Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Full blood count normal, Gait disturbance, Headache, Heart rate increased, Hepatic enzyme increased
Clinical narrative: Fever (101-103 F) for 13 days beginning 6/9/2021, elevated heart rate, muscle aches, confusion, abnormal gait, extreme pain in calf muscles, difficulty walking, lost 13 lbs. in 2 weeks, extremely weak, loss of balance, pain in feet, numbness in feet, pain in neck, stiffness in neck, sleepiness, body aches, shortness of breath, night sweats, felt like I was going die the nights of 6/23 & 6/24, falling down (6/20, 6/23, 6/24, 8/13, 9/13) sprained ankle 9/13 requiring medical attention.  6/15 Dr visit, ordered labs, elevated liver enzymes.  6/16 negative COVID test.  6/17 Emergency Room Visit - spent 5 hours in ER, they ran all kinds of tests, X-rays, EKG, cultures and could not find anything abnormal except elevated liver enzymes, I was diagnosed with a fever from an unknown cause. I began walking with a cane 6/24.  7/7 saw Internist - ordered labs - all negative except elevated liver enzymes. 7/8 saw Neurologist told me to stop taking carbamazepine, ordered PT for strength and balance issues, ordered MRIs for upper and lower back thought vaccine may have inflamed the spinal cord, did not think this was related to neuropathy, thought surgery might be needed at lower back for feet issues, suggested I see a neurosurgeon.  7/8 saw PCP - ordered labs for 7/28 all came back normal, assumed the carbamazepine may have caused the elevated liver labs. Saw chiropractor 7/14, 7/16 & 7/19 for dry needling to both calves, this did not help the pain in the legs.  7/19 began PT for strength and balance issues 8 PT sessions. 8/13 stumbled and fell, bruised hip, shoulder and cut knee. 9/13 fell in yard picking up Hurricane debris. sprained ankle very badly. 9/14 saw orthopedic surgeon walked in with cane, positive with severe upper ankle sprain, ordered walking boot for 6 weeks, ordered PT for sprain had 10 PT sessions for sprain, discontinue PT for strength. 9/22 saw neurosurgeon as follow up from neurologist - NS did not think upper or lower back was necessary to resolve feet issues, ordered MRI of neck - resulting in surgery 11/11 for ACDF of C2-C7. Cervical MRI showed much change from 2019 and there was chance of irreversible damage if surgery was put off, recommended I consult with a Rheumatoid Arthritis doctor. 9/27 saw RA, order multiple tests, determined I did not have RA.  To date (1/25/2022) I am still having issues with balance, coordination and with pain/numbness in my feet. I firmly believe is a direct result of a reaction with the 2nd COVID 19 Vaccine on 6/9/2021.  6/9/2021 -fever started ~ 3hours after 2nd vaccine 6/15 - FNP: fever 101.4-102.9, headache, ear pain, sleeplessness, imbalance. NSAIDS, acetaminophens, fluids (mild improvement). No abdominal pain, chest pain, congestion, coughing, diarrhea, muscle ache, nausea, rash, sore throat, urinary pain, vomiting or wheezing. Tachycardia present. RX Augmentin 2xday for 10 days, she wanted to prescribe in case I had something bacterial although she could not identify what? ordered CBC Auto Differential & Comprehensive Metabolic Panel. - Told to follow up with Neurologist. 6/16 - FNP called Labs came back negative except elevated liver enzymes. Ordered COVID 19 test - Tested negative. 6/17 - FNP called to see how I was doing, was short of breath, was told to go to ER. At ER had chills, tachycardia, shortness of breath, no chest pain, no urinary symptoms, no rash on body, no neck pain, no abdominal pain. Normal whiter blood count, lactic acid was normal. blood cultures negative, negative for influenza, no mono, normal neurological exam, do not believe to have meningitis, no skin findings to sugest abscess/cellulitis. Abnormal LFTs notes. No evidence of any obstructive physiology on CT scan. EKG normal. Follow up with PCP. 7/7 - CMP - elevated liver enzymes, Hepatitis panel- negative 7/28 - CMP - liver enzymes back to normal, all other labs normal. 9/27 - Cyclic citrate peptide antibody, C-reactive protein, CMP, ANA, anti-DNA antibody, Rheumatoid factor uric acid - all labs negative for RA  I understand that the Booster side effects should be similar to what I experienced with the 2nd vaccine. I do not want to get the Booster and go through all the pain and misery I am still suffering with.