Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Blood magnesium normal, Blood thyroid stimulating hormone normal, Electrocardiogram, Full blood count, Hyperhidrosis
Clinical narrative: Adverse reaction to covid vaccine sent o ED First immunization 12/30/2020 Pfizer Second immunization 8/25/2021 Pfizer (admit to ED 8/25 0948, discharged from ED 1416)  Pt came in for 2nd Pfizer vaccine where she reported her first dose (back in December 2020) caused "a hot tingly feeling going from the injection site, which happened 3 different times and then started sweating and threw up twice." Pt was sent to the ER after 1st dose and continued to have episodes of tingling and vomiting on and off for 5 days. Pt reported extremely dry mouth each time. Pt reports seeing cardiologist and allergist, both of which found no issues with pt health or vaccine. Both providers gave pt okay to get 2nd dose. Pt received 2nd dose at 8:56AM on 8/25/21 and within 5 minutes reported the tingling sensation again. Pt was given 25 mg liquid diphenhydramine in case of allergy, but reported no other symptoms. Pt sat in waiting area for around 45 minutes and had 3 episodes of tingling that were getting longer with each episode. Pts blood pressure was taken twice (~162/88 and ~152/80), but patient reports she was nervous and anxious which was playing a role in high BP. Pt was sent to ER for further monitoring.   Patient is a 58 y.o. female presents to ED for a possible allergic reaction to the Pfizer COVID vaccine. Pt explains that she received the second dose of the vaccine around 0900 today. Afterwards, pt began having whole body tingling and sweating. Pt reports a similar reaction during her first dose of the vaccine in December 2020. Pt was told to come to ED for further evaluation. Pt has already taken an antihistamine before coming to ED.    Patient denies F/C, N/V, CP, dyspnea.    Date/Time: 8/25/2021/9:53 AM   Attending Attestation: The documentation was recorded by acting as scribe in my presence at the time of the encounter and accurately reflects the service I personally performed.  Vaccine reaction, initial encounter Diagnosis management comments: Patient seen and evaluated by Doctor and care followed by PAC.  Patient with past medical history of MI reports for evaluation neuropathy following 2nd dose of COVID vaccine.  Patient states she had her initial vaccine in December 2020.  Following that dose she experienced intermittent burning/whole-body tingling described as being of her head radiating to her toes.  She was seen at multiple ERs and was told she was having vasovagal response.  Symptoms resolved after several days.  She was told prior to 2nd dose to self medicate with antihistamines and complied.  She reported for her 2nd dose this am at 9.  She reports similar burning sensation that began almost immediately after injection; she was told to report to ED for further evaluation.  Patient states the sensation begins at her head and radiates door her feet and is described as a burning/tingling sensation.  She also reports associated dry mouth that was similar to previous injection and body aches beginning in her lower back.  Denies any previous illness, fever, chills, chest pressure, palpitations, shortness of breath, difficulty swallowing, headache, vision changes, injection site reaction, rashes, or any other associated weakness.  Physical exam reveals no focal neurological deficits.  Will further evaluate with EKG, CBC, TSH, magnesium, CMP.   Laboratory evaluation unremarkable.  EKG with normal sinus rhythm.  After initial episode, Patient continues to have no complaints while in the ED for observation upon re-evaluation.  Discussed side effects and return precautions at length with patient.  She will continue Benadryl for the next 24-48 hours and may take Tylenol/ibuprofen for any body aches that may arise.  Patient will follow-up with primary care provider or return to local ED for any new concerns as discussed including chest pain, shortness of breath, difficulty swallowing.