Age: 52.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Asthenia, Blood creatine phosphokinase MB, Blood creatine phosphokinase increased, Blood creatinine normal, Blood magnesium normal
Clinical narrative: Narrative:  51 Y.O. FEMALE patient w/ PMH significant for migraine (w/ aura that includes vision loss and ear symptoms), occipital neuritis, neck pain, lower back pain (disc buldge 145), wrist pain, b/l knee pain (prior ? stress fracture), heel spurs, and ear pain. The following details were summarized from the 4/28/21 note & 4/21/21 vaccination administration note: On 4/15/21, the patient had a nerve block at the facility for occipital neuralgia on the left side. She suggests that she had symptoms after the nerve block; had noted a bit more bruising on the neck and had felt that her left arm had felt "puffed up" after the nerve block. On 4/21/21, the patient received her 1st Moderna COVID-19 vaccination at a vaccination clinic at ~10:57am. Shortly after the injection (approx 10 minutes-11:10am), she started to c/o "L arm numbness, tingling, and warm sensation." MD was at patient's side. Vitals taken: BP: 124/82, P:70, O2: 97%. Grip strength checked: patient had equal strength in bilateral arms/hands. Patient further assessed by clinic MD. Patient c/o acid reflux at time of assessment and given diphenhydramine 25mg and famotidine 20mg PO (with crackers). Patient tolerated medication well. At approximately 11:20, patient c/o numbness progressing to L side of face and forehead. 911 called so that patient could be taken to outside ER for further work up. Vital signs recheck: BP: 133/79, P:68, O2:98% Patient transferred to outside ER and had ct/cta/mri done without findings. neurology was consulted via telemedicine and picture was consider either one of complex migraine or side effect of her 4/15/21 occipital nerve block. Notes from outside ER suggest her neurologic exam showed 5/5 strength and there were minimal? findings on observation of her face regarding facial droop. There was not mention of slurred speech but patient suggest that this persisted throughout that day. Her other symptoms resolved within 5 days. She stated she had other reactions to the shot including body aches, sore arm, and fevers. Notably, due to a prior reaction to the H1n1 shot, she had recently been referred to an allergist to address the safety of vaccination in general and was felt by that allergist to not have had a true allergic reaction to the h1n1 shot and was advised to proceed with the Moderna COVID-19 vaccination. She has since contacted her allergist to discuss the safety of getting the second Moderna shot and was advised to get the 2nd dose and stay for longer observation. On 9/17/21, patient received her 2nd Moderna COVID-19 vaccination at a vaccination clinic. On 9/20/21, the patient called the Telephone Care Program reporting, "body chills, fever of 102, body weakness, migraines, & bruising of the L arm due to getting the C-19 vaccine on9.17.2021 x 4 days." Later in the progress note it states, "Patient report fever, migraine, SOB, loss of taste and cough that began 3days ago after getting the second dose of moderna. Symptoms have not improved after day 3 and she is worried because developed stroke like symptoms after the first dose in April." Considering symptoms of SOB and loss of taste, she was advised to proceed to the ED to r/o covid. Per 9/29/21 primary care nursing call, patient stated she did not go to the ER after the 9/20/21 telephone care program call. Per progress note, "Her fevers resolved soon after call in so she felt stable to not present to ER. had issues with migraines, bruising, fevers post injection." Per note, patient reports, "Feeling fine today, however there was a linger skin "bump" near her wrist which she says was unusual, some swelling and area looks like "a bee sting"." [Regarding her headaches, in addition to the nerve block for the occipital neuralgia, she had also been getting botox but the last injection for that was earlier in March 2021.]