Age: 41.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Abdominal pain upper, Emotional distress, Feeling abnormal, Headache, Loss of personal independence in daily activities
Clinical narrative: P/C from patient. States she took the vaccine on 4/1/21 @ 1:30 PM. When she heard of the issues that were in the news about the vaccine she thought she should call.  4/1/21 Thursday: That evening around 6 PM she started to have a rash. It started on her L arm where she got her vaccination traveled up her neck, covered her face and trunk. It started out as an itchy red rash but became raised hives. It resolved on it's own and on Saturday she did not have the rash anymore. Never had any difficulty with breathing. Her left arm where she received her vaccination still has some discoloration. States on Thursday evening she started having a "brain fog".   4/2/21 Friday: The next morning she woke up and was unable to finish a sentence, states she was confused, "felt like I was on pain medication, like I was drugged". States she was confused, could not think and could not remember anything. Cried all day over nothing. Would tell her daughter something and then immediately ask what did I just say as she couldn't remember what she said. She was working on the graduation hooding ceremony and scribbled all over her papers like a 3 year old and the papers were strewn all over the floor. She reports that she had a mild headache all over her head dull pain and pressure 4/10. Took tylenol but that didn't help at all. Denies having any visual problems, trouble breathing or chest pain. Did have some abdominal dull cramping with nausea and even though it felt like she was going to have diarrhea there was no diarrhea or vomiting . The abdominal pain went away after friday but the nausea stayed through Sunday.She states she got lightheaded if she stood up too fast or turned her head too fast. This just happened on Friday. Denies having any weakness, lack of coordination, or speech issues. She states she was crying and could not stop all day on Friday. She told her boss she was having a mental breakdown and had to go home.  4/3/21 Saturday: Patient states she felt stupid, could not think, could not remember anything she said. States that the horrible headache came on Saturday. It was so bad she had to lay down in a dark room with a wet washcloth over her eyes. The horrible headache.lasted about 1 hour at a 10/10 level. Took some more tylenol but does not think it helped. Went to sleep and when she woke up the headache was still there at a rete of 4/10. She was still nauseate but the crying had resolved.  4/4/21 Sunday: Again, had a  severe migraine when she woke up. 7/10, not as bad as the one on Saturday. It lasted a couple of hours and then went back to the 4/10 headache that has persisted at the 3-4/10 level the entire time since she got her vaccination. The headache never stops hurting and stays 3-4/10.   4/5/21 Monday: Had a regular headache 3-4/10. Still felt "loopy" and with brain fog.  Went to work on Monday and told her boss about it and that she still says she can't think straight. Her boss has been very supportive and has helped her to complete her assignments to get them in on time.   4/6/21 Tuesday: Still had a  headache, It has been continuous ever since Friday. Still taking Tylenol and it doesn't seem to help. Yesterday she even tried Ibuprofen and it didn't help.   4/13/21 Today is day 13 and she still can't think straight. still has 3-4/10 headache, still all over her head. Feels that she still has brain fog, but not as "loopy". Feels like she can remember what she has said better.   She called the nurse line at her husband's work.They told her that it was just a reaction to the vaccine. The patient didn't think to report it to the Health Center.  She got the vaccine from the Health Center (she asked if employees could get the vaccine and said she would prefer that)  She is not pregnant.  She has no chronic health conditions and takes no medications routinely  She denies being allergic to any medications and states she has taken the Flu shot without any reaction in the past.  NOTE: Tested positive for COVID on 2/4/21 and was told it was OK to get the vaccine. She lost her taste and smell and said she felt she had a mild flu for a couple of days. Has regained her sense of taste and smell and has had no residual symptoms.   Instructed patient to go to the ER for an exam. She needs a full neuro exam and at least a C_T scan of the head. She would like to contact her Primary Care Provider. States she hasn't seen him for a couple of years but feels like he would want to know. Instructed patient to call me with the outcome of her visit to her PCP or the ER. Patient verbalized understanding of and agreement with plan.  Signed by: APRN-CNP on Apr-13-2021 at 04:04 PM Locked by: APRN-CNP on Apr-13-2021 at 04:04 PM