Age: 43.0
Sex: M
Vaccine: COVID19
Symptoms: Abnormal loss of weight, Asthenia, Chills, Decreased appetite, Disturbance in attention
Clinical narrative: Here are the facts of the case:   Friday, August 13, 2021: patient receives Moderna COVID Vaccine. Saturday, August 14th, 2021@1:00 AM: patient wakes up with fever, chills, body aches, nausea, and vomitting - Symptoms continue throughout the weekend. O2 sats drop to 92, lethargy and lack of appetite begin and continue through Sunday. Monday, August 16th, 2021: patient wakes up feeling a bit better and goes to work with only a headache, muscle soreness, and lethargy. Wednesday, August 18th, 2021: patient notices that the lymph nodes in his neck start to swell abnormally, complains of sore throat. Thursday, August 19th, 2021: Lymph node swelling continues, sore throat worsens, ear pain starts to become present. Leaves work at 11:00AM Friday, August 20th, 2021: All symptoms worsen, patient is unable to go to work. He works from home but is finding it increasingly hard to focus because of the pain. Takes Ibuprofen, Alieve D, and OTC ear pain drops. Patient finds it increasingly hard to consume solid food.  Saturday, August 21, 2021: All symptoms continue to worsen. Patient stops eating and tries to sleep it off. Sunday, August 22nd, 2021: Patient drives himself to Urgent Care. Doctor prescribes OTC ear drops, Tylenol, and Augmentin.  Monday, August 23rd, 2021: Patient's pain continues to worsen, but knows that medicine takes time to work. He remains at home. Tuesday, August 24th, 2021: Patient's pain in ear is unbearable. Symptoms of the previous weekend: Nausea, fever, body aches, chills, lethargy, throat pain are consistently worse. He is now on a fully liquid diet. He has a video calls with our GP, who says to continue the course of treatment that the Urgent Care has prescribed.  Wednesday, August 25th, 2021: Patient wakes up to a ?cauliflower ear? (something akin to fighting) and realizes that something is really wrong. Our doctor told him to call if he got worse, so he called to no response. At 3:00 PM his wife, drives him to the doctors office on the off chance he will see him in person. He sees him, gives him a shot of Toradol for the pain and adds to the medicine that the Urgent Care has prescribed. He adds Bactrim, and Ciprofloxin ear drops with Dextamethazone. Patient starts the treatment. Thursday, August 26th, 2021: Swelling is worse, pain is worse, fever is worse, but patient continues the treatment. After consulting a doctor, he also starts a Medrol pack that we have in the cabinet to see if a course of full-body steroids don?t help with the swelling and pain as well. Patient reports tingling on the right side of his face and neck. Friday, August 27th, 2021: Patient's spirits are up even though symptoms remain the same. The swelling starts to recede on Friday afternoon and patient feels well enough to try and venture out of the house. His energy level is extremely low because he is still on a liquid only diet, and he can only make it about 30 min outside of the house. Saturday, August 28th, 2021: The swelling in the ear has almost completely receded and leaves behind red skin and white bumps. He is continuing on all medications religiously. He still isn?t eating and continues to sleep most of the day. Moaning in pain during sleep. At this point, he has lost 15lbs? All symptoms continue to worsen or stay the same through...  Tuesday, August 31st: At this point, patient has lost 22lbs and calls his doctor and his doctor directs him to ER. He calls ahead and gives instructions to admit him and give him pain meds (Morphine) and Unasyn (a very strong antibiotic) Orders bloodwork and CT scan.  2PM - patient arrives at the ER and checks in.  3:30PM - patient sees first ER doctor: she finds two perforations in his right ear. 5:30 PM - Nurse comes to draw blood, punctures left vein, draws blood from the right.  8:00 PM - The nurse inserts IV port to start fluids, and infiltrates his right arm (I have pics, but I?ll spare you). He almost passes out from the experience and gets chills after the IV was put into the other arm. Once hooked up to the fluids, he heads back to his chair in the hallway of the ER. 8:30 PM - Gets taken back to have a CT scan. 9:40 PM - Ear pain significantly worse and throat pain equally persistent 10:00 PM - CT results come back normal. Plan is still to get him taken back to start the antibiotics when there is a gurney available. Wednesday, September 1st:   2:30 AM - A place for him on a gurney in the hallway of the ER is found. He is able to lay down. 6:30 AM - Sees next ER doctor who starts Unasyn and offers Morphine. Patient starts the antibiotic by tries to avoid the morphine because it makes him itch. This doctor says the ear drum is a concern. The doctor says he is working on getting an ENT in the hospital to take him on, if not, they will refer him out. 7:00 AM - Bloodwork and labs have not come back yet. 9:30 AM - Patient first sees the doctor. Patient is starting to get frustrated because this is the 4th ER doctor he has seen. The doctor comes and asks all of the same questions the other doctor has and says, ?I do not see a reason to keep you here. You should probably try to see and ENT.? Patient has to walk him through the last week and a half and explain why he is there. After patient explains, the doctor says ?OK, well, we will keep you on these meds and see if it starts to help.? The doctor comes back and says there are no ENTs in the hospital to see him.  12:30 PM - Still no bloodwork back, the doctor calls to tell the hospital that he wants patient admitted for 3-7 Days, kept on the Unasyn and given pain meds as needed. The antibiotic is starting to work, patient is starting to enjoy jell and pudding.  3:30 PM - Ear pain is worse, patient finally asks for pain meds. 9:30 PM - Patient is finally given Dilaudid. Pain meds work within 20 min, providing relief and sleep for the first time in days.  Thursday, September 2nd: 7:00 AM - Patient's report is positive. He was finally able to sleep some and the pain meds are helping provide relief. The pressure in his ear sees to have lessened, but the throat pain remains consistent. Over night a new symptom seems to have emerged, tingling and aching at the base of his skull. Possibly muscle pain from the experience. Nurses tell him they are just monitoring him and waiting for him to take a turn.  8:00 AM - There is a shift change at the hospital. Patient eats his liquid diet and seems to be moving around more. He is finally feeling a little better. 9:30 AM - Patient has a second conversation with the doctor. He tells the patient that he is ready to go home, he says that he is giving him a spray for his throat and something to keep clearing up his ear. patient tries to explain that this course of action goes against what our primary care physician has set and the doctor doesn?t care. He is the same as before: short, cold, and corse. The doctor explains that he can?t see perforations on his ear drum, that he has an ulcer on his uvula and laryngitis that seems to be clearing up.  10:40 AM - Arguing with the doctor and trying to convince him to keep treating the patient with the antibiotics and pain meds he is on is getting exhausting. The Nurses and PA at the time talk with the patient and they agree with both doctors. They decided to try a hybrid. 11:00 AM - Patient eats an applesauce, pudding, one graham cracker and 4 saltines and a bit of a turkey sandwich - AFTER they spray his throat with Lidocaine as directed by the doctor.  12:30 PM- The charge nurse tells him he gets to go home, they bring him discharge papers and he is instructed to leave.  1:00 PM - Patient has walked from the ER to the center where his wife picks him up.  The discharge instructions are as follows: Tylenol as needed, pseudoephedrine as needed, ciprofloxin with hydrocortisone bid. (This    discontinues patient's treatment of antibiotic and pain medication.) -The doctor also prescribes benzocaine nasal spray for the throat. Patient never sees the doctor after 9:30 AM. In total, he saw him for about 15 min. In that time, this doctor has ignored the patient's concerns, disregarded his GP?s instructions, and overridden his care. He has also falsified patient improvement by first numbing his throat before he ate so that he could write on the chart that he ate. All of this is extremely disheartening, unprofessional, and negligent to the Hippocratic oath that he has sworn.  7:00 PM - All of the drugs that patient had in the ER have worn off and the infection symptoms and pain come back with a vengeance. We continue on the drops prescribed, because they are stronger than the ones the doctor prescribed and take OTC pain medication. Patient is glad to be home, but still unable to eat more than 2 solid bites of food and continues on the liquid diet.  He sleeps well in his own bed after taking a shower. Friday, September 3rd:  8:30 AM - Patient wakes up with completely plugged ear and painful sharp pressure. The throat pain is exactly the same. He is feeling worse than he was in the hospital (which is to be expected because they took him off the right antibiotic and pain treatment!) 9:00 AM - Patient is able to get an appointment with an ENT on 9/9/21 at 2:20PM at ENT.  We continue to use the ear drops prescribed.  We sought help elsewhere and started Tylenol with Codeine and Cipro to try and continue (to a small degree) what was started in the hospital.