Age: 35.0
Sex: F
Vaccine: COVID19
Symptoms: Flushing, Swelling face
Clinical narrative: Three minutes after receiving the first dose of the Pfizer\BioNTech COVID19 vaccine today (time 11:34 am), this vaccine study participant developed swelling of both cheeks and "was able to bite on both cheeks" as well as vague flushing of the cheeks.  She did not immediately report these symptoms but returned to the site of her injection (research study site) and reported the cheek swelling and facial flushing to our study nurse.  She denied  lip/tongue/airway swelling, difficulty breathing, nausea or vomiting, diarrhea, cough, wheezing, shortness of breath, rapid breathing, fever, headache, paresthesias, rapid heart rate, chest pain, or other symptoms at that time.  I am a sub-I for Pfizer\BioNTech vaccine study and authorized an immediate dose of Benadryl 50 mg orally which she received.  I examined her at 12:40 pm and she had a reassuring physical exam as follows:  Constitutional:      Appearance: Normal appearance; well-hydrated and alert; no retractions, tachypnea, nasal flaring, or audible wheezing/breath sounds.  No pallor. HEENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal without visible discharge.    Mouth: Mucous membranes are moist.     Cheeks:  Minimal edema of both cheeks is present; no visible erythema on exam. Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equally round and symmetric. Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm, HR 80-90.    Pulses: Normal pulses in left wrist 2+/2+; warm hands. Pulmonary:     Effort: Pulmonary effort is normal; RR 12-14.    Breath sounds: Normal breath sounds.  Abdominal:     General: Abdomen is flat.  Neurological:     Mental Status: She is alert; speech and comprehension are normal. The patient still felt unusual by 2:00 pm and was referred to our Emergency Room for further evaluation.  In our ER, she had the following vital signs and exam findings: BP 140/87  | Pulse 73  | Temp 98.1 °F (36.7 °C)  | Resp 16  | SpO2 100%  Gen: well appearing, no apparent distress, speaking in full sentences, no dysphonia Head: normocephalic, atraumatic, no hematoma Eyes: pupils equal reactive to light, extraocular movements intact ENT: hearing grossly normal, oral mucosa moist without edema/angioedema Resp: speaking in full sentences, clear to auscultation bilaterally, no rubs/crackles/wheeze, normal effort Abd: normoactive bowel sounds, nontender nondistended, no rebound/guarding, no organomegaly, faint/resolving urticaria abd x2 Ext: no deformities, no joint swelling, no edema, faint patchy erythema bilateral upper arms Neuro: alert, nonfocal Psych: AAOX3, normal affect/mood   I walked to our emergency room and reexamined her, and the only new finding were some pink small nonraised popular lesions on her abdomen and proximal arms, but she had no urticaria.  Her lungs remained CTA and she was otherwise as before.  The emergency room only gave famotidine 20 mg to her and discharged her with an EpiPen to use at home (they specifically felt she did not need it in the ER), but gave her oral cetirizine 10 mg to take daily for the next few days.  I asked her how she felt upon discharge from the ER and she felt fine/normal.