Age: 51.0
Sex: F
Vaccine: COVID19
Symptoms: Tongue disorder, Urticaria, Wheezing
Clinical narrative: Vax Clinic note: Approximately 10 minutes after receiving J&J vaccine c/o lips tingling and tongue feeling thick.  Medicated with 10 MG cetirizine.  VS o2Sat 97%, Pulse 84, BP 146/74.   Pt states has had allergic reactions to IV contrast that involved tongue swelling. staets this feels similar but not as bad.  o2Sat continues at 97%, Pulse 58, BP 128/68, pt trying to relax, c/o slight headache.     Swellig has spread to her lips, and cheeks feeling heavy, O2Sat 97%, Pulse 75, medicated with 50mg benadryl. 911 called to transfer pt to ED for further eval.  States throat is feeling tighter. And unable to swallow    Epi given 11:18, daughter aware and will meet her at  ED.    BP 148/82, PUlse 75, O2Stat 97% swelling in tongue decreasing, throat n o longer tight, tongue still feels thick, has some hives between her eyes, and forehead.    Pt transported via EMS to ED  Intake ED note:  51 y.o. F here after getting J&J vaccine and 10 min. After she c/o her tongue feeling thick and lips tingling Pt given zertec Then 15 min later pt felt lips swelling and had hives around eyes and forehead Pt c/o difficulty swallowing and was rx'd with epi pen Pt has no stridor, or resp issues on arrival, able to speak in full sentences. Pt denies COVID sx  2nd ED note:  Pt arrived to ED via EMS from community health center S/P Covid vaccination.  About 15 minutes after receiving vaccine - felt nausea and smelled "medicine" followed with upper lip swelling and numbness to tongue associated with difficulty swallowing and redness to forehead.  Pt alert and oriented at this time.  Speaking in full sentence, drinking bottled water without any difficulty. No drooling noted.  Denies SOB, chills or fever.   Emergency Department Attending Attestation Note   See resident/PA/student note for further details of HPI, history, exam, ED course, and diagnoses.   Briefly, this is a 51 y.o. female with PMH reviewed in chart and w/ patient notable for insulin dependent diabetes, depression, prothrombin mutation, migraine, p/w concern for allergic reaction.  Emesis or change in Covid vaccine today.  10 minutes after receiving the vaccine, patient reports feeling thick in her tongue with tingling in her lips.  Patient was given Zertec.  The minutes later, her lips began to swell up and was also noted to have new erythematous rash between her eyes and forehead.  Patient was given 50 mg of Benadryl.  Patient felt like she could not swallow with worsening lip swelling.  She was given EpiPen and 911 was called. No stridors.  No wheezing.  Reports continued tingling and the numbness in her mouth but no lip swelling or tongue swelling.  Denies any difficulty swallowing at this time.  No wheezing.  No abdominal pain or nausea.  No rash at this time.   Of note, patient also notes left-sided facial, arm, and leg numbness starting about 10 minutes prior to arrival to the emergency department.  She reports that she has had recurrent numbness on the left side in the past, which was thought to be due to migraine versus TIA.  She has had extensive work-up and multiple hospitalization for this symptom.  She reports that she is allergic to iodine and gadolinium containing contrast.  Denies any headache at this time though she had a mild headache after receiving the vaccine.  Denies any blurry vision.  Denies any weakness in her bilateral upper and lower extremities.  Assessment and Plan:    Vital signs notable for O2 sat of 96 to 98% on room air without tachypnea.  Patient is mildly hypertensive.  Patient is well-appearing speaking full sentences without any dysarthria.  Pupils are equal and reactive to light.  Extraocular movement intact.  She notes diminished sensation to her left face, left upper extremity, and left lower extremity.  Tongue is midline.  Hearing is intact bilaterally.  No facial droop.  She has 5 out of 5 strength in bilateral upper and lower extremities.  No pronator drift.  Normal gait.  No tongue swelling or lip swelling.  No stridors.  No uvula swelling.  No pharyngeal or erythema.  Lungs are clear to auscultation bilaterally without wheezing or rhonchi.  Cardiac exam without murmurs rubs or gallops.  Regular rhythm.  No abdominal distention or tenderness on palpation.  No CVA tenderness.   51-year-old female who is presenting to the emergency department with improving lip swelling and numbness in her mouth, raising a concern for anaphylaxis related to her Covid vaccine.  Reassuringly, status post EpiPen, her symptoms are improving.  However, she has new onset left-sided numbness, with without any headache.  She reports that she has had this numbness in the past the last time she had the numbness on the left side was approximately 10 years ago.  Her neurologic exam is only notable for diffuse numbness on her left side including her face.  Differential diagnosis include migraine headache and TIA.  Stroke is possible though less likely given the patient has had the same symptoms in the past with negative work-up.  Will defer code stroke at this time but will emergently consult neurology.  Will get labs including BMP and CBC.  We will continue to monitor her from the anaphylaxis perspective.  We will also give her a dose of steroid.  Prednisone 60 mg by mouth given 12:29 PM  NEUROLOGY CONSULT NOTE  Assessment: Formulation- Diagnosis is guarded. Localization structurally would suggest subcortical (thalamic) or small brain-stem in a sensory territory on the right. Etiologies could be stroke given her vascular risk factors but seems unlikely given there is stereotypy of earlier symptomatology. Demyelinating would be another possibility as well, but again, the stereotype. Seizure unlikely because of the timing of rush from toes to body was minutes and duration of some occasions being days. Complicated migraine possible, has some risk factors, but should be treated as dx of exclusion. She does make complaint of headache, which could support. Some FND elaboration on her anxiety-ridden allergic reaction is also possible, but no objective non-structural signs to support.