Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Loss of personal independence in daily activities, Magnetic resonance imaging, Magnetic resonance imaging head abnormal, Malaise, Muscle rigidity
Clinical narrative: PT had 3 strokes on 2/23/2021, Tuesday, between 8:00-9:00 a.m. This was less than 48 hours after his 2nd Moderna shot on Sunday, 2/21/2021, at 10:00 a.m.  On Monday, the next day after his 2nd Moderna shot, he felt unwell, was irritable and took a long nap.   On Tuesday, the second morning after his 2nd Moderna shot, his arms and legs started involuntarily shaking and twitching. He complained of having a very bad headache, threw-up and could no longer stand. He used his arms to lower his body. He happened to be in the bathroom? He lowered his body into the bathtub, as he lost control of his legs.   I discovered him lying in the bathtub, unresponsive, with his eyes tightly closed.   I tried to move him from the bathtub initially, but his legs would not work and were unresponsive. He held the weight of his body up by a bar in the bathtub, as his legs were not working. I called 911.   He was taken in an ambulance to the emergency room. The emergency room staff did not know what was wrong with him and initially tried to discharged him, but he was unable to walk out of the hospital. From the emergency room, he was then admitted to the hospital. He stayed in the hospital for 5 days.  After receiving a head MRI, he was diagnosed with having 3 strokes. He still was having great difficulty walking and was having balance problems. His legs appeared unresponsive, rigid and stiff.   Vision was affected as well.  He could not see on his right side; he was unable to see the food tray or silverware when he was eating.   His cognition/brain/mental capacity was obviously affected. He did not know his correct age, and could not remember short-term and long-term events. He lost some use of language. He had a lot of trouble using the telephone.   After 5 days in the hospital, pt was admitted to a physical rehabilitation center for 16 days. He attended physical therapy, occupational therapy and speech therapy daily.   By the time he discharged, he was walking with a walker. He did NOT use a walker pre-stroke.   He also still had significant loss of language, memory and cognitive ability.    He still could not see well on the right side, and would often walk into visible obstacles / walls on his right side as he could not see them.   After the rehabilitation center, pt returned home and had home healthcare services. He had Occupational therapy, physical therapy, speech therapy, 1:1 nurse, as well as a home health aide who helped him to shower.   At home, he some Occupational Therapy and Physical Therapy sessions. Due to his new vision and balance problems following the strokes, and being newly on a blood thinner after the adverse reaction, he was in danger of falling and needed the home health aide to assist with bathing ( so that he would NOT fall in the shower).   Speech (cognitive) therapy lasted the longest out of all 3 home healthcare therapies. Even at the close of speech therapy, he still presented significant deficits in both short-term and long-term memory, as well as in his cognitive ability. He can no longer budget his finances.   On June 29th, a neurological ophthalmologist diagnosed him with loss of peripheral vision on both right sides. He lost right peripheral vision in both eyes.   These 3 strokes, following the 2nd Moderna shot, greatly changed pt's quality of life.   Prior to the vaccine and strokes, he used to drive, take care of his grandchildren, manage his finances, shop for food, clean and cook daily, as well "care-take" for his wife who has her own physical injuries. He was 100% independent and helped many members of his family regularly. He helped his family with day-to-day practical tasks, offered emotional support, career direction, and shared his wisdom regularly.   Today, almost 7 months later, he can no longer drive, manage his finances nor bank accounts. He regularly writes checks for money he does not have. His mental capacity is extremely diminished. He also gets lost easily. When he is dropped off at a doctor?s appointment in a hospital on his own, he easily gets lost and confused. He is also more easily frustrated, confused and irritated. This causes great strain on his relationships with his wife and family, as he used to be the solid foundation of the family. He has still lost all right peripheral vision in both eyes. His vision has not returned. He also still struggles with both his short-term and long-term memory, and general cognitive / brain / mental function.   His quality of life is greatly affected and diminished. The quality of life of his family who depended upon him has been very negatively impacted as well.