Age: 68.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Dry eye, Eye swelling, Fatigue, Malaise
Clinical narrative: Tested positive for COVID-19 January 11th 2021. Feb 26th 2021 went in to get the first COVID vaccine around 1130 with Public Health. COVID vaccine manufacturer was Moderna. Given in the left deltoid, IM. Patient did stay an extra 30 minutes post vaccine b/c she has lots of allergies. About an hour After the vaccine she experienced pain in her left arm and up into her neck on the left side. Symptoms are very simulair to something that she ingested and had an allergic reaction to in the past. Felt okay the first day, second day (2-27-2021) she had chills, fatigue, aches and pains. Started to feel like she was improving on Monday around the 28th of February 2021. Fever was down.  Still felt fatigued. Nose felt like it was runnng, itching. Experienced dry eyes, started using the eye drops more frequently. Ear canals were itching. She noticed a tickle in her throat later. Not conscious of everything all the same time, she just didn't feel well overall. Vagina and anus were itching. Started to use the estradiol compound daily hoping that might help. Itchy all over and then realized that the reaction was sort of the same reaction she had in the past with the statin medication. Few days after that had abdominal bloating and cramping, also loose stool and finally diarrhea. Around that same time she reports that she was very dizzy and saw stars, had to sit down, did not actually faint. Denies any fainting episodes, but felt faint. Resolved after 5-10 minutes of sitting down, did not feel clear headed after that for several days. Did do her daily walk, starting on 2-28-2021, felt like she had less stamina.  Feels more tired in general still now. Does regret getting the COVID vaccine now. Took some benadryl at the time of the reaction and at hs PRN, benadryl makes her feel drowsy. Takes zyrtec, flonase daily and singulair. Pt's husband is a physician, and he prescribed a Medrol dose-pak, which did not seem to help. At the time was taking all of her prescribed medications amlodipine, benazepril. Has taken pepcid for heart burn in the past, was not taking it as the time.  Taking prn omeprazole. Denies experiencing any wheezing. Experienced Generalized swelling of eyelids, face, hands, feet. Tongue is kind of swollen today, and she feels like it has been swollen on and off since the vaccine. Prior to the vaccine she felt pretty good overall. Went out for a few days and went skiing with her family. Has a place out of town that she deep cleaned, felt like maybe she over did it, but she recovered after she rested briefly. Was due for the second vaccine last week. She held off until she could discuss with her doctor, and they discussed that she should not have any further doses. Physically she felt that she should not receive the 2nd vaccine. Continued  symptoms include itchy throat (tickle), vaginal and anal itching all day every day. Itching has become a little more like soreness of the tissues.  No bruising. Patient has not had the shingles vaccine (Shingrix), thinks she should not get it now. She has pretty much avoided getting vaccines throughout her life b/c she has had poor reactions to flu shots in the past as well.  One year, we tried a "half-dose" regimen of the flu shot, giving 0.5ml IM , waiting one month and repeating 0.5ml IM.  She did tolerate this well with no reported adverse outcome and did not get influenza that year though it was very active in the community. Since the Moderna vaccine, pt describes  Abd distention, bloating of small intestine, "I look 6 months pregnant." pt states her stomach has been like this since the COVID vaccine reaction.