Sex: U
Vaccine: COVID19, COVID19
Symptoms: Injection site pruritus, Injection site rash, Lip swelling, Magnetic resonance imaging, Neck pain
Clinical narrative: 9/4/2021 went to urgent care. 9/8/2021 Lip swelling seen in office Pt asked to come in to discuss, had sent numerous web encounters (multiple calls were made to pt to come in) and web encounters are below which were of concern for possible allergy/new meds, multiple symptoms. Hi Dr, I went to see my Uro/Gyn this morning. They wanted to put me on Estradiol but were detained because of my liver enzyme report that popped up from 2020.I told Dr that my levels had normalized since then but she said that system required them to see lab work proving that. I told her that you had just taken blood work so could you please send to Dr?  Thank you! I wanted to give you an update. I didn't go to the ER because a couple of EDS friends shared that they get the symptoms that I was experiencing and said that the hospital would just stabilize me and send me to see a specialist. More specifically a neurosurgeon so I decided to go that route since it was on my list of to do's that you and I discussed anyway. I took 3 ibuprofen and was able to sleep. I also had to take Benadryl because the arm where I got the covid vaccine started itching because of a rash. I looked it up and found that this can happen sometimes 5 days  after getting vaccine. I will keep you updated. Thank you:) Called clinic-Left message for Dr 9293734480-no call back, as per receptionist no documentation of reaction to covid pos lip swelling on Sat. Called NOERTHWELL URGENT CARE: again patient was told VISIT REPORT WAS REQUESTED FOR 9/4/2021. WILL BE FAXING TO US TODAY-WITHIN THE HOUR-no report or call back, discussed with pt if any swelling or SOB to go to ER-also discussed that she should ask the UC if VAERS was needed or reported, per Sim and our Nursing, should be done at UC if they felt reaction to COVID 19. Pt also started on new medication at same time of her swelling which could cause angioedema, epi pen prescribed and given and showed how to administer and when. Pt presents to discuss allergic reaction, possibly to Covid vaccine and recommendation on if should  receive 2nd shot. Pt got the Moderna vaccine on Aug 11th. 5 days later awoke with left arm itchy and swollen. She saw her PMD that day who marked area of redness and advised her to take Ibuprofen. Since that time, she has been having rashes on chest and ears, and itching, then lip and tongue swelling. Pt went to urgent care 4 days ago to get Covid tested as had exposure last Thursday and while there asked to be evaluated for this. She reports that she was given steroid shot and prescribed Medrol Dosepack-has 2 days left. Pt reports that Urgent Care physician had advised her not to take vaccine again. Pt reports still with rash and itchyness on chest and ears, swelling of lips and tongue still there but improved. No difficulty breathing, no change in difficulty swallowing from her baseline. Pt reports that on Aug 12th went to Ortho and Gyn. New Gyn med taken for prolapse of bladder and urethra-Myrbetriq and Estradiol cream- she is not sure if started meds before rash began. Pt had telehealth visit Dr. on Aug 20-had C-spine xray which she reports showed degen changes, and MRI/MRA without contrast was ordered and done-results pending. Pt reports that neck pain has gone, and headaches improved but still there. Pt reports that Covid PCR test was done Sept 6th and results are pending. 9/6 visit from Dr reviewed only one faxed. Hospitalization, Urgent Care or ED-Since Last Visit Hospitalized? Visit to Urgent care or ED? Yes Pt saw Urgent care-Self Referral Since Last Visit Self referred to a specialist or other provider? No. Nurse:  NURSES NOTES***Patient is here for f/u with Dr.  Vital Signs Temp 97.3 F, HR 69/min, RR 16/min, BP 108/69 mmHg, Ht 63 in, Ht 160.02 cm, Wt 140 lbs, Wt 63.5 kg, BMI 24.8 Index, Pulse Ox 97%, Initials kh. Examination General Examination: General: No acute distress, pleasant affect. Head and Face: Normocephalic, atraumatic, + mild facial swelling. Eyes: Pupils equal round reactive to light, aniteric, no conjunctival injection. Ear Nose Throat: Tympanic membranes intact bilaterally, pharynx without erythema or exudate, no throat, tongue, or uvula swelling, +mild swelling of lips and sublingual area. Neck and Thyroid: Supple, no lymphadenopathy.  Heart: normal S1S2, no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender.  Extremities: No clubbing or cyanosis, no edema. Neurological: awake, alert and oriented, no gross focal deficits. Skin: Warm, intact, + chest erythema, skin around ears dry and rough. Musculoskeletal: No skeletal deformities noted. Assessments: 1. Allergic reaction, subsequent encounter-T78.40XD (Primary) 2, Allergy-T78.40XA 3. Female bladder prolapse-N81.10 4. Nonintractable episodic headache, unspecified headache type-R51.9 Treatment 1. Allergic reaction, subsequent encounter Start EPINEPHrine Auto Injector kit, 0.15 mg, as directed, intramuscularly, once, 1 day, 1, Refills 0 Clinical Notes: On 9/9/21 PA called and spoke to pharm and changed the Epipen Jr Rx to Epipen. Pt was called and told of this change as well. She had not picked up medication yet. Pt reports was actually able to get an appt with an allergist on 09/10/21 at her ENT office. She was advised to keep appt with Dr. Oct to discuss guidance on future Covid vaccinations. Referral To: Allergy/Immunology Reason: Allergy 2. Allergy Clinical Notes: 5 days after getting Covid Shot, pt had left arm swelling and redness. Then pt started having rashes, and then lip and tongue swelling. During this time period, pt took ibuprofen, and started Myrbetriq and Estradiol Cream. She was seen at Urgent Care 4 days ago and reports being given steroid shot and prescribed Medrol dose pack. Pt was referred to allergist Dr. Pt was advised to take Zyrtec and Pepcid daily and follow up with allergist ASAP. Epipen was prescribed and pt was educated on how to use it and under what circumstances, and to call 911 if needs to use. Treatment goals: Minimize discomfort and impact of current symptoms on the patient's quality of life. Impression: Pt symptomatic for allergic reaction.  PLAN: See allergist. Finish Medrol Dosepack. Take Pepcid and Zyrtec daily. For any worsening sx, pt to go to ER. Epipen prescribed to be used only incase of anaphylaxis, and pt instructed in use.  PATIENT EDUCATION: Common causes of pts current symptoms discussed with patient. Pt instructed in use of Epipen. All of the patient's questions were answered. FOLLOW UP: RTO as directed. CARE PLAN REVIEW: Reviewed Treatment Care Plan and Treatment Goals. Assessed and addressed potential barriers to meeting treatment goals and the importance of medication adherence. Printout of the Care Plan with information about new prescriptions and visit summary/progress note was either provided at the visit or mailed or made available to the patient via the patient portal. The patient and/or Caregiver acknowledged understanding of prescribed medications and treatment care plan. Reminded the patient to call our practice from any other facility at which they seek care, to confirm the current Care Plan. z 3. Female bladder prolapse Clinical Notes: Pt reports bladder and urethra propose-seeing urogyn Dr. Pt instructed to call Dr. to discuss stopping Myrbetriq which just recently started until allergic reaction abates and until further workup/guidance with allergist. 4. Nonintractable episodic headache, unspecified headache type Clinical Notes: Pt seeing Dr. for headaches and neck pain. She reports that he ordered a Cspine xray which showed degen change, and an MRI/MRA without contrast and results are pending. Follow Up 2-3 weeks