Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Anaphylactic reaction, Chest discomfort, Dizziness, Dysphonia, Fatigue
Clinical narrative: Called patient to follow up on her reaction to the COVID vaccine administered on 3/4/21. She was transported by EMS to the ER after having anaphylaxis to her second Pfizer vaccine. She states she was hospitalized in the ICU overnight and was discharged home this afternoon. Patient feels she is doing much better. She does note feeling very tired from all the medications they gave her. She plans to call her PCP on Monday to schedule an appointment and has follow up scheduled with allergy specialist. She denies any further questions or concerns. Patient is appreciative of phone call.    Progress Notes: 3/4/2021      Subjective Patient is a 74-year-old female who was seen at COVID Vaccine Clinic today for her second dose of the COVID 19 vaccination.   She was given the Pfizer vaccination in the left deltoid muscle.  During her 30-minute waiting period after the injection, the patient began to experience hoarse voice.  She denied rash, difficulty breathing, difficulty swallowing, dizziness, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and she was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to rapid progression of symptoms.   PMH of anaphylaxis x 3, with one hospitalization.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of chest tightness (she later developed chest tightness when she was in the bay prior to epi-pen administration.)   Patient denies chills, fever, malaise/fatigue, facial swelling, cough, shortness of breath, wheezing, rash, hives, eczema, itching of skin and abdominal pain    Hoarse voice.:  Negative for nausea:  + lightheaded.:     Previous Reactions: anaphylaxis to medications. Never to vaccines. Pt's husband with her today. He states she progresses rapidly with her anaphylaxis and wishes for her to get epi pen now based on her symptoms.  She typically starts out this way.      Vitals:   03/04/21 1135 03/04/21 1140 BP: (!) 187/100 (!) 163/95 Pulse: 93 95 Resp: 18 16 SpO2: 100% 100%        Physical Exam Constitutional:      Appearance: She is well-developed. She is not toxic-appearing or diaphoretic.     Comments: flushed  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: Clear airway. Voice is hoarse.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Gait: Gait normal.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: benadryl 50 mg IM R leg antihistamines and epinephrine x 1 at 1136 in L leg Follow up response to treatment: good. She started to have return of symptoms when AMR was leaving with her. Patient discharge: Transported to ED by ambulance.  Differential Diagnosis: Anaphylaxis (dyspnea, stridor, drooling, tongue swelling)   Pt with early onset of presumed anaphylaxis that responded well to epi-pen. Pt sent to ED for closer observation/treatment via AMR.  Husband voiced great appreciation of pt's care today.     3/4/2021 11:40 PM   Addendum: ED charge nurse, RN was notified of patient coming.