Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoaesthesia, Hypoaesthesia oral, Injection site erythema, Injection site pain, Injection site swelling
Clinical narrative: She received first dose of Moderna vaccination on 1/5/2021 into left deltoid. It was painless. Approximately half an hour after injection, she began to feel tingling in the left arm, hand, and fingers. It resolved on its own and she was fatigued that evening and went to bed early. The next day she had soreness of the arm, fatigue coming through the day in waves. On 1/7, low grade fever of 99.1, headache, and fatigue. She slept for 14 hours. From 1/8-11 she had no significant issues although she did feel slightly off balance. On 1/12, she noticed left axillae lymphadenopathy and had soreness at the injection site again, which worsened the next day. On 1/14, arm was red, swollen, and tender to touch. These symptoms persisted the next day and she began to have numbness and pins and needles of the left hand. She was given 7 days of dexamethadone and cephalexin by her PCP. She slept very poorly. The next day, the numbness, swelling, and redness were all improved. On 1/17, she continued to gradually improve and there was no swelling and only slight numbness. She did have fatigue, headaches, and insomnia.    On 1/21, she had visit with an allergist to discuss preventative measure for second dose. A delayed reaction was theorized and a preventative course of premedications was outlined. The next day, the numbness in the hand worsened and headache returned. On 1/23, she felt headache, confsuoin, anger, imbalance, pins and needles in the hand, difficulty holding a glass with one hand. On 1/24 pain at the injection site recurred. She felt there was change in her vision and hearing, nausea, vibration throughout the body, mouth numbness, and heart racing. On 1/25 all these symptoms persisted other than improvement in confusion. On 1/26-27, she had continued pins and needles in hands and feet. Still felt vision and hearing were "off". She was fatigued and body felt "like jello". On 1/28, she was prescribed a second course of dexamethasone as well as citalopram 20mg and diazepam. With citalopram, she had nausea, hot/cold sensations, dizziness, insomnia. She also had itching of the arm, back, leg; tremor, thirst, and pallaor. She reported symptoms to PCP and citalopram was discontinued next day. On 1/30-31 she felt disoriented at times, intermittent arm soreness, noted small abnormal bruising, hot/cold, off balance, headache, and fatigue.    Since that time, predominant symptoms have been daily headache. Wakes with left posterior dull aching which escalates through the day 5/10 but will become 8/10 if she does not take anything. She is taking ASA in AM daily with second dose around 3PM when headache recurs approximately 5x/week. Sensation in feet has normalized, but she continues to have numbness in left>right hand. She feels off balance with need to specifically concentrate when walking. No falls. She also has persistent abnormal tremor of left finger. When she goes to type, she will press key 3-4 times. She feels difficulty opening water bottles, but is able to do some. She is lifting pans with both hands.