Age: 65.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Anion gap, Anti-Jo-1 antibody, Anti-PM/Scl antibody, Anti-cyclic citrullinated peptide antibody negative, Anti-thyroid antibody
Clinical narrative: Proof that there were no autoimmune problems before pandemic details contin pg 2/7/1984 Normal autoimmune: Complement C3 139, and Titer 1:140. 7/12-8/1/93 Normal autoimmune: ANA, RA Factor, and HLAB. 2001 PCP 11/7/2001 Normal autoimmune: ANA negative 1:180f and RA (negative) Factor 20. 5/31&8/30/2002 Normal autoimmune: ANA test. Before 2020 (started insurance) Rheumatologist was my ongoing Arthritis Specialist.  10/23/2020 Initial insurance Intake Appointment PCP Vit D 25Hydroxy 23 0 abnormal Cardiac - Cholesterol 295 abnormal, LDL Cholesterol 204 abnormal, NonHDL Chol 222 abnormal Triglyceride 90 normal, Chol/HDL Ratio 4.04 normal, HDL Chol 73 normal. Thyroid Studies - Normal (TSH 1.156). CRC w Autom Differential CBC. Hematology CBC - Normal (WBC 4.8, RBC, 4.63, Hemaglobin 13.4, Hematocrit 42.3, MCV 91.4, MCH 28.9, MCHC 31.7, Platelet Count 250, Mean Pit Volume 10.3, Neut Auto 51.9, Lymph Auto 37.6, Mono Auto 8.2, Eos Auto 1.1, Baso Auto 0.6, RDW 13.0, RDW-SD 43.2, Neutrophil Abs 2.47, Lymphocyte Abs 1.79, Monocyte Abs 0.39, Eosinophil Abs 0.05, Basophil Abs 0.03, Imm Gran Abs 0.03, Imm Gran Auto 0.6, NRBC Abs 0.00, NRBC/100 WBC 0.0). General Chemistries - Normal (Potassium 3.7, Glucose 87, BUN 9, Creatinine 0.70, Sodium 137, Chloride 98, Bicarbonate 28, AGAP 11, Calcium 9.4, AST 17, ALT 12, Alk Phos 59, Albumin 4.6, Total Protein 7.7, Bili Total 0.6, GFR >60 Afr Am & Non Afr Am {above labs dated 10/23/2020}  Pfizer Covid vaccines by Health Dept  2/4/2021 Pfizer EL 9264 2/25/2021 Pfizer EL9266 Adverse events began in 2021 after Covid vaccines.  Raynaud's episodes. And scalp Itch extended with no visible indication 1. Compromised Immune System. 2 Scalp Itch. 3 Raynaud's. 4 Heart/Upper GI. 5 Jerk/Spasms. 6 COVID positive. 7 Foot Cramping.  COMPROMISED IMMUNE SYSTEM SIGNIFICANT ABNORMAL - ANA BY IFA positive A, ANA Titer 1:160. Confirming tests results on 2/14/22, 3/15/22, 3/31/22, 4/13/22, 5/23/22, 11/2022, 7/17/23.  Acute Prolonged Scalp Itch 6/28/2022 onset until [after9/13/22, but before 9/30/22], ie. almost 3 months misery. Extreme 24/7 prolonged Scalp Itch with no visible indications. 9/8/2022 Virtual Med Appt APRN (with Dr.) No visible indication. Whether skin dryness is cause or not, same two suggestions - Selsun Medicated Shampoo (prior since 7/4/22 patient had tried non-Medicated ) & Zyrtec 10mg OTC (Patient had prior tried Allegra/Benadryl). [NOTE 12/13/2022 Rheumatologist Dr. of Clinic suspects extended scalp itch of 2022 was possible flareup of immune system.]  RAYNAUD'S Code I73.00 (without gangrene) 2021 mid October - early December 2021 prolonged onset events 2022 - 2023 Auto-Immune problems confirmed by appointments with rheumatologists & other doctors with lab results on 2/14/22, 3/15/22, 3/31/22, 4/13/22, 5/23/22, 11/2022, 7/17/23, {Detail test results & physician contacts listed later in these continuation VAERS pages.} 4/1/2022 Amlodopine 2.5 prescribed for use as needed. (Rx renewed 10/26/2022) Dates of Raynaud's (with Rx Amlodopine if after March 2022). 2021 mid October - early December 2021 prolonged onset events M5-6am2/8/22(left side), S1am5/8/22, S5/21/22,S6-10am6/12/22, R6/17/22-F10pm6/18/22, Wam8/17/22, W10pm9/14/22, S7am9/24/22, T11pm10/11/22, S7-11pm 10/15/22(right side), M1-2pm10/17/22, T1pm10/18/22, R9pm10/27/22, S6pm10/29/22-S10/30/22, S3-4pm11/5/22, T7-11pm11/8/22, F9-11pm11/11/22--11amS11/12/22, F9pm11/18/22-Spm11/19/22, Fam9-11am11/25/22 S11/26/22, M11pm11/28/22-T3am11/29/22, M12/26/22-M1/9/23prolonged Raynaud, M12pm-12am1/23/23, T6-8am1/24/23, S1-3am1/30/23(right side), W6-11pm2/22/23, Ram2/23/23, S7am-2pm3/11/23, F8am3/17/23, S11pm3/18/23. M10:30am3/20/23, W4pm3/22/23, F3/31/23, S2am4/1/23, Mam5/22/23, R10pm5/25/23-F11am5/26/23, S2-4am5/27/23, M1-2am5/29/23, M10-11am6/12/23, R2-11am6/22/3, S10-11am6/24/23, S5-7pm6/25/23, M8pm7/17/23-T6am7/18/23, W9-11am7/19/23. R8pm7/20/23, M8-11pm7/24/23, T9am7/25/23, W9-11am7/26/23, F11am7/28/23, S1/11am7/29/23, T8pm8/1/23-W1pm8/2/23, T2-3pm8/15/23, W4-5pm 8/23/23, F5-7am8/25/23, S7-11am8/27/23, T9pm8/29/23-W11am8/30/23, S9pm9/2/23-S11am9/3/23, W12am9/6/23, M12am-4pm9/11/23, Tnoon9/12/23, W1-2am9/13/23, R1-11pm9/14/23, M12-7pm9/18/23, R10pm9/21/23-F3am9/22/23. Heart or Upper GI Symptoms {But I do not attribute heart symptoms to vaccine.} The following data is provided because instructions request all incidents since vaccine. It is my non-medical opinion that the heart symptoms 2020-2023 were probably GERD Gastro Esophageal Reflux Disease that was not recognized until April 2023. Although there were heart pains during 2020, heart was deemed healthy according to Cardio Tests done in 2020 before the 2021 vaccine. 10/19/2020 consult and 11/3/2020 Cardio Stress Test and Echo Sonogram by Dr. Dates of heart attack symptoms or left rib pains following the vaccine: M1-6am2/8/21, S1am4/10/21, R5-8pm4/22/21, F4am4/23/21, S7pm5/15/21, F1-3am3/4/22, F9-11pm3/11/22, M9-11pm5/9/22, W9-11pm5/11/22, Tam9/6/22, F12-1am11/4/22, S1/22/23, Mpm1/23/23, T8am 1/24/23, S2/25/23, S3/4/22, S9pm-12am3/18/23, S9pm-12am3/25/23. 4/12/2023 PCP Dr. New Rx Proton Inhibitor Pantoprazole 40 1xD Dates continue of heart pain symptoms: R10:30pm6/1/23-F1am6/2/23, F5-7pm6/2/23, S11-11:30pm8/6/23, S8-9pm8/19/23, M10-11pm8/21/23, T2-3am8/22/23, R2-3am8/24/23, F2-3am8/25/23. 4/27/23 Upper GI Endoscopy and Balloon procedure done by Dr. Dates of Heartburn Symptoms or pills lodged in Esophagus: F11:15-11:45pm4/8/23, S3-3:30am4/10/23, Spm5/14/23, Spm5/21/23, Rpm5/26/23, Sam5/27/23, Mam-pm5/29/23, Tam5/30/23, Wpm5/31/23, Ram-pm6/1/23, S9pm6/3/23-S3am6/4/23, S11am6/4/23-T4am6/6/23, T9pm6/6/23-W3am6/7/23, 6/26/23, W6pm6/7/23-R1am6/8/23, R12-11:45pm6/28/23, F10-11am6/9/23, F8-11pm6/9/23, S11-11:45am6/10/23, S4-7pm6/10/23, S12-11am6/11/23, M12-1pm6/12/23, T2-5am6/13/23, T10-11pm6/13/23. 6/14-7/142023 PCP Dr. Add Rx Sucralfate 1gm 2xDay. Dates continued of heartburn/Esophagus Issues: R1-2am6/14/23, R4-5pm6/14/23, F5pm6/16/23, S10-10:30am6/17/23, S1-2pm6/17/23, S2pm6/18/23, M7-11pm6/19/23, T8-11pm6/20/23, S9-11pm6/24/23, S1pm6/25/23-M2am6/26/23, W12-6am6/28/23, R10-11pm6/29/23, M7-11pm7/17/23, M7-11pm7/24/23, R1am8/3/23, M12:30-1am8/7/23, W1-4am8/9/23, S10-11pm8/19/23. M10-11:30pm8/21/23, T2:30-3:30am8/22/23, R12:30-2:30am8/24/23, M6pm9/11/23, W2am9/13/23, T2;45pm9/19/23. Dates of throat constricting exhales: Mam5/15/23, Tam5/16/23, Wam5/17/23, R5/18/23, Mam5/22/23, Tam5/23/23, S10-10:30am6/17/23, S10-11pm6/24/23, F10am7/21/23, T8pm8/1/23-W1pm8/2/23, 8/10/2023 Rx Approved Renewal; Restart 8/14/2023 Rx Sucralfate 1gm 2xD. Dates continued of throat constricting exhales (especially severe when horizontal): T8-11am8/29/23, F2-9am9/1/23, S1-3pm9/2/23, S10-12pm9/2/23, W3-4am9/13/23, M9-11am9/11/23, S9-11am9/16, S10am-3pm9/17, M9-11am9/18, T9-10am-1pm9/19/23. Limb Jerks or Spasms {I doubt this is associated as an Adverse Event} {Except for two occasions (4/10/23 & 9/16/23), I was exhausted from inability to sleep when these phenomena occurred.} F2:45am10/14/22, S1-2am3/11/23, S3,3:15,3:30am4/10/2023, W1-2am4/19/23, T9,9:30,10am8/15/23, R11:15, 11:30pm9/14/23, S1:15,1:30am&11:30,11:45pm9/16/23, W15minApartEach2:30-4:30am9/20/23.  {I do not think this is an Adverse Event as many vaccinated people later got Covid} 7/29/2022 Covid Tested Positive (the 2 Pfizer vaccines were in 2021) Govt's at-home-test-kits: 7/26/22-8/13/22 ill: 7/27/22 neg, 7/29/22 test positive, 8/5/22 neg. 11/30/22 neg Ill-12/5/22.  Foot Cramping {I doubt this is associated as Adverse Event.} Self administered external Magnesium Cream OTC offered eventual relief. R10-11pm9/14/22, W10-11pm1/14/22, W9-11pm10/19/22, R2am7/27/23, F1am7/28/23. +