Age: 54.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Acute kidney injury, Alanine aminotransferase increased, Albumin globulin ratio, Anion gap, Arthralgia
Clinical narrative: 04/18/2021 - Pfizer Lot - EW0162   I had sharp pain in my jaw on both sides 15 minutes after taking the Pfizer Vaccine. I started having joint pain mostly in my arms and muscle pain all over my body, but the mostly in my arms.  I had numbing sensations started happening a few days after getting the shot that were on my face, head and arms that would move around.  My symptoms faded into the second Pfizer shot on May 9th, 2021 (Another VAERS Report for 2nd Shot).  Visit Date/Time: 6/1/2021 at 2:15 pm Mode of Arrival: Car Primary Care Provider: MD   ASSESSMENT & TREATMENT SUMMARY   Nursing Chief Complaint:  Chief Complaint Patient presents with o Tachycardia     MEDICAL DECISION MAKING   Pt here with multiple vague symptoms, including palpitations. He seems convinced all his symptoms are due to the covid vaccine. I explained to him I could not definitely say one way or the other whether this is true or not. Given his bilateral joint pain, fatigue, I think he may benefit from seeing a rheumatologist. He does have renal insufficiency with creatinine of 1.7. recommended outpatient w/u for this. D/c home     Clinical Impression:  1. Acute renal insufficiency      New Prescriptions:  Discharge Medication List as of 6/1/2021  5:42 PM       Follow-up Care:  MD  In 1 week     discharge   Disposition:   Home HISTORY OF PRESENT ILLNESS   History Provided by: self, wife   Nursing Triage Note:   ED Triage Notes, ED Triage Notes    RN 6/1/2021 14:28       ED Triage Note   Patient is a 54 y.o. male with a chief complaint of:  Racing HR.        Arrived by: The patient arrived by private car and is accompanied by spouse. Pt with concern for racing HR. No HX of the same. No CP. Pt states he feels really weak. Pt states muscle ache, joint pain, and numb sensations since his last COVID shot on 5/9/21.                HPI/Additional History:  Patient is a 54 y.o. male who presents to the Emergency Department with palpitations. States he was doing nothing then all of sudden felt his heart racing. States he felt very fatigued. C/o headaches, bilateral joint pain. He attributes this all to getting his covid vaccine, pfizer which was given 3 weeks ago. He states "I was totally healthy, then I got the covid vaccine. I wasn't old before then, that doesn't happen all of a sudden!"     REVIEW OF SYSTEMS A comprehensive review of systems was negative. ROS reveals no other complaints.   Other pertinent items as noted in the HPI All other systems reviewed and negative    PHYSICAL EXAM   Vitals:   06/01/21 1430 06/01/21 1600 06/01/21 1630 06/01/21 1700 BP: 167/72 128/82 117/68 110/72 Pulse: 89 73 70 71 Resp: 16 16 13 11 Temp: 36.6 °C (97.9 °F)       TempSrc: Tympanic       SpO2: 99% 98% 99% 99% Weight:             Physical Exam: General Appearance: well-developed, well-nourished Head: Atraumatic, normocephalic. Ears: external ears normal Eyes: conjunctiva normal and intact Nose: nares normal, septum midline, no drainage Throat: oropharynx normal, teeth and gums normal Lungs: lungs clear to auscultation bilaterally Heart: RRR. No murmurs, clicks, gallops, or rubs Abdomen: Abdomen soft, non-tender, BS normal, no masses or organomegaly, rectal examination deferred Neuro: alert and oriented X 3, 5/5 strength in all extremities, normal finger/nose, sensation grossly intact, CN 2-12 intact Extremities: Extremities atraumatic, warm, without clubbing, cyanosis or edema. Psych:  Normal Skin: Normal   LABORATORY & IMAGING RESULTS   Laboratory Studies: Ordered and independently interpreted laboratory tests.   Results for orders placed or performed during the hospital encounter of 06/01/21 CBC with Differential Result Value Ref Range   White Blood Cells 13.79 (H) 3.8 - 11.0 x 10^3/uL   Red Blood Cells 4.72 4.20 - 5.70 x 10^6/uL   Hemoglobin 14.9 13.2 - 17.0 g/dL   Hct 43.1 39.0 - 50.0 %   MCV 91.3 80.0 - 97.0 fL   MCH 31.6 27.0 - 34.0 pg   MCHC 34.6 32.0 - 35.5 g/dL   RDW-CV 12.4 11.0 - 15.5 %   Platelet Count 210 150 - 400 x 10^3/uL   MPV 11.1 9.4 - 12.4 x 10^3/uL   % Neutrophils 71.1 %   % Lymphocytes 20.0 %   % Monocytes 7.3 %   % Eosinophils 0.4 %   % Basophils 0.5 %   % Immature Granulocytes 0.7 %   Absolute Neutrophils 9.79 (H) 2.00 - 7.30 x 10^3/uL   Absolute Lymphocytes 2.76 1.00 - 3.40 x 10^3/uL   Absolute Monocytes 1.01 (H) 0.00 - 0.80 x 10^3/uL   Absolute Eosinophils 0.06 0.00 - 0.50 x 10^3/uL   Absolute Basophils 0.07 0.00 - 0.10 x 10^3/uL   Absolute Immature Granulocytes 0.10 (H) 0.00 - 0.03 x 10^3/uL   % nRBC 0.0 /100 WBC Comprehensive Metabolic Panel Result Value Ref Range   Na 136 135 - 145 mmol/L   K 4.1 3.5 - 5.3 mmol/L   Cl 98 (L) 99 - 109 mmol/L   CO2 27 20 - 36 mmol/L   Calcium 9.2 8.5 - 10.2 mg/dL   Anion Gap 11.0 5 - 16   Albumin 4.5 3.5 - 5.0 g/dL   BUN 26 (H) 8 - 25 mg/dL   Creatinine 1.7 (H) 0.70 - 1.30 mg/dL   Glucose 102 (H) 65 - 99 mg/dL   Total Protein 7.1 6.2 - 8.2 g/dL   Globulin 2.6 1.8 - 3.5 g/dL   Albumin/Globulin Ratio 1.7 1.2 - 2.8 ratio   Alkaline Phosphatase 52 35 - 115 U/L   ALT 37 10 - 65 U/L   AST 24 10 - 45 U/L   Bilirubin Total 0.6 <=1.5 mg/dL   Estimated GFR 45 (L) >=60 mL/min/1.73m2   Bun/Creatinine 15 12 - 20 ratio POC Troponin I Result Value Ref Range   Troponin I, POC 0.00 See Ref Notes ng/mL TSH Result Value Ref Range   TSH 1.590 0.45 - 5.10 uIU/mL ECG 12 lead Result Value Ref Range   VENTRICULAR RATE EKG 90 BPM   ATRIAL RATE 91 BPM   P-R INTERVAL 127 ms   QRS DURATION 86 ms   Q-T INTERVAL 361 ms   Q-T INTERVAL (CORRECTED) 442 ms   P WAVE AXIS 67 degrees   QRS AXIS -34 degrees   T AXIS 26 degrees   INTERPRETATION TEXT         Sinus rhythm Left axis deviation   Confirmed by MDon 6/1/2021 7:43:38 PM         Imaging Studies:  Imaging studies ordered and interpreted by radiology include: No orders to display       I also independently visualized the above images and informally interpreted them contemporaneously in the emergency department.     ED COURSE and INTERVENTIONS   Medications administered in the Emergency Department include:   Medications - No data to display                                                                                                                               ECG Report   Rate:  90,  Normal sinus rate,  no st-t changes                                                                         DATA GATHERING   The patient was seen and evaluated by myself.   I reviewed the nurses notes and flow sheets.   Prior EMR records reviewed in EPIC as available and clinically relevant.   EDIE Alert: All Emergency Department patients have an EDIE and PMP query on registration.  Information only appears if thresholds are met.  I reviewed the EDIE data as available and relevant. (including prior to prescribing narcotics)    PAST HISTORY   Past Medical History:  Past Medical History: Diagnosis Date o Enlarged tonsils and adenoids   o GERD (gastroesophageal reflux disease)   o Microscopic hematuria     Worked up o Sleep apnea     During sleep study-did not meet full criteria and underwent surgery afterwards   Patient Active Problem List Diagnosis o Sprain of medial collateral ligament of left knee, initial encounter o Routine general medical examination at a health care facility o GERD (gastroesophageal reflux disease) o Microscopic hematuria o Chest pain o Benign neoplasm of descending colon o Screening for colon cancer     Past Surgical History: Past Surgical History: Procedure Laterality Date o OTHER SURGICAL HISTORY       OTHER MUSCULOSKELETAL - bone spur o OTHER SURGICAL HISTORY       OTHER ENT - deviated septum o OTHER SURGICAL HISTORY       TONSILLECTOMY o PR COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ   12/23/2016   Procedure: COLONOSCOPY W/ SNARE POLYP;  Surgeon: MD;  Location: F GASTRO / SPECIAL PROCEDURES;  Service: Gastroenterology o PR EXCISION TURBINATE,SUBMUCOUS   12/14/09   Procedure:SEPTOPLASTY; Surgeon:; Location:; Service:Otolaryngology o PR REMOVAL OF TONSILS,12+ Y/O   12/14/09   Procedure:TONSILLECTOMY; Surgeon:; Location:; Service:Otolaryngology o SINUS SURGERY         Social History:  Social History   Tobacco Use o Smoking status: Never Smoker o Smokeless tobacco: Never Used Substance Use Topics o Alcohol use: Not on file     Comment: Alcoholic Drinks/day: rare o Drug use: Not on file     Comment: Drug use: No       Family History:  Family History Adopted: Yes Problem Relation Age of Onset o Other (see comment) Mother         Other - healthy o Other (see comment) Father         Other - healthy   Family history reviewed by me   Home Medications list:  Current Outpatient Medications on File Prior to Encounter Medication Sig o omega-3 1000 MG CAPS Take  by mouth. o predniSONE (DELTASONE) 10 mg tablet 4 po daily x 2, then 3 po daily x 2, then 2 po daily x 2, then 1 po daily x 2. o Probiotic Product (PROBIOTIC PO) Take 1 Tab by mouth every day. o triamcinolone (NASACORT) 55 mcg/nasal spray 2 sniffs right  nostril bid.     Allergies:  Allergies Allergen Reactions o Bee Pollen   o Uncoded Nonscreenable Allergen       PROVIDER ATTESTATION   Please see top of note for assessment, diagnosis and disposition.     MD 6/1/2021 11:54 PM   This document was generated in part using voice recognition software, occasional wrong-word or "sound-alike" substitutions may have occurred due to the inherent limitations of voice recognition software. Read the chart carefully and recognize, using context, where these substitutions have occurred. In addition entries are made by physician typing and scribe typing.  Although every effort is made to edit the content, transcription and typing errors may occur.     MD 06/01/21 2357   at 06/01/21 1520   RAP Note:                                               6/1/2021     Patient is 54 y.o. male GERD who presents with tachycardia. The patient reports he started having elevated HR a few hours ago while doing nothing. He recalls his HR being 96 prior to arriving to the ED and states it is abnormally high for him because he is typically in the 70-80s. He associates his elevated HR with new weakness and lightheadedness. He mentions he had his 2nd Pfizer vaccine on 5/09/21. He states after the vaccine he had a reaction consisting of a HA, numbness, "arthritic pain," and hand and feet swelling.   He denies any CP, nausea, vomiting, or vision changes.   EXAM:   Heart: regular rate Lungs: normal respiratory effort.   To ER Main for further evaluation.  Initial labs and/or imaging ordered.         DISCLAIMER:      All medical record entries made by the scribe were at my direction. I have reviewed the chart and agree that the record accurately reflects my personal performance of the history, physical exam, medical decision making, and the emergency department course for this patient. I have also personally directed, reviewed, and agree with the discharge instructions and disposition.   Scribed for PA-C by scribe 3:35 PM, 6/1/2021     PA-C 3:35 PM 6/1/2021                       PA-C 06/01/21 2105   ED Notes Nurse at 06/01/21 1600 Assumed care of pt. Pt comes in complaining of feeling his "heart racing" with associated weakness and lightheadedness. Recently received second covid vaccine. Pt placed on cardiac monitor and continuous pulse ox. NAD noted. Speaking in clear, full sentences. Call bell within reach.  ED Triage Notes Nurse at 06/01/21 1426 ED Triage Note   Patient is a 54 y.o. male with a chief complaint of:  Racing HR.        Arrived by: The patient arrived by private car and is accompanied by spouse. Pt with concern for racing HR. No HX of the same. No CP. Pt states he feels really weak. Pt states muscle ache, joint pain, and numb sensations since his last COVID shot on 5/9/21.