10/30/21 (day of vaccine) ED visit: 61yF h/o asthma, cerebral meningioma presents with concern for allergic reaction to Pfizer booster 2/2 tongue swelling and lip tingling. Received booster at 15:45 and received epi pen @17:05. No fever, rash, chest pain, shortness of breath, nausea, vomiting, urinary or bowel irregularities    Review of Systems  Constitutional: Negative.   HENT: Positive for facial swelling.   Respiratory: Negative.   Cardiovascular: Negative.   Gastrointestinal: Negative.   Genitourinary: Negative.   Musculoskeletal: Negative.   Skin: Negative.   Allergic/Immunologic: Negative.   Neurological: Negative.   Hematological: Negative.   Psychiatric/Behavioral: Negative.    Physical Exam ED Triage Vitals [10/30/21 1755] BP: 116/73 Pulse: 60 Pulse from  O2 sat: n/a Resp: 18 Temp: 98.1 °F (36.7 °C) Temp src: Oral SpO2: 96 %   BP (!) 99/57  | Pulse 67  | Temp 98.1 °F (36.7 °C)  | Resp 18  | SpO2 100%   Physical Exam Vitals reviewed.  Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic.     Right Ear: Tympanic membrane normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No posterior oropharyngeal erythema.     Comments: Airway patent, No tongue or lip swelling Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: No stridor. No wheezing, rhonchi or rales.  Chest:     Chest wall: No tenderness.  Abdominal:     General: Abdomen is flat. There is no distension.     Palpations: Abdomen is soft. There is no mass.     Tenderness: There is no abdominal tenderness.     Hernia: No hernia is present.  Musculoskeletal:        General: Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not jaundiced.     Findings: No bruising, lesion or rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert.  Psychiatric:        Mood and Affect: Mood normal.   ED COURSE Patient Reevaluation: 61yF h/o asthma, cerebral meningioma presents with concern for allergic reaction to Pfizer booster 2/2 tongue swelling and lip tingling. Patient well appearing, maintaining airway without evidence of  Respiratory distress. Will give fluids, steroids, pecid benadryl, and monitor and reassess  2211 Doctor: Patient reassessed and reports improvement of symptoms. Strict return precautions have been given. Patient will be prescribed epi pens. All questions answered and concerns addressed  10/31/21 return ED visit 61 yo woman with Hx of asthma with recent ED visit for angioedema and ?anaphylaxis who presents to the ED again for facial swelling and concern for worsening symptoms.   Symptoms began yesterday after receiving COVID booster, manifested as facial swelling, swelling of the tongue, no respiratory distress or loss of consciousness, unclear if BP dropped, but received 1 dose of epi in vaccine center and transferred to ED, received steroid, antihistamines, and IVF, discharged with recommendation to have epi-pen accessible, apparently with no outpatient treatment.   Today, she presents with some worsening of facial swelling and peri-orbital swelling, denies shortness of breath, wheezing, chest pain, palpitation, nausea/vomiting, abdominal pain, skin rash. She has not secured epi-pen as she wanted to wait until Monday when she can take it from Hospital pharmacy. The history is provided by the patient.  Allergic Reaction Presenting symptoms: swelling   Presenting symptoms: no difficulty breathing, no difficulty swallowing, no itching, no rash and no wheezing   Severity:  Mild Prior allergic episodes:  Allergies to medications Context: medications   Relieved by:  Antihistamines and steroids Worsened by:  Nothing   Patient with mild facial swelling and slightly enlarged tongue size, suggestive of delayed-phase allergic reaction (angioedema), HDS with no evidence of airway compromise.  - Explained the natural Hx of allergic reaction to the patient, explained that complete resolution of symptoms will take 3-5 days - IV methyl-prednisone, benadryl, and famotidine - Encouraged to have epi-pen all the times for the next 3-5 days - loratadine 10 mg tid - Prednisone 20 mg for the next 3 days - Discharge home with return precautions 11/1/21 3rd ED visit: Patient presents today with new chest pressure radiating to jaw since this morning.  Positive nausea.  No diaphoresis or exertional symptoms.  Patient received 5 her vaccine Saturday afternoon this is her 3rd visit in 3 days 1st 2 visits were for presumed allergic reaction for which she was given antihistamine steroids.  Symptoms prompting today's visit are different, predominantly chest pressure.  No vomiting.  Patient continues to feel sensation of oropharyngeal swelling was given intravenous Solu-Medrol yesterday took prednisone this morning was waiting on taking Claritin.   Admitted for chest pain observation.  Abnormal stress test by EKG only with no pain No coronary artery calcification Most likely a false postive Follow up with PMD in one to two weeks Return with any worsening symptoms