Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Dizziness, Feeling abnormal, Joint stiffness, Laboratory test
Clinical narrative: HPI: 44 year old  female here for initial evaluation for possible Lyme disease.    She had the covid vaccine 4/1/21 and the second shot on 4/23/21 the Pfiser shot.   She did sign up for the VAERS reports and did do some reports with that.    She has been having  weird symptoms after getting the vaccine over 2 months ago. She started with right side hip pain 1 week after the first vaccine- the right hip, which hasn?t fully resolved. She noticed her knee joints being a little more stiff as well for a couple of weeks in late June, they are improved now. Then around July first her fingers were achy in the mornings as well as her feet at times. She has had enlarged lymph nodes in her groin. An ultrasound to check that  in early July  looked benign.   She also has had had foggy brain/ frequent eye floaters and some dizziness first thing in the am. She had labs drawn to check for Lyme etc and her Rocky Mountain spotted fever came back positive. It was positive 2 years ago and was treated with 3 weeks doxycycline and then 3 months of herbs.   The floaters have seemed to calm down somewhat over the last month.   The doctor never rechecked the RMSF as primary dr said she would need to go to infectious disease dr to recheck per insurance regulations. She never had any symptoms like this in 2019.   She was treated with doxycycline in 2019 for 3 weeks as well as some herbal tick support.   She has mild tinnitus- nothing new since the vaccine.   She did start taking some liposomal glutathione from pure encapsulations one a day about a month ago and she seems to be improving.   In 2019 she had some knee stiffness and soreness. Friends who were with them on the 4th of July became ill with Lyme and RMSF.    She was not sick, just got tested as her friends were ill. She did not have a herxheimer reaction to the doxycycline.     She grew up in the  mountains in . They did have indoor and outdoor cats, some of them feral and some flea issues where they had to bomb the house.    She has never found a tick on her. No history of rash. No unexplained fever in the summer. No cat scratch that made her ill, but did have her fair share of scratches.    She has been healthy her whole life. Age 12 she had a sarcoma on her L hand. She had skin graft from her groin initially. Then she had injections later to stretch the skin to help the scarring. No chemo or radiation.   Family history: M age 75 with DM, CHF, mini strokes, she smoked , D age 79 with CAD, CHF, chol, HTN(he was a smoker) They both stopped after she sarcoma.    Past Medical History/Past Surgical History/Allergies/Medications/Family History/Social History:   Review of Systems:The patient's initial history form including a 14 point review of systems is reviewed with the patient and the ROS  is negative EXCEPT:always sun sensitive- light colored eyes. mild tinnitus not new. some numbness and tingling first 3 fingers while driving, not when sleeping. Mild anxiety. Cold extremities exp in winter. Occasional lightheadedness on standing.  Just the increased joint pain after the vaccine. Sometimes hard to get up in the ams.  .  Women: Age of first menses 11,  age of menopause No yet, no abnormal vaginal bleeding, no  yeast infections, no abnormal discharge, no fertility problems                Menses: Interval30-35 days, duration4-8 days,  regular yes,                 Premenstrual symptoms: no emotional changes,  no fluid retention, no breast tenderness .  Pregnancy/complications: G2P2. 7/16/08 and 4/12/06    Objective  Edit GENERAL: In no acute distress, well developed well nourished, appears stated age SKIN: normal color, moisture, pigmentation, nails, hair. No ecchymosis, no rashes, no lesions hemangioma R temple area about 1 cm EYES: PERRLA, normal conjunctiva, normal sclera, no nystagmus, no lid lag, no exophthalmos, no ptosis.EARS: normal tympanic membranes, normal external canals, no discharge NOSE: normal airways, normal mucosa, normal septum MOUTH: normal lips, normal teeth, normal gums, normal tongue THROAT: normal tonsils, normal pharynx,  without visible post nasal drainage. NECK: supple, no masses, thyroid normal size without masses or tenderness NODES: no occipital, cervical, or submandibular nodes BREASTS: not examined LUNGS: clear to auscultation, full and equal breath sounds, no wheezing or rales (even with forced expiration) HEART: regular rate and rhythm without murmurs or extra sounds, extremities are without edema ABDOMEN: soft, non-tender, normal bowel sounds, no hepatic or splenic enlargement apparent,  no guarding, no rebound, no masses GENITAL/RECTAL: not examined BONES/JOINTS/MUSCLES: fingers, hands, wrists, elbows, shoulders all non-tender without swelling or deformity. Normal range of motion of hips and knees without swelling deformity or tenderness. Normal ankles without swelling or tenderness. No bunions or pes planus NEUROLOGIC: alert and oriented to person, place, and time. Cranial nerves II-XII grossly intact, normal patellar and brachial deep tendon reflexes bilaterally, normal gait.     Assessment :  Probable post- vaccine inflammatory syndrome- mild    Go to Generic lovasa Rx fish oil 2 twice a day with meals. do that for 2 months then go back to the krill oil Increase the liposomal glutathione to 2 once a day for 2 months  Go on melatonin 2-10 mg at bedtime for 2 months  Continue the vitamin C and D you are taking  If not well with that could consider course of ivermectin 3mg 4 tabs daily for 10 days.  Could do a course of steroids as per the protocol if not calming down