Report #2869816

Received Oct 31, 2025

ER / ED visitOffice visit

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Overview

Sex: Male
Age: 54 yrs
State: NY
Recovered: Recovered
Vaccinated: Oct 17, 2025
Onset: Oct 19, 2025
Days to onset: 2
Hospital days: —

Vaccines (2)

Type	Name	Manufacturer	Dose	Lot	Route / Site
COVID19	COVID19 (COVID19 (MODERNA))	MODERNA	UNK	3052550	IM / LA
FLU3	INFLUENZA (SEASONAL) (FLUBLOK)	SANOFI PASTEUR	N/A	TFAA2546	IM / RA

Symptoms (9)

Chest discomfortComputerised tomogram abdomenDyspnoeaElectrocardiogram normalHyperventilationHypoaesthesiaMobility decreasedMusculoskeletal stiffnessTroponin normal

Symptom narrative

Shortly after dinner, patient experienced chest tightening and difficulty breathing while at home. The symptoms progressed over the course of an hour, causing the patient to hyperventilate. When the patient's hands became numb, they decided to go to the ER. On the way to the hospital, the patient's hands began to clamp down and stiffen, making it difficult to move them. No nausea, no abd pain. Patient was given fluids, mylanta, famotidine, toradol at ER and discharged home feeling better. Had follow-up w PCP 10/30/25 and currently without symptoms of GAD, labs pending. We are awaiting records from ED. Of note, it appears that patient had only received Pfizer vaccines prior to getting Moderna on 10/17/25.

Current illness

Medical history

h/o splenectomy (when age 3), tension headaches, hld (no meds), erectile dysfunction, macrocytosis since 7/2025

Other medications

flonase qday, tadalafil 5mg qday, loratidine 10mg qday, PO B12

Allergies

amoxicillin sensitivity (rash)

Lab data

EKG benign. CT chest, abdomen, pelvis done though patient is unsure of results - we have requested records. Troponin wnl.