Age: 69.0
Sex: M
Vaccine: COVID19
Symptoms: Exercise tolerance decreased, Fatigue, Feeling abnormal, Feeling cold, Gait disturbance
Clinical narrative: He got his vaccine, at first he felt weak and tired, and felt like he had a headache, he did not feel himself.  He felt chilled, had some decreased appetite.  The next day he felt the same, and then he started getting like he had a sorer throat, did not feel like eating, and then started coughing.  Then he started coughing in the morning and night, and he has never had a coughing problem, and never got COVID itself.  He is an asthmatic and so he tries not to cough.  His really GP retired and has been seeing an herbalist.  Within a week or so on his right rear hip he had a knot, he kept palpating it and about the size of a 1/2 ping pong ball deep in the muscle.  Then he had one in his thigh, down his knee and on the back.  he then noticed 7 in the right leg over the next 3-4 days, and then he satrted seeing a couple on the left.  The ones on the right kept growing.  he saw the herbalist who gave him some massage oils, and to get coconut oil and told him to have myofascial massage.  He kept trying to get all these differnt type of things.  His back then started to hurt about a month after the vaccine.  Then he felt it was just a little stiffness, and asked if he wanted therapy and seemed to get better and does landscape stuff and aggravated his back more and went to therapy.  He still had teh cough and still the things growing in his legs.  The girl at the PT felt that it was a form of muscle area, and did exercises and he informed her that his leg was painful and she gave him exercises over the weekend and it was hard for him to do.  He saw her on Friday and then on Tuesday and he told her that he felt he was getting worse and hurting more.  She had him push against his hand and the inside of his right thigh felt like somebody inside pushing against his legs.  That day she tried to do some massage things and he informed him that it hurt and lifted his legs and it felt like she was breaking his back.  She made the break worse and told him to go to get an MRI of his back and the status of his legs have to be resolved until they could do anything about his back.  He went to the MRI place to get an MRI and due to it being December and was able to get a cancellation appointment and had wait to get his leg scanned and it will be in 2 weeks from today, 12/15/23.  He then went to the orthopedist and told him that his back was broken, and told him that he had seen his herbalist and told him that it was not minor and not just muscle.  He then gave him a brace and told him that he might have blood clots.  The next day he went to the ER and had him behind a curtain and went through 2 shifts of people and delayed treating him.  He has a fracture at L3, and told him to come back if his leg swelled back up and then did not go back.  He did saw an Dermatologist and he told him to get a PCP, which he say yesterday.  They tried to get his records straight but dermatologist told him to take prednisone and was told not to ice his legs, but told him if he ices it then he can walk on it some.    They gave him Ancef, and was going to send him home with a new antibiotic as they felt it was not an infection, and they feel that he has an underlying infection with cellulitis and more blood tests which are delayed between 7-30 days.  Dermatologist did a biopsy and had to stitch it close, and his leg is swollen.  He was given Cephalexin and then took Ibuprofen which did not help him at all .  Was able to sleep as he is so exhausted.  The leg pain is off the chart.  He wears the brace every time he can, but he cannot elevate his legs with the brace on.   The cough has gotten better, and he is allergic to licorice.  Every time he straightens his legs he has excruciating pain to try and get it comfortable.  They still cannot find out what is going on.  He was a runner and running 4 miles or on a machine, and very active and very healthy prior to the vaccine, and now his quality of life is not good, cannot walk without a cane, and hard to get around.   It is also impossible to sleep through the night and cannot sleep at least an hour, he cannot eat as his pain level if 9/10 due to the nausea from the pain.  He lives alone and he has to go up 4 steps to get into the house and it's impossible for him to function.  He can only drink spring water and cannot carry a gallon of it, and used to go and get the water himself at the spring.  With the aortic dissection if he can eat, nourished and rest then he is OK, but he is not able to do that and he has dizziness and exhausted.  He feels he has to get to the bottom of this and see what is going on and how it can be treated.