Age: 26.0
Sex: M
Vaccine: COVID19
Symptoms: Tenderness, Troponin normal, Urine analysis, White blood cell count normal
Clinical narrative: 23-Jul-2021: Vaccine administered on upper left arm at 3:00 PM. No allergic reaction. At around 4-6 pm, I felt some sort of mild temperature sensation in the forearms, especially on the left arm. Sensations went away after urinating. At 11:00 PM, I went to bed and shortly after started to have a low-grade fever (100.4 F) accompanied with elevated heart rate (110-120 bpm), headache, and body aches with emphasis at certain locations throughout the night: legs, chest, upper abdominal, arms, lower back. I was able to get up and move around as needed. Took 500 mg Tylenol and lots of water. At 5:00 AM, I walked over to my neighbors apartment and spent the night there in case of any emergency. I hardly slept that night due to the pain. 24-Jul-2021: Symptoms persisted overnight into the next morning, but fever had lessened slightly to about 99.9 F. I became concerned when I still was feeling a high heart rate accompanied with aches near my chest. At 8:30 AM, I went to an outpatient emergency care to checked for any serious issues. Staff performed urinalysis, EKG, blood work w/ a focus on troponin levels, and PCR COVID-19 test, and provided IV saline solution and 650 mg Tylenol. Results came back normal besides an elevated level of neutrophils due to immune response. PCR COVID-19 test showed NEGATIVE. During my visit, aches were lessening, especially the chest/upper abdominal aches. I was discharged at around 2:00 PM and proceeded to get food. Later that night, I experienced dull pain and discomfort in my head and arms and my hands were cold indicating an immune response. I took 200 mg Advil to help alleviate symptoms, but it was an ineffective low-dose. Symptoms subsided sometime in a few hours, but I hardly slept that night too. 25-Jul-2021: Continued to take 500 mg Tylenol and plenty of fluids. Immune response continued to persist at the evening/night time and then eventually subside. Felt nausea and loss of appetite. 26-Jul-2021: Visited urgent care at 7:00 AM and described symptoms to PA. PA checked vitals, which showed normal, and stated that it sounded like a normal vaccine reaction. I later visited a primary care doctor at 4:00 PM. He saw vitals were normal and asked if my symptoms were worsening. I stated that I felt they were slightly getting better, and the doctor noted everything as a normal vaccine reaction. In the evening/nighttime I experienced an immune response again with difficulty in eating. 27-Jul-2021 ? 3-Aug-2021: Difficulties in eating and triggered immune responses persisted. I started taking 30 mg Zinc, 1000 mg Vitamin C, and 5000 IU Vitamin D3 since 7/30/2021. Severity of immune response symptoms are lessening over time and becoming less frequent. Sleep is gradually improving. 4-Aug-2021: Experienced immune response, especially with tender and warm aches in the upper abdominal sometime after consuming a milkshake in the evening. Upper abdominal aches and pain persisted throughout the night with some heartburn. Took Tums which provided mild relief. 5-Aug-2021: Strong loss of appetite resulting in very minimal food consumption with long periods of fasting. Visited primary care doctor and had blood work completed (CBC, WBC, ESR, CRP, and EFGR). Blood work showed normal results with the exception of slightly elevated monocytes and slightly lowered lymphocytes outside of respective reference range. 6-Aug-2021: Visited gastrointestinal (GI) doctor and described symptoms. GI doctor palpated abdominal area, which elicited only discomfort and not pain. He prescribed 40 mg Pepcid. He ordered CT scan of abdominal/pelvic at my request. CT scan was performed with barium solution and IV contrast (Isovue-370, 80.00 cc). CT results showed no significant abnormalities detected. Noticed a slight increase in appetite and lessened severity in immune response. 8-Aug-2021-9-Aug-2021: Slight appetite continued, but small meals were consumed. Mild chest tightness occurred during the evening, especially after moving around at a quickened pace. Diastolic blood pressure was elevated after movement (85-95), but subsided to normal ranges (75-80) when achieving rest. Breathing felt mostly normal. Mostly felt tired and some sort of slight heaviness in the chest. Started taking 40 mg Pepcid. 10-Aug-2021-11-Aug-2021: Mild fatigue and aches in the upper abdominal and chest during the morning. No difficulties in working and moving equipment in hot temperatures. Felt more fatigue and muscle aches the next day. 16-Aug-2021-20-Aug-2021: Took methylprednisolone (4 mg dose pack) 24 mg on first day and had painful hot flashes overnight, primarily on the upper body. Discontinued medication, but still experienced burning nerve pain that diminished with time. 23-Aug-2021-24-Aug-2021: Noticeable return in appetite. Felt like I was back to my usual health prior to vaccination. Experienced heart palpitations with periods of bradycardia (35-40 BPM RHR) mostly in the evening; however, likely related to Sertraline (Zoloft) 25mg that I started on 20-Aug-2021. Visited outpatient emergency care at doctor's recommendation. Outpatient emergency care performed EKG, heart monitor, orthostatic blood pressure checks, and blood work with a focus on troponin. Results came back normal.  25-Aug-2021: Visited primary care doctor and had EKG performed. EKG displayed occasional PAC, but considered benign and asymptomatic. 30-Aug-2021: Fully recovered from any vaccine side effects.