Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Ophthalmological examination, Oxygen saturation, Pharyngeal paraesthesia, Physical examination, Psychiatric evaluation
Clinical narrative: throat tightness; chest tightness; feverish condition; unable to articulate; SOB; Dizziness; anxious; posterior oropharynx tingling/ felt the back of her throat tingling; allergic reaction; This is a spontaneous report from a contactable consumer (Patient herself). A 44-year-old female patient received first dose of bnt162b2 (Solution injection; Batch/Lot Number: EP7533), via an unspecified route of administration, administered in Arm Left on 15Apr2021 (at the age of 44-years-old) as single dose for covid-19 immunisation. Medical history included ongoing anxiet panic attack in 2019 and never smoker. She had no known medication allergies. She never smokes. Her family history was negative. Concomitant medications included aspirin [acetylsalicylic acid], docusate sodium (COLACE), hydromorphone hydrochloride (DILAUDID) , methocarbamol (METHOCARBAMOL), camphor, menthol (SARNA [CAMPHOR;MENTHOL]) and paracetamol (TYLENOL). On 15Apr2021, patient experienced throat tightness and shortness of breath (SOB), feverish condition, dizziness and unable to articulate onset approximately 15 minutes after receiving dose 1 of PFIZER vaccine. She was brought to the ER for possible allergic reaction to Pfizer Covid vaccine. She started having some tightness in her chest and felt the back of her throat tingling. She has no other allergies to anything else. She was given 0.3 mg of 1M epinephrine. Currently the patient stated she was feeling somewhat better. She denies any shortness of breath. Denies any facial or tongue swelling. She had posterior oropharynx tingling. Neck: Denies neck pain, neck stiffness  Cardiovascular: Denies chest pain, palpitations, syncope, edema Respiratory: Denies cough, dyspnea Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea  Musculoskeletal: Denies leg pain, leg swelling, myalgia, arthralgia, back pain Peripheral Vascular: Denies extremity swelling, extremity coldness, Neurological: Denies dizziness, headache, Integumentary: Denies rash, lesion, Allergic and Immunologic: + Possible allergic reaction; denies frequent infections, Hematologic and Lymphatic: Denies bleeding, bruising. All other systems are reviewed and are negative.ED Course/Discussion: Evaluation w/ HPI, physical exam, labs and studies as above. Hemodynamically stable. Airway intact. Patient had slight chest tightness and posterior oropharynx tingling after Covid vaccination today. She was empirically given 1M epinephrine. Overall she looks well. She has significant anxiety at baseline. Discharged home will observe for multiple hours. Patient reassessed. No wheezing. Posterior oropharynx symmetric with no edema. There is no evidence of anaphylaxis. Will discharge home for outpatient follow-up. The patient is well appearing and stable for discharge home. The patient was given an opportunity to ask questions prior to discharge and had none at that time following my verbal discussion of the plans for treatment, expected course, indications to return to ED and recommended follow up as planned. Advised to return if condition worsens. Pt verbalized understanding and agreement with plan and instructions. Physical examination showed that she had significant anxiety at baseline. She was empirically given 1M epinephrine. Discharged home will observe for multiple hours. Patient reassessed. No wheezing. Posterior oropharynx symmetric with no edema. There is no evidence of anaphylaxis. Will discharge home for outpatient follow-up. The patient is well appearing and stable for discharge home. Patient was advised to return if condition worsens. Patient received second dose of bnt162b2 (Solution injection; Batch/Lot Number: ER8735), via an unspecified route of administration, administered in Arm Left on an unspecified date as single dose for covid-19 immunisation. The patient underwent lab tests and procedures which included HENT examination showed atraumatic. Moist mucous membranes. Airway was patent. Handles oral secretions easily. Posterior oropharynx was symmetric with no erythema or edema. Uvula was midline. No edema to lips or face. Eyes examination showed pupils equal round; sclera nonicteric and noninjected. Neck: Supple. No evidence of meningismus. Respiratory/Chest examation showed no evidence of respiratory distress. Patient was speaking in full sentences without accessory muscle usage. Clear to auscultation biltaterally. NO wheezing, rales or rhonchi. Cardiovascular examination showed regular rhythm and rate, no murmurs. Upper extremity pulses are 2plus and symmetric. Gastrointestinal examination showed soft to palpation throughout, non-distended and non-tender. No rebound, guarding, or rigidity. Musculoskeletal examination showed moves all four extremities. No edema or calf pain. Well perfused. Neurological examination showed alert, awake, and appropriate. Normal speech. No acute neurological deficits appreciated. Skin was warm and dry. No rashes or lesions. Psychical examination showed good eye contact. Appropriate in content/context. Anxious affect. Looks well, was alert, awake, was conversive, and was in mild distress. Pleasant, anxious, cooperative with exam, resting comfortably in bed. Her Pulse oximetry on room air was 100 percent. Therapeutic measures were taken as a result of the events and patient was treated with 1M epinephrine 4 mg zorian ODT. The outcome of the events anxious, SOB, unable to articulate, feverish condition, throat tightness, posterior oropharynx tingling/ felt the back of her throat tingling and allergic reaction was unknown while the outcome of the event chest tightness was recovering.  Follow-up attempts are completed. No further information is expected