Age: 84.0
Sex: F
Vaccine: COVID19-2
Symptoms: Inflammation, Insomnia, Joint swelling, Laboratory test normal, Loss of personal independence in daily activities
Clinical narrative: She got her vaccine, when she woke up the following day she had swelling and pain that was extreme. Nerve pain, extreme muscle and joint pain and all her joints were swollen, hot and very very painful. She had pain in her right shoulder blade that moved to her right arm, her elbow, and her forearm. This made nerve pain and horrible. She called her doctor, saw her and she took off of her statin medication hoping that the muscle pain would disappear. She had the medication already for 20 years, which did not cause her pain prior to the vaccine. She was not put on anything else. When this did not help she had an EMG of her right arm showing that she had bilateral carpal tunnel problem. They thought that was where the pain came from her arm, and had a carpal tunnel release in February of 2021. That did not relieve her symptoms. She was then referred to an orthopedic for an x-ray of her shoulder and an MRI of her shoulder as well. They did not do the MRI, but on x-ray he felt that she needed a shoulder replacement.  Her age was a concern and so he gave her an injection in her shoulder which was not helpful and did not relieve her pain. In October she saw her PCP on a routine visit and recommended a 2nd opinion by a spine specialist and felt that her troubles had nothing to do with the vaccine or COVID. Then she saw a doctor at the local Clinic, first saw Dr. "Private" and he ordered an MRI of her lumbar area as started with physical therapy. At that time he mentioned that she had a gait disorder and muscle atrophy. 11/10/21 he was talking about that she needed surgery, and showed her that the problem was in her lumbar and back area. On 12/10/21 the family was having a get together and was wondering about the booster shot which she suggested she get it as she felt that it could not do any harm. On 12/10/21 she got the booster, the next day she had all the symptoms of COVID and came back negative. She then had flare up of the pain, and she had pain in her shoulder area again. She had tremors and could not lift anything, and was so exhausted that she could not function or use her arms to do anything. She could not sleep due to the pain which seemed to be worse during the night. 3/3/22 she had an APT with Dr. who is a neurosurgeon who felt that she did not need any neck surgery at that time, and referred her to alternate Dr. because he felt that her pain was muscular nerve related. He prescribed her Pregabalin 3 times a day and it took about a week to feel any results, but she started to have edema in her legs due to that. She has deteriorated from February of 2021 and is scary. On 3/11/22 her pain level was improving, was given injections. She was no longer able to walk and had to use a cane and also lost control of her bowel and bladder, but that did come back later. On 3/27/22 she had a lumbar puncture and on 4/22/22 an EMG. The EMG showed that she had arthritis but nothing out of the ordinary that could put their fingers on. Then on 5/4/22 she asked for a referral to a peripheral neurologist as she deals with muscles and nerves and ordered lab work, and nothing stuck out as causing her problems. Then she was sent to an orthopedist doctor and rheumatologist. They came to the conclusion that she has mild to severe arthritis problems, osteoarthritis and inflammation and septic arthritis, and degeneration of articular cartilage and something to expect at her age. On 7/14/22 she had an APT with Dr. of orthopedics and decided that she had severe arthritis on the right side of her shoulder and moderate on the left side. On 7/23/22 she had sciatica and was not able to talk and was put on Ketorolac Tromethamine 30 mg injection solution. She also was put on Methylprednisolone and put her on Meloxicam and had an APT with Dr. who is a rheumatologist. On 8/10/22 her diagnosis was mild to severe OA. On 8/11/22 she had a yearly check up with her PCP and because of the sciatica she cannot walk anymore, and so she referred her to Dr. who is a pain specialist for severe sciatica pain and is scheduled for an injection on 10/12/22 in her lumbar spine and 14 days she is scheduled to a have nerve block for her right shoulder and if that works the same thing in the left shoulder. Her balance is a little better now and her bowel/bladder issues are getting better. On 9/12/22 she was put in a COVID recovery clinic and she met with specialist and her conclusion was that instead of COVID long-term effect that she had an adverse immune allergic reaction of the COVID vaccine. She wants her to go to an immune/allergic specialist. She researched it on the computer and found our site and she falls under the category of having a persistent incapability of having a normal functioning life. She cannot do anything anymore and she was fine prior to the vaccine. On 9/15/22 she asked to see Dr. for pain and swelling in her upper and was given a 6 day course of Methylprednisolone and is on that now on day #4. Her arms are calming down and the swelling is gone from her arms, but the pain level has not gone. She then had her booster vaccine on 12/10/21, Pfizer, lot#FH8030.