Age: 23.0
Sex: F
Vaccine: COVID19
Symptoms: Electrocardiogram abnormal, Fibrin D dimer normal, Full blood count normal, Hyperventilation, Metabolic function test normal
Clinical narrative: From ED note:  Briefly, this is a 23-year-old female with past medical history of not allergies, asthma who presents for evaluation of shortness of breath, nausea and chest discomfort following Covid vaccine 30 minutes prior to presentation.  Patient received her first dose of Pfizer Covid vaccine this morning, was observed and ultimately started to drive home with mother when she developed shortness of breath, nausea and chest discomfort.  These have been progressive.  She reports she is not taking her Flovent.  No vomiting, no rash, no weakness, headache or dizziness. Remainder of history per note above.   Vital signs as noted above (tachycardia, tachypneic).  On physical exam, the patient is anxious appearing, hyperventilating; HEENT exam with MMM, clear conjunctivae, normal TMs & clear oropharynx without uvular swelling or edema; neck is supple; cardiovascular exam is stable with regular rhythm, mild tachycardia, no murmurs; pulmonary exam is clear to auscultation bilaterally, good aeration, no wheezes; abdomen is soft, non-tender & non-distended; neurologic exam nonfocal, moves all four extremities, 5/5 strength in upper and lower extremities, carpal spasm of bilateral hands (L>R).   My impression is that this patient is having a panic attack given her rapid onset of hyperventilation, chest discomfort, and bilateral carpal spasms. Carpal spasms improved with controlled breathing. Considered anaphylaxis given patient's history, but absolutely no wheezing, rash or significant GI symptoms; no hypoxia; no hypotension. Epi-pen at bedside, but not given. Considered asthma, but no wheezing - patient is not wheezing and has good aeration on exam, she is requesting albuterol, which I think will help with her anxiety surrounding this - 2 puffs given. No evidence of persistent tachycardia to suggest PE (no OCPS). Initial ECG with sinus arrhythmia, one PVC, slightly prolonged QTc 477 - will check repeat. Patient briefly on NRB for comfort - slowly able to be weaned off and during observation in ED, symptoms improving but not completely resolved. Repeat ECG w/ NSR, slightly prolonged QTc 460. Given persistence of symptoms, patient given epi-pen and had almost complete resolution of symptoms within 10 minutes. We will plan to observe for 4 hours post-epi administration. Recommended discussion of second COVID vaccine with primary care provider but may have to avoid given this could have represented a serious allergic reaction. Recommend follow-up with PCP/cardiology for repeat EKG.   Admit to Ed Observation Status  Diagnosis: Allergic reaction  Goals of observation: (1) Ensure continued improvement of symptoms, (2) Improved HR  Interventions: (1) CRM, (2) Close monitoring, (3) Frequent exams  5/7/2021  15:00   23-year-old female received COVID-19 vaccine today and after which developed shortness of breath.  Initially felt this was anxiety however symptoms persisted.  Treated with albuterol as well as epinephrine and observed.  Developed shortness of breath and complaints of chest pain after approximately 3 hours of observation.  Repeat EKG obtained and is normal.  Labs were obtained which demonstrated normal CBC.  Normal D-dimer.  Normal electrolytes but an elevated TSH (known hyperthyroidism).  Treated with cetirizine and steroids with improvement of her symptoms.  Discharged with PCP follow-up in 2 days.