Age: 54.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Headache, Hypoaesthesia, Joint swelling, Laboratory test normal, Mobility decreased
Clinical narrative: 05/09/2021   After the second shot. My symptoms from the shot went away for a few days. I had weird sensations in my brain, including a sensation of cool water flowing through my brain around the second day. I had other fluttering sensations that would move around in my brain.   After a few days, my muscle pain became more intense. My hands and feet and tongue began to swell up and my joints in my hands began to swell and hurt. My muscles in my arms felt like they were contracting and pulling my fingers in. It felt like I had pressure behind my eyes. My neck was stiff and I started to have numbing sensations on my head, face and arms that would come and go.  I had headaches and sometimes it felt like I had fluttering in the center of my brain. I had sensations that felt like an alien was crawling up my back.  I also felt very fatigued. I then had what I would call my first attack where I felt really weak and I thought I was going to faint.  My heart started racing. I felt like I was having a stroke. June 1st, 2021, I went to the Medical Hospital the first time. June 9th, 2021 - Emergency Room - The second attack, my body was having involuntary muscle spasms all over. My muscles were shaking in an involuntary manner.  I felt very weak and I felt like I might faint.  I ended up going to Medical Center.  All tests came back normal both times.  The third attack was muscle spasms mostly in my neck and mouth below my tongue.  I was not sure if my airway was going to close.  It lasted about 45 minutes.  I tried to relax and meditate to make it go away.  In both my hands and wrists, with my right middle finger, I was not able to make a fist due to arthritis like symptoms in my finger joints and the hair on my head has continued to fall out since getting the second COVID Shot.  This lasted for 10 months.   Today - 04/10/2024 - I have chronic fatigue.  My endurance is half of what it was before taking the Pfizer shots. I have swelling and pain in my muscles and joints in both my hands, feet, legs and ankles.  My hands, wrists, forearms, toes, feet and ankles feel like they have been soaked in ice cold water in perpetuity.  I have arthritis like symptoms, but do not have arthritis. My muscles are not the same.  My muscles fatigue quickly and hurt and ache after physical use.  I have sharp muscle pains that happen all over my body that come and go, but have persistent muscle and joint pain.  Additional information for Item 19: Pts wife calling to request more referrals from agent for Rheumatology and Neurology. All 4 referrals to facility will require OUT OF NETWORK authorization from Coordinated Care.   Explained to wife that at this time 0 of the referrals have that authorization at this time. Referrals have been marked as "authorized - no auth needed" most likely on the basis that referral was to in network facility which is incorrect.   Also explained that getting OON auth is going to take time and that referrals to facility may be more appropriate due to timeliness of appts. She would like agent's opinion on this matter - whether or not to stick it out with facility in the hope auth is obtained or switch to more certain facility. She feels if the switch to facility is made, keeping the Infectious Disease referral with facility is most important as they have already started consulting on pts case.   Pts first appt with any of the specialists is not until 6/30/21.   Will update referral coordinators on need for OON auth.      Agent at 06/10/21 0835 Was in ER all day at facility yesterday, after calling friend at facility they received guidance that ID department at facility is the best- they want to go there. His wife was gravely upset, reported to me that facility told her he would need a PA to see them- referral has not even been placed yet to facility.   Wife reports he has been feeling worse, at facility he had blood in his urine, which is new. Elevated creatinine was a little lower than usual. I reminded her I've referred him to Nephrology at facility and it is authorized, she requested I transfer it to facility so I did, and marked it as urgent (including the facility referral to ID), as he is feeling worse.   Guillain Barre r/o at facility ER.   Wife very upset, wants answer right now. Tried to reset expectations, that he is currently not in distress, and I do not know that he needs a PA, the ID referral has yet to be rejected as the facility ID referral was only sent by myself 5 minutes ago, he may or may not need one, based on how insurance makes the decision. Wife v/u   Advised her I do not know how fast he will be seen, once he is approved.    Encouraged her to schedule with Nephrology when they can, and get the venous ultrasound I ordered for him days ago.  Apparently he had called to schedule but was told he would hear back. Provided her with numbers of multiple locations.   Assured wife she has done all that she can do at this time.  She thanked me for the call.    CMA at 06/10/21 0835 Agent signed referral, I faxed to facility, sending high priority to referrals pool. CMA t 06/10/21 0824 Wife calling. They need urgent prior authorization to see facility Infectious Disease "in the next five minutes."   Pt was in hospital yesterday and last week.   Facility ER put in referral but pt was told they need PA from PCP office.   Phone number hoping to hear back STAT.  I let them know we likely would not be able to get PA in the next five minutes but would work on this as quickly as possible.   Please review and sign if you agree. MA please fax pending referral and route high priority to referrals pool and call pt/wife to update them.  Additional information for Item 23: