Age: 55.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Metabolic function test, Nausea, Paraesthesia, Pharyngeal swelling, Troponin T
Clinical narrative: possible anaphylactic reaction vs. anxiety.   HISTORY OF PRESENT ILLNESS: This is a 55-year-old brought by EMS from vaccine clinic after receiving the Pfizer COVID-19 vaccine.  She reports having history of anaphylaxis to bee stings, most recently needing treatment about 2 summers ago.  Today after the vaccination she began developed symptoms that were reminiscent to her of that.  Soon after receiving it, she said she was feeling sweaty, starting to become out of breath, and felt like she had swelling developing in her throat.  She noticed that she was breathing with some difficulty and started to feel tingling in her face hands and feet.  She received an epinephrine intramuscular injection and soon after her symptoms started to improve.  EMS responded within minutes and brought her to the emergency department for further evaluation.  She did not have loss of consciousness.  She did not develop hives.  She had nausea but no vomiting or diarrhea.  She reports that with her previous anaphylactic reaction to bee stings, she did not develop hives or GI symptoms, but felt like she was puffy all over and had airway symptoms.  Today she and her husband do not think that she started to have a change in her voice, but she did think that her throat was starting to swell.  After arrival in the emergency department, she said it was starting to feel a little bit harder to breathe again and that she is developing some central chest pressure. CHIEF COMPLAINT: POSSIBLE ALLERGIC REACTION     Assessment/Plan    DIAGNOSIS at time of disposition:   1. Vaccine reaction, initial encounter  2. Acute chest pain   MEDICAL DECISION MAKING From the description of her symptoms it is unclear to me whether she truly had an anaphylactic reaction to the vaccination or whether she instead had an acute anxiety reaction associated with hyperventilating.  The sense of tingling around the lips, hands, the along with her not having any change in the quality of her voice would tend to support this.  However she notes that with previous bee sting systemic reactions she did not necessarily have a change in voice if she gave her epinephrine quickly enough and typically did not develop hives then either.  To treat for the possibility anaphylaxis, I will also give her IV dexamethasone, IV diphenhydramine, IV famotidine.  Given her complaint of some chest discomfort, we will check an EKG, troponin x2, chest x-ray.  Given her history of diabetes and now having chest pain, I would have some degree of concern for ACS and will give her aspirin as we do the workup.  Her most recent workup was July 1, 2019 when she had a nuclear medicine stress test, with normal results.  She does seem to be hyperventilating and feels nervous, in addition we will give a dose of lorazepam.  If her symptoms improve, and her troponin is negative, based on her story EKG believe her HEART score would be 2 due to underlying risk factors and that she would be appropriate for outpatient followup of the chest pain.  From the reaction standpoint, if she is feeling well few hours later without any recurrence of symptoms, it would be reasonable to discharge her.   At this point her x-ray and labs are pending and I will sign her over to the oncoming physician.