Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Cough, Dry mouth, Dysgeusia, Pain in extremity, Rhinorrhoea
Clinical narrative: ASSESSMENT: 57 y.o. female with PMHx of HTN who presented today to the Vaccine site for her second COVID vaccine. She c/o only a sore arm for 1-2 days after her first vaccine but otherwise tolerated it well. NKDA. She states that about 5-10 min after the vaccine she developed rhinorrhea so she went to the bathroom and blew her nose and it improved some but did not resolve. She did not inform us of this until her 15 min timer went off so I completed an evaluation.   I am the physician assistant on site at the vaccine clinic who  monitors the patients and is there for emergencies. If a patient feels they are having a reaction I complete an exam on the patient.    She states the rhinorrhea was still there but was better than it was. Associated with a sensation of "oil in my throat, like eating some butter" but denies throat itching or tightness. Associated with intermittent dry cough and throat clearing. Denies difficulty breathing, wheezing, tongue/lip swelling, mucosal or skin itching, hives, palpitations, lightheadedness, dizziness, SOB, headache, nausea, vomiting, diarrhea, abdominal pain.    She has experienced similar rhinorrhea and dry cough in the past with certain medical masks like the one we provided her today. She also experiences this with her seasonal allergies. Her allergies have not been flaring up the last 2 weeks or so but they were before that. She states she has dry mouth and has to drink a lot of water or she will develop a dry cough and throat clearing like she has today.   Reports she has never had an allergy to any vaccine or injectable medication in the past.   ROS:  Constitutional: Negative for chills, fatigue, fever, diaphoresis and weakness.  Eyes:  Negative for blurred vision, photophobia, vision loss and visual disturbance.  E/N/T:  Positive for rhinorrhea. Negative for hearing loss, ENT Pain, ear pain, nasal pain, sore throat and hoarseness.   Cardiovascular:  Negative for chest pain, palpitations, tachycardia, edema, dyspnea on exertion, irregular heartbeat and near-syncope.  Respiratory:  Positive for cough (dry, intermittent, associated with PND). Negative for shortness of breath, wheezing and sputum production.   Gastrointestinal:  Negative for abdominal pain, diarrhea, stool changes, nausea and vomiting.  Musculoskeletal:  Negative for myalgias.  Integumentary:  Negative for pruritus, rashes, color change and flushing.  Neurological:  Negative for dizziness, headaches, paresthesias, weakness, difficulty with concentration, disturbances in coordination, focal weakness, light-headedness, loss of balance and vertigo.  Allergic/Immunologic: Positive for allergies and environmental allergies. Negative for frequent illnesses, urticaria, hives and persistent infections.  Psychiatric/Behavioral:  Negative for anxiety and depression.      OBJECTIVE:   Vitals: 15 min after vaccination  B/P: 140/88 Pulse: 70 Temp: 98.2  Resp: 12 SpO2: 99%    Vitals: 25 min after vaccination  B/P: 148/90 Pulse: 68  Resp: 14 SpO2: 98%    Vitals: 40 min after vaccination  B/P: 150/92 Pulse: 67  Resp: 12 SpO2: 99%    Vitals: 70 min after vaccination  B/P: 142/82 Pulse: 70  Resp: 12 SpO2: 99%    PHYSICAL EXAM CONSTITUTIONAL Vitals reviewed.  GENERAL APPEARANCE: Well-developed.  GROOMING: Well groomed.  LEVEL OF DISTRESS: The patient is not distressed, nervous/anxious, diaphoretic or tearful. She appears to be well. The patient is not lethargic or toxic. The patient does not appear tired.  EYES:  LIDS/CONJUCTIVA: Lids and conjunctiva are normal.  PUPILS/IRIS:  extraocular movement intact. ENT EXTERNAL EARS/NOSE: External ears and nose are normal. SEPTUM/MUCOSA: Negative for sinus tenderness. LIPS/TEETH/GUMS: Normal lips, teeth and gums. No lip edema. OROPHARYNX:Mucosa:  Mucosa appears normal. No edema of lips, face, tongue, oropharynx or posterior pharynx  NECK: Neck normal. RESPIRATORY EFFORT AND PATTERN: Effort normal. No tachypnea, intercostal retractions, accessory muscle usage, hypopnea and irregular rate. AUSCULTATION: Normal breath sounds with no rales, rhonchi, wheezes or rubs. No coarse breath sounds or decreased breath sounds. CARDIOVASCULAR AUSCULTATION: Rate: Is normal.  Rhythm: regular. Heart sounds:  S1 is normal.  S2 is normal. S3/S4 not present. With no murmurs heard. EDEMA/VARICOSITIES: No edema or varicosities. RADIAL: radial pulses normal bilaterally PEDAL PULSE: Normal bilateral posterior tibal pulses.  LYMPHATIC OTHER NODES: No neck adenopathy. MUSCULOSKELETAL STABILITY: Normal stability. INTEGUMENTARY SKIN INSPECTION: Normal.  PALPATION: Normal. No diaphoresis, no flushing, no urticaria Injection site is unremarkable, no swelling or erythema  NEUROLOGICAL GAIT, COORDINATION, REFLEXES  Gait: normal PSYCHIATRIC ORIENTATION: She is alert and oriented to person, place and time. MOOD/AFFECT: Normal mood and affect. INSIGHT/JUDGEMENT: Normal insight/judgement. The patient has good insight with good judgment.            ASSESSMENT/PLAN:    Rhinorrhea - Airway remained clear, breathing was normal, circulation was good and mentation was good.  - She was monitored for 60 min after the rhinorrhea began, vitals remained stable and WNL (despite slightly elevated BP). She drank 1.5 bottles of water which improved her dry cough. She stated she was feeling back to normal before she left the clinic.  - Warned her that she likely was having a mild allergic reaction to the vaccine and warned that it is possible for allergic reactions to worsen. Reviewed signs and symptoms of anaphylaxis in detail and gave strict ER warnings if any develop, especially difficulty breathing, throat/facial swelling or any worsening symptoms occur. Warned her while driving to work (15 min drive) she keep an eye on her symptoms and pull over and call 911 if any signs or symptoms of anaphylaxis develop.  - Advised she take a non-sedating antihistamine like Claritin on her way to work. I advised she let her colleagues at work now to keep a close eye on her at work.  - She expressed understanding and stated she was feeling well and wanted to go to work - All questions were answered.   I informed her PCP and sent them my note.  I called 4 hours after the vaccine to follow up  but had to leave a voicemail,.  I spoke with her the following day on 3/31/21 and she stated she felt great besides localized soreness at the injection site. Otherwise she felt well. The rhinorrhea, cough and throat clearing had completely resolved after taking 1 claritin. Denied shortness of breath, difficulty breathing, wheezing, fever, chills, n/v/d, chest pain, hives, itching, palpitations, dizziness, syncope, neear syncope or headache.   She did not require any further treatment and did not need to have a visit with her PCP and did not need to go to the ER or hospital.