Age: 43.0
Sex: M
Vaccine: COVID19
Symptoms: Laboratory test abnormal, Magnetic resonance imaging head normal, Malaise, Metabolic function test normal, Mitral valve incompetence
Clinical narrative: Began having vague symptoms of not feeling like himself 5 days after vaccine administration in early part of afternoon. Later in the afternoon he felt dizzy and nauseated like he was going to pass out, In the evening, he began having R arm numbness which prompted him to go to an Urgent Care. Urgent Care did EKG which showed abnormal, sent him to ER. He presented to the ER that night with complaints of R arm tingling and numbness associated with lightheadedness, sweating and nausea. Preliminary tests in ER showed 50-69% stenosis of proximal R extracranial internal carotid artery with soft tissue plaque formation and calcifications. He was then admitted for further testing and management. Neurology, Cardiology and Vascular Surgery was consulted. Ultimately, was given dx of TIA, unknown etiology. However, was advised it was more a diagnosis by elimination and no definitive proof of TIA. Other than R carotid stenosis, no significant findings with imaging or labs. Ultimately, he was given no explanation/medical reason for cause of symptoms. Recommended to follow-up with PCP in 2-3 days and with Vascular Surgeon in 3 months. Once discharged, he expressed to me (spouse) that he still was not feeling quite right, tired and nauseated. He followed up with PCP 3 days after discharge (3/21/22). Daily aspirin recommended, advised to f/u with specialists as directed by ER. I was not there at follow-up visit, but patient stated to me that his PCP did not order any additional testing or recommend anything in particular, was only with doctor for a few minutes. Medical records show labs were to be rechecked but no results in records that were provided to me. He then followed up with PCP via telemed 4 days later (3/25/2022), symptoms somewhat improved at that time. Patient stated to me that he did not feel well for about 6 weeks after initial sx started on day he presented to ER. Sometime at end of April, he stated he was feeling like his normal self again. Was planning to follow up with Vascular Surgeon in June as advised by ER. On 6/7/22, he began to have flu-like symptoms: fatigue, slight congestion. Our daughter had been sick with viral illness few days prior, she tested negative for Covid during illness, was not tested for Influenza or any other viral panel done. We assumed his symptoms were from same viral illness that our 3 year old daughter had just recovered from. On 6/8/22, he worked his regular work day (8am-5pm) but stated he did still feel that he was coming down with something and was tired. He ate a normal dinner but afterwards stated it made him nauseated. He also stated prior to going to bed for the evening at 10pm that the "body aches are starting to kick in." He had mild congestion and sniffles but no shortness of breath or cough. I then found him sitting on the toilet, unresponsive and with no pulse at 6am. 911 was called and I performed CPR until medics arrived. Medics continued CPR during transport to hospital and resuscitation efforts, including intubation, were performed for in the ER before pronouncing him deceased officially. The PCP was contacted by authorities to make death notification and PCP signed off on death certificate listing diagnoses from hospital admission: TIA, hyperlipidemia, carotid stenosis. We then had private autopsy performed which listed ARDS, viral syndrome, septic shock as cause of death. He tested negative for COVID in the hospital. Our son also had viral symptoms the day after (6/10/22) and also tested negative for COVID.