Age: 49.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Influenza like illness, Laboratory test, Liver function test abnormal, Magnetic resonance imaging head, Magnetic resonance imaging heart
Clinical narrative: Overview  No Major health issues entire life, not sick at all for 2 years before Pfizer vaccine.   1st dose  = 7/11/21, 2nd dose 8/1/21 3 days flu like symtoms immediately after vaccine, went away  8 days after 2nd dose mild breathing issues Breathing issues got progressively worse for next 3-4 weeks, to point where it was hard to breath  3rd-4th week after 2nd dose chest pain and pressure, start of extremities getting cold (feet, hands, legs, ears, nose) 5th week after vaccine  heart issues  Tachycardia/ Arrhythmia / Blood work abnormal, starting to feel extreme fatigue, headaches, Brain Fog, Dizziness Severe Heart Issues Persisted for 4-5 weeks (breathing issues slightly subsided as soon as heart issues started) 9th week after 2nd dose  Tachycardia started to subside, new neurological issues started 9th week after 2nd dose  Complete numbness, sometimes mild paralysis in arms, numbness in feet, arthritis in hands and feet, tingling and heat sensation of spine and brain, Brain Fog and Dizziness, Extreme fatique 10th week to 13th week after 2nd dose  Continuation of numbness in arms, feet  arthritis getting worse in hands and feet, brain fog / dizziness more frequent , extremities still very cold every day  I have seen PCP, cardiologists, neurologist, pulmonologist, and rheumatologist Diagnosis by cardiologist is vaccine induced ongoing cytokine storm / myocarditis and pericarditis  Diagnosis by rheumatologist is vaccine induced ongoing autonomic never system disorder and antiphospholipid syndrome  Diagnosis by pulmonologist is severe allergic reaction to vaccine  Negative Covid PCR Tests (9/10/21, 9/21/21, 9/26/21, 10/2/21, 10/10/21, 10/24/21)  Tests ------ EKGs (about 10 tests over 2 months' time)  Blood Labs  - multiple blood labs over 2-3 months period Chest x-Ray Echocardiogram (heart) Holter monitor Cerebrovascular duplex exam Lower Extremity Benous Color Duplex Scan Lower extremity Arterial Ultrasound Spect cardio Stress Test w/ perfusion Liver ultrasound Cardiac MRI MRI of brain Electromylogram Table Test (for Pots)   Medications given Dexamethasone 4mg Pulmiicort flexinhaler Hydroxychloroquine 400 mg /day Clonazepam  2mg Montelukast 10 mg Cyclobenzaprine 10mb Famotidine 20mg Nebulizer / Albuterol   Blood Work  Abnormal results only  (note there are about40-50 more tests for various auto immune and others that were negative)  Abnormal Blood Results (from 9/10/21)  AST  31 Normal  ALT  49 H  PROTEIN TOTAL  8.2 H  Abnormal Blood Results (from 9/22/21)  HOMOCYSTIEN  17.5 H AST  44 H  ALT  111 H  very high  WHITE BLOOD CELL COUNT  12.0 H HEMOGLOBIN  17.7 H HEMATOCRIT  50.3 H ABSOLUTE NEUTROPHILS  8940 H  AB(IGG) - >750 H  Suggestive of past Epstien-Barr  EBV NUCLEAR AG (EBNA)  413.00 H  Suggestive of past Epstien-Barr  SARS COV 2 AB(IGG) SPIKE,SEMI QN - >20 H  VITAMIN D25-OH TOTAL, IA  29 L ANA Screen IFA  NEGATIVE SARS COV 2 AB (IgG), NUCLEOCPSID, QL  NEGATIVE SARES CoV 2 AB (IgM), SPIKE, QL - NEGATIVE  Abnormal Blood Results (from 9/29/21)  AST  30 Normal  ALT  68 H  WHITE BLOOD CELL COUNT  9.5 Normal HEMATOCRIT  48.1 N ABSOLUTE NEUTROPHILS  6859 N   Abnormal Blood Results (from 10/13/21)  Over 40 Blood Tests ordered ANA Screen IFA  POSITIVE ANA TITER  1:40 H CARDIOLIPIN AB (IGM) -26.4 H B2 GLYCOPROTEIN I (IGM) AB  24.4 H ALBUMIN  5.0 H IMMUNOGLOBULIN E  313 H CREATININE, RANDOM URINE- 416 H ALT  59 H ABSOLUTE NEUTROPHILS  3229 N   Symptoms  -------------- Trouble Breathing  (8/9  Present) Chest Pain (8/20  Present) Arrhythmia/Tachycardia (9/9  10/14) Myocarditis / Pericarditis (diagnosis by cardiologist 9/14  Present ) Possible Liver Issues - Abnormal ALT levels bloodwork  Possible Kidney Issues - Abnormal levels CREATININE, RANDOM URINE bloodwork Autonomic Nervous disorder  HRV analysis suggestive, bloodwork suggestive (9/30-present) Twitching legs, arms, misc. back and upper leg muscles Complete Numbness of both Arms, numbness of Feet, Legs Tingling of toes and feet and ankles and arms, feeling of heat sensations in nerves Twitching of muscles in random areas such as lower back, random areas in legs, nerve pain in arms and feet Tingling and heat feeling of lower spine and spine in back of neck, also at times in head Brain Fog / Dizziness Continuous Icy Cold toes, Ankles, - coldness in upper ankles, coldness in fingers, Nose, ears (9/20-present) Continuous random Fogginess / Dizziness  (9/20-present) Continuous Extreme Fatigue  (9/20-present) Continuous arthritis - ankles, feet, knees (9/20-present) Pain in tendons and muscles, especially in ankles, feet,  knees .. also in areas of past very old injuries Possible POTS, where heartrate at times randomly increases 30 bmp while standing , then decreases 30 bpm while sitting (no confirmed diagnosis, as it only happens at random times)    History of symptoms and dates of doctors visits  2nd Pfizer Vaccine dose administered 8/1/21  8/2-8/6  Flu Like symptoms (fever, chills, fatigue, normal post vaccine side effects, but longer duration than usual)  8/9-9/9  Trouble Breathing -  Asthma like issues starting gradually 1st week, then getting progressively worse and worse week by week  8/20-9/9  Started Experiencing chest pain (along with severe trouble breathing)  chest pain day by day got progressively worse and worse, developed mild Cough. I thought this would go away over time, but by 1st week of September (4-5 weeks into 2nd dose), breathing got very bad to point where it was extremely hard to breath and chest and heart area hurting very much  9/9/2021  Visit PCP (DO / PA-C)  Diagnosis  Asthmatic Bronchiti / Covid-19 suspect  Recommended covid-19 test   Prescriptions : Azithromycin 5 days, Singlair , Albuterol, Nebulizer Covid Test Followup  Negative Rapid on 9/9, Negative PCR on 9/10  9/10  Heart started hurting with tremendous pain, extreme heart and chest muscle pains, feeling of heart attack symptoms  and Myalgia in chest / heart area - Went to Urgent Care,  9/10  Visit (Urgent Care)   EKG  Abnormal   Blood Labs Ordered (CBC, CMP)  Chest x-Ray  EKG abnormal   Recommended seeing Cardiologist immediately  9/10-9/14  Extreme chest pain, heart palpitations, shortness of breath,  foggy brain, dizziness 9/14/21  Visit (Cardiologist)  Initial diagnosis  EKG   TTE w/ Doppler, complete  Holter Monitor (24 hours)  Diagnosis showed sinus rhythm 102 bpm, sinus tachycardia, possible left atrial enlargement , left anterior fascicular block, Poos R progression in V1, V2 Bpm spiking to 140-150 bmp while in doctors office Cardiac Murmur, unstable angina, non ST elevation (NSTEMI) myocardial infarction   Prescriptions:  Pulmicort, Famotidine, Decadron (Dexemethozone)  3 day prescription  9/14/21-9/22/21  continuation of Extreme chest pain, heart palpitations, tachycardia, shortness of breath,  foggy brain, dizziness  9/22/21 - Visit (Cardiologist) Assessments:   Myocarditis Unstable angina Palpitations Shortness of breath Abnormal EKG Myocardial Infarction Tachycardia Bradycardia Atrial premature depolarization Cold Extremities (especially feet, hands, ears)   Labs / Blood work ordered  Cardiac MRI ordered Chest x-Ray ordered Liver Ultrasound  9/22/2021  Visit PCP (DO / PA-C)    9/22/21-9/29/21  continuation of Extreme chest pain, heart palpitations, tachycardia, shortness of breath,  foggy brain, dizziness, Cold Extremities (especially feet, hands, ears)  9/23/2021 - Visit (Cardiologist) Assessments:   Shortness of breath Chest Pain Palpitations Abnormal EKG  Tachycardia Non-ST elevation myocardial infarction Elevated Blood Pressure   9/29/21 - Visit (Cardiologist)   Assessments:   Shortness of breath Chest Pain Palpitations Abnormal Liver Function Blood Results Elevated white blood Cell Count Abnormal EKG  Abnormal result of other cardiovascular studies Tachycardia Bradycardia Non-ST elevation myocardial infarction Elevated Blood Pressure  Labs / Blood work ordered  Sputum Cytology  Urinalysis complete Blood Culture  9/30/21  Start of Neuropathy symptoms and start of nervous system  9/30/21  Right Arm completely started to go numb while sleeping and right foot and toes   10/05/21 - Visit (Cardiologist) Assessments:   Shortness of breath Chest Pain Palpitations Abnormal EKG  Tachycardia Non-ST elevation myocardial infarction Elevated Blood Pressure  10/06/2021  Visit PCP (DO / PA-C)   10/06/21 - Visit to (Cardiologist)  Assessments:    10/08/21 - Visit to (Cardiologist)   10/11/21  Visit to (Neurologist)  Assessments:  Numbness in feet and legs and in both arms Tingling of feet and hands, feeling of heat in feet , ankles up to knees Tingling / Numbness generally focused on complete right side of body, however still some feeling in left side  Brain Fog Cold Extremities (especially feet, hands, ears)   10/12/21  Visit to (Rheumatologist)  1st visit Assessments:  Numbness in feet and legs and in both arms Tingling of feet and hands, feeling of heat in feet , ankles up to knees Tingling / Numbness generally focused on complete right side of body, however still some feeling in left side  Cold Extremities (especially feet, hands, ears) Brain Fog    Brain MRI - Negative  10/13/2021  Visit PCP (DO / PA-C)  10/18/21  Visit to (Neurologist)  Assessments:  Numbness in feet and legs and in both arms Tingling of feet and hands, feeling of heat in feet , ankles up to knees Tingling / Numbness generally focused on complete right side of body, however still some feeling in left side  Cold Extremities (especially feet, hands, ears)  Eletromylogram Test  Negative     10/25/21  Visit to (Cardiologist) Assessments: Chest Pain /Heart Pain Trouble Breathing Cold Extremities (especially feet, hands, ears)  Numbness in feet and legs and in both arms Tingling of feet and hands, feeling of heat in feet , ankles up to knees Tingling / Numbness generally focused on complete right side of body, however still some feeling in left side  Brain Fog   10/26/21   Visit  Post Covid Clinic  Assessments: Chest Pain /Heart Pain Trouble Breathing Cold Extremities (especially feet, hands, ears)  Numbness in feet and legs and in both arms Tingling of feet and hands, feeling of heat in feet , ankles up to knees Tingling / Numbness generally focused on complete right side of body, however still some feeling in left side  Brain Fog  They did nothing for me.. they said that clinic was for covid patents, and not for vaccine side effects and to take dexamethasone prescribed by rheumatologist and said if I wanted to follow up I could in 6 weeks    10/26/21  Vist to (Pulmonologist) Assessments: Chest Pain /Heart Pain Trouble Breathing Cold Extremities (especially feet, hands, ears)  Numbness in feet and legs and in both arms Tingling of feet and hands, feeling of heat in feet , ankles up to knees Tingling / Numbness generally focused on complete right side of body, however still some feeling in left side  Brain Fog   Said he thinks this is an allergic reaction to vaccine.  Said to stay on course with moderate doses  of steroids and pulmicort.   10/27/21   Visit to (Cardiologist)  Table Test (Pots)  Negative table test results