Age: 77.0
Sex: M
Vaccine: COVID19
Symptoms: Lymphocyte count decreased, Lymphocyte percentage decreased, Mean cell haemoglobin concentration decreased, Mean cell haemoglobin decreased, Metabolic function test normal
Clinical narrative: Narrative: 02/09 COVID vaccine dose #! 02/16 pt sends secure msg: On December 18, 2020, I was given a steroid shot in the left shoulder for possible tendonitis. I was told if it did not get any better to have an MRI done. Since then I have developed pain in the right shoulder, both knees, both upper legs and hips. I am taking tylenol to help relieve the pain so I could sleep. I am also using a heating pad on the joints to relieve the pain.: 03/01 pt calls RN and reports for the past three weeks he has had bilateral knee pain that shoots up from the knees up to the hips. patient did not fall. He also has pain in his shoulder and arms. Patient also got the shot three weeks ago. Referred to xray. 03/02 Covid vaccine dose #2 03/16 pt sends secure msg stating "The pain in the joints is not getting better. My legs have swell up and I am having trouble getting in an out of bed and chairs. I am unable to bend over." 0/19 pt seen by PCP w/ c/o "aching pain on entire body except for both hands and below both knees...developed about 3 month ago." Treated with methylprednisolone IM, given rx for methocarbamol and prednisone 03/26 pt sends secure msg stating "You gave me two injections and prescription for two medications. The pain disappeared for four days. It is now back with as much pain as before. I am still taking methocarbamol three time a day." Provider prescribes topiramate. 04/09 pt went to ED due to 10/10 pain, was "only able to walk with a walker b/c of pain and weakness," admitted to non clinic hospital x 1 day, diagnosed with rheumatoid arthritis; hospitalist believes COVID vaccine triggered his immune system and triggered rheumatoid arthritis; rx'd prednisone 04/23 pt sends secure msg stating "I took my last prednisone on Wednesday night. since then pain in my joints has been slowly returning. Pain starts at knees and goes up through hips, back, shoulder, neck, and arms. I am taking all medication as prescribed." PCP prescribes diclofenac gel and recommends to take tylenol 05/07 pt sends secure msg "i am still having joint pain," only medication that relieved pain is prednisone. 05/17 PCP prescribes prednisone 05/19 pt reports to RN" He states that he has pain from his knees up. He reports that the pain is constant and he already had left knee x- rays done by doctor at ortho and he told him that nothing is wrong with his knee. He states that the pain is "constant", he cannot sleep or get comfortable. He states that the pain at his joints started after he took the second COVID shot. He states that the pain was actually already present but got worse after the shot. When asked what makes the pain better, he states the prednisone takes most of the pain away. He states when he was in non-clinic hospital, they suspected an autoimmune problem and recommended he see a rheumatologist. He reports that his hands have been swollen since last week and he has pain at his hip and back with difficulty walking." 06/04 pt reports to RN "at 1am on the morning, the meds run out and pain returns to both hands and knees, pain level 4/10, when i take medicine at 8am, it doesn't work until noon;" PCP increases topiramate to 50mg qhs 12/17 pt reports he "no longer has generalized pain, swelling, and myalgia that occurred within 24 hours after receiving the 2nd dose of COVID vaccine;" OCO discontinues topiramate, prednisone, and diclofenac gel