Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Condition aggravated, Cough, Decreased appetite, Diarrhoea
Clinical narrative: 1/28- Moderna vaccine to left deltoid approximately 1000 AM. Felt fine the rest of the day. Very tired in the evening and went to sleep early. Took PM medications- Xyzal 1 tab PO HS, Xanax 0.5 mg PO HS. 1/29-Woke to Left arm was sore, felt like I had received TDap injection, like I was punched in the arm- localized to Deltoid.  Took AM medications as normal- Wellbutrin XL 150 mg QD, Effexor 75 mg QD, B12 SL, Multivitamins QD As the day progressed, left arm soreness and discomfort became more pronounced and then went from localized to circumferential to left arm. Also noted discomfort and soreness to left axilla and soreness to left lateral/posterior cervical neck area. Became increasingly tired, weak, left arm was weaker than right arm with grip.  Headache was pounding and predominantly bilateral temporally.  Decreased appetite. Non productive cough.  Mid day, started to have freezing bilateral upper and lower extremities. Applied wool socks and clothing layers to accommodate. Temperature to forehead was 99.0, Right ear 101.4 and Left ear 102.0. Pulse ox 97% on room air. Took 1 gram APAP prophylactically, also took Zicam SL. Tolerated as much PO fluids as possible, water.  Increased flu like signs and symptoms for the rest of the day, no actual fever recorded. Literally had on thermals, top and bottoms. 2 pair of wool socks, gloves, and a hoodie. Wrapped in bed with 2 blankets.  Through the night, had discarded all clothing and remained in shirt and had sheet covering. Difficult night sleeping with the soreness to left arm and left axilla, was not able to get comfortable.  1/30- Woke, still, felt signs and symptoms of flu, body aches, pains, weak, tired, and decreased appetite.  A noticeable audible wheeze, shortness of breath with minimal exertion, and persistent dry cough. Cough remained non-productive.  All other signs and symptoms from the day before remained and the soreness to the left upper arm, left axilla, and left neck. Flu like signs and symptoms were just as intense as day before. Chills were consistently inconsistent with start and end, noticeable bilateral hands and feet were freezing. Afebrile, pulse ox 97% room air . Continued to treat prophylactically with APAP and Zicam, po fluids, rest.  1/31- Difficult night sleeping again related to discomfort to left side of upper torso. Felt a little better concerning weakness and being tired. Headache subsided some from it?s intensity. Started to have stomach discomfort, diarrhea, and remained short of breath with minimal exertion. Felt as if I was not able to expand my lungs to their full capacity, thus yawned a lot and had to continue to try to expand lungs. Continued to have flu signs and symptoms (not as intense as past 2 days), diarrhea STARTED, and feeling tired continued. Shortness of breath decreased in severity and lungs continued to feel a decline in expansion with inhalation. Continued to treat prophylactically and rest. Pulse ox 99% room air. Afebrile. 2/1- Difficult night sleeping related to left upper torso soreness and discomfort. Diarrhea continued into this day. No nausea. Tolerating PO fluids; however, feeling weak and tired.  Left upper arm soreness and discomfort less than initial onset. Left axilla remained sore and left side of neck. Pulse ox 99% room air. Afebrile. 2/2- Diarrhea subsided, flu signs and symptoms continued to decrease in initial intensity. Shortness of breath not as extreme; however, continued to feel as if not able to expand lungs to full capacity. Left upper arm soreness and discomfort almost resolved, left axilla beginning to decrease in soreness along with left side of neck. Only prominent s/s is feeling tired and inability to expand lungs to full capacity. Pulse ox 99% room air. Afebrile. 2/3- Feeling 95% better, closer to baseline. Worst days were the first 2 after the injection; however, still remain unable to expand lung capacity to full expansion with inhaling, thus requiring multiple attempts and yawning. Pulse ox 99% room air. Afebrile 2/4- 99% to baseline and feeling better, continue to have decreased expansion of lung capacity. Pulse ox 99% room air. Afebrile