Age: 33.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Antibody test negative, Antinuclear antibody positive, Back pain, Blood cholesterol normal, Blood test abnormal
Clinical narrative: Hand tremors, involuntary movements, high blood pressure (hypertension), fatigue, muscle soreness & pain, muscle pain, memory issues and trouble processing thoughts and events     Patient went to alternate location at the beginning of August 2022 and his CPAP machine broke on the flight. We were unable to get another CPAP machine for 3 weeks and Patient was very tired. A week before receiving the Pzier vaccine, his hands began to shake (essential tremors). He left the home country September 8, 2022 and came to alternate location.  9/19/2022 - Doctor Visit with GP. His blood pressure was 140/95 and she prescribed Vitamin B for 15 days, 100mg of Aspiring every 24 hours and Lozartan 50  mg every 12 hours.  Blood Pressure Measurements  Date Time BP 9/20 12:05 pm 163/111 9/21 9:30 am 12:40 pm 190/103 140/100 9/22 8:00 am 150/100    9/20/2022 - Blood work studies - Hematic Biometry, Blood Chemistry, TSH 9/23/2022 - Doctor Visit with GP. BP was 140/90 and she prescribed Amlodipino 5 mg every 24 hours and Lozartan 50 mg every 24 hours. 9/27/2022 - Neurologist visit with Dr. and he stopped teh Amlodipino and prescribed Patient take Lozartan 50mg every 12 hours, Metoprolol 100mg ½ tablet every 12 hours and Akineton 2 mg ½ tablet every 8 hours. Diagnosed with hypertension and essential tremors.  Patient started feeling very tired, his blood pressure stabilized (came down), started having pain in his arm and leg muscles and involuntary movements in the shoulders and head. He would get a headache whenever he was tired. He started having trouble processing thoughts and was slower in understanding information.  9/30/2022 - CT Scan of his head. Results: Normal with some signs of sinusitis 10/11/2022 - Neurologist visit with Dr.; no changes made 10/12/2022 - Doctor Visit with GP Dr. and she prescribed Patient take Rosuvastatina 10 mg every 24 hours; Metoprolol 100mg ½ tablet every 12 hours; Vitamin B (Tribedoce) 1 every 24 hours at breakfast, and Omeprozol 20 mg every 24 hours for 7 days. Patient didn?t take the Omeprozol. Patient changed his diet to eating more vegetarian with Salmon twice a week. Started taking an Omega 3 supplement of 1400mg every 24 hours. Stopped eating chicken and red meats daily and only eats them once a week or every other week. Stopped taking Akineton since it didn?t help with his blood pressure. 10/28/2022 - Ecocardiograph with Cardiologist Dr.  11/8/2022 - Neurologist visit with Dr.; no changes made 11/11/2022 - Lyme?s disease blood study; negative results delivered 11/17/2022 11/23/2022 - Doctor visit with GP Dr. BP was 136/95 and she prescribed Lozartan 50 mg every 24 hours. Noted more weakness in his right hand. Recommended we see a specialist. 11/30/2022 - Visit with Internist Dr. he prescribed Lozartan 50mg 1 every 12 hours and Metoprolol 100g ½ tablet every 24 hours; probably an autoimmune disease; see neurologist 12/5/2022 - Thyroid profile, Muscle enzimes, Lipid profile 12/6/2022 - Dr. said to stop taking Rosvastatina bc cholesterol levels were normal 12/10/2022 - Electromyography with rehabilitation practitioner 12/23/2022 - Neurologist visit with Dr., noticed patient's reflexes are slower; no signs of Parkinsons; probably Polyradiculoneuropathy post-vaccine; ordered electromyography to be performed by Neurophysicst  New Symptom: Back pain near lungs; needs to stop and take deep breaths occasionally; snoring during sleeping with CPAP  12/30/2022 - Electromyography; came back clean - no signs of any polyneuropathy 1/13/2022 - Neurologist visit with Dr., recommends Lumbar Puncture; Brain Activity test and diagnosis is probably Long Covid post vaccine Mentioned we've eliminated all common diseases Patient could have and wants to find the source of the essential tremors.  Recommended we see a Pneumologist for breathing problems.  Patient currently takes Metaprolol 50mg every 12 hours, Lozartan 50 mg every 12 hours, and Omega 3 once daily and one multivitamin/day.  1/28/2023 - Pneumologist Vist with Dr. Cough & Breathing issues are from allergies and sinus inflammation; suspects inflammatory polyneuropathy; blood pressure was 140/95 Prescribed:  Cough:  Smbicort 160/4.5 Micrograms 1 puff morning and night until cough goes away Allergies & Sinus Inflammation: Montelukast 10 miligrams 1 tablet at night for 1 month Salt Water Nasal Spray - 1 Spray in each side 3 times a day for 10 days Nasal Spray - 1 spray in each side morning and night for 15 days Gastritis (bc of Polyneuropathy treatment) Pantoprazol tablet 40 miligrams - 1 tablet before breakfast for 1 month Blood Pressure: Metoprolol 100 miligrams ½ tablet morning and night Lozartan 50 miligrams 1 tablet morning and night Amlodipino 5 mg 1 tablet in the morning Polyneuropathy: Pregabalina 75 mg - 1 tablet at 8 pm Nucleo CMP Forte Tablets - 1 tablet morning, afternoon and night Prednisone Tablet 20 mgs  A. 3 tablets together daily for 7 days   B. 2 tablets together daily for 7 days   C. 1 tablet daily for 7 days Memantina Tablet 10 mgs ½ tablet at night for 5 days, then 1 tablet at night ongoing  3/8/2023 - Bloodwork for autoimmune diseases shows ANA positive; all other antibodies negative  2/28/2023 - Neurologist visit with Dr.  Patient's symptoms are not neurological. Referred to rheumotologist. Stopped Nucleo CMP and Memantina 3/31/2023 - Rhemotologist Dr., Patient doesn't have any signs in his tests of an autoimmune disease apart from ANA positive blood work. Believes symptoms were caused by vaccine and will start treatment for one month.  Continue blood pressure medicine. Deflazacort 30 mgs tablets - one a day for one month Biprofenid 150mgs tablets - take one daily as need for muscle pain Depo Medrolamp 40mgs - apply one injection daily for 2 days