthritis, Asthma, Essential hypertension, Hyperlipidemia, Immune thrombocytopenia (HCC) (related to covid vaccine), Osteopenia, and Squamous cell carcinoma of skin.   She has a past surgical history that includes cystocele repair; Rectocele repair; Skin cancer excision; and tah and bso.   Patient's family history includes Asthma in her brother; Brain Cancer in her brother; Cancer in her maternal aunt; Coronary Artery Disease in her father and mother; Heart Attack in her father and mother; None Reported in her sister; Stroke in her sister, sister, and sister.   Social history: Married.  Remote history of smoking x10 years, quit in the 1970s.  No alcohol use.      Medications   Current Outpatient Medications:  ?  albuterol (VENTOLIN HFA, PROAIR HFA, PROVENTIL HFA) 90 mcg/actuation inhaler, Inhale 2 Puffs by mouth every 6 hours as needed for Wheezing., Disp: 1 Inhaler, Rfl: 3 ?  albuterol sulfate (PROAIR HFA) 90 mcg/actuation HFA aerosol inhaler, Inhale two puffs by mouth into the lungs every 6 hours as needed for Wheezing or Shortness of Breath. Shake well before use., Disp: 25.5 g, Rfl: 0 ?  amLODIPine (NORVASC) 5 mg tablet, Take 5 mg by mouth daily., Disp: , Rfl:  ?  aspirin EC 81 mg tablet, Take 81 mg by mouth daily., Disp: , Rfl:  ?  atorvastatin (LIPITOR) 10 mg tablet, Take 1 Tab by mouth daily., Disp: 90 Tab, Rfl: 3 ?  docusate (COLACE) 100 mg capsule, Take one capsule by mouth twice daily as needed for Constipation. Indications: constipation, Disp: 30 capsule, Rfl: 0 ?  famotidine (PEPCID) 20 mg tablet, Take one tablet by mouth twice daily. Indications: gastroesophageal reflux disease, Disp: 180 tablet, Rfl: 1 ?  lisinopril (PRINIVIL; ZESTRIL) 20 mg tablet, Take 2 Tabs by mouth daily., Disp: 180 Tab, Rfl: 1 ?  magnesium oxide (MAGOX) 400 mg (241.3 mg magnesium) tablet, Take one tablet by mouth daily for 180 days. Indications: myalgias, Disp: 180 tablet, Rfl: 0 ?  multivitamin (BEE-ZEE) tablet, Take one tablet by mouth daily. Indications: lack in minerals, vitamin deficiency, Disp: 90 tablet, Rfl: 1 ?  polyethylene glycol 3350 (MIRALAX) 17 g packet, Take 17 g by mouth daily., Disp: , Rfl:    Allergies:  Allergies Allergen Reactions ? Seasonal Allergies EYE IRRITATION, RHINORRHEA and SNEEZING     plt count normal by 22 Nov 2021