Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Pruritus
Clinical narrative: PT STATED DEVELOPMENT OF ITCHING ALL OVER LEGS AND BACK. AFTER RECEIVING THE VACCINE.  PRESENTED TO URGENT CARE FOR TREATMENT  AT 10:30 AM  Office Visit  2/5/2021 Urgent Care Main  Family Medicine Allergic reaction to drug, initial encounter Dx Respiratory Distress , itching all over Reason for Visit Progress Notes  Expand All Collapse All       Subjective   Patient ID:  57 year old female.  Patient had second Covid vaccination today, afterwards she developed itching all over the body, mostly on the legs and on the back skin, also feels mildly short of breath, She had first Covid vaccine and did not had any allergic reaction, Modifying factors worse after the vaccine shot, Symptoms have been persistent.  Prior h/o similar complain- not sure, may be No new pets/soap/detergents/cream This is a new problem to me.  Review of Systems  With the exception of pertinent +/- in the HPI above, a complete review of systems was reviewed and are negative.  Constitutional: Negative for fever, weight loss, malaise/fatigue and diaphoresis.  HENT: Negative for nosebleeds, congestion, sore throat and ear discharge.  Eyes: Negative for blurred vision, double vision, photophobia, pain, discharge and  redness.  Respiratory: Negative for cough, hemoptysis Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Negative for heartburn, nausea and vomiting.  Genitourinary: Negative for dysuria, urgency, frequency and hematuria.  Musculoskeletal: Negative for myalgias, joint pain and falls.  Neurological: Negative  The following have been updated as appropriate in this visit:-  Tobacco | Allergies | Meds | Problems | Med Hx | Surg Hx |     The following have been reviewed-  Medical History History reviewed. No pertinent past medical history.  has a current medication list which includes the following prescription(s): aspirin, atorvastatin, clopidogrel, diltiazem, furosemide, metformin, and triamcinolone. No family history on file.  Social History     Socioeconomic History ? Marital status: Not on file     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History ? Not on file Social Needs ? Financial resource strain: Not on file ? Food insecurity     Worry: Not on file     Inability: Not on file ? Transportation needs     Medical: Not on file     Non-medical: Not on file Tobacco Use ? Smoking status: Current Every Day Smoker ? Smokeless tobacco: Never Used Substance and Sexual Activity ? Alcohol use: Not on file ? Drug use: Not on file ? Sexual activity: Not on file Lifestyle ? Physical activity     Days per week: Not on file     Minutes per session: Not on file ? Stress: Not on file Relationships ? Social connections     Talks on phone: Not on file     Gets together: Not on file     Attends religious service: Not on file     Active member of club or organization: Not on file     Attends meetings of clubs or organizations: Not on file     Relationship status: Not on file ? Intimate partner violence     Fear of current or ex partner: Not on file     Emotionally abused: Not on file     Physically abused: Not on file     Forced sexual activity: Not on file Other Topics Concern ? Not on file Social History Narrative ? Not on file      Objective   BP (!) 133/84  | Pulse 80  | Temp 97.1 °F  | Resp (!) 22  | Ht 5' 4.8" (1.646 m)  | Wt 169 lb (76.7 kg)  | SpO2 99%  | BMI 28.30 kg/m²    Constitutional: oriented to person, place, and time. well-developed, well-nourished and in no distress. HENT:  Head: Normocephalic.  Eyes: Pupils are equal, round, and reactive to light.  Neck: Normal range of motion. No tracheal deviation present.  Ear- Normal  Mouth- Tongue, uvula- Normal, No oral rash Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no  gallop and no friction rub. No murmur heard.  Pulmonary/Chest: Effort normal and breath sounds normal. NO W/R/R, noticed to be breathing fast,  Abdominal: Soft. There is no tenderness. S/NT/ND Musculoskeletal: No edema and no tenderness.  Lymphadenopathy: has no cervical adenopathy.  Neurological: Neurological: Pt displays no motor weakness, no tremor, normal facial symmetry, and normal speech. Psychiatric: Affect normal.  Skin, noticed erythematous skin all over the body, with rash mostly noted on the legs, on the trunk, also on the arm     Impression/Plan   Patient was seen today for respiratory distress and itching all over.   Diagnoses and all orders for this visit:   Allergic reaction to drug, initial encounter -     Sodium Chloride 0.9% infusion 1,000 mL -     famotidine (PEPCID) injection 20 mg -     diphenhydrAMINE (BENADRYL) injection 25 mg -     albuterol 2.5 mg /3 mL (0.083 %) nebulizer solution 2.5 mg -     ipratropium (ATROVENT) 0.02 % nebulizer solution 0.5 mg -     methylPREDNISolone sod suc(PF) recon soln 125 mg   Other orders -     triamcinolone (KENALOG) 0.5 % ointment; Apply topically 2 (two) times a day.   Patient evaluated and worked up for over 50-minute during urgent care visit. Time was spent was for preparing to see the patient by reviewing patient's medical history and previous test results,directly obtaining information regarding today's encounter, evaluating the patient, performing an examination, communicating test results, placing orders.  Patient was seen second time and discussed the finding of lab results and assessment plan is discussed in detail.  Patient was put on the monitor chair, given IV fluid with Benadryl and Pepcid, also given DuoNeb treatment, watched for over 60-minute, patient felt better but continues to have itching on the skin, also has mild redness, symptoms had improved, but still had itching all over, Therefore Solu-Medrol was given, Breathing improved, patient did not had any shortness of breath, Discharged home on Claritin, Benadryl, Pepcid, New patient complain to me Symptoms improved treatment here,  Stable at d/c-  no SOB/Wheezing, No throat swelling,   Cool compresses to the skin will help.  Claritin or Zyrtec once a day Benadryl 25-50 mg every 8 hours for 1st day & then as needed If the symptoms flare again,go to Nearest emergency STAT  Reviewed prior labs, diagnostic test & prior visit notes.     Reviewed current medication and management planned considering current prescription/meds.   Please note this clinic note was performed utilizing voice recognition software.  Due to the natural inherent tendency of voice recognition software there may be grammatical errors inadvertently enclosed that do not reflect the nature of the visit. For worsening of symptoms, Patient is instructed to return sooner either to ER or urgent care/PCP.    Patient is instructed to follow up in 1-2 weeks with PCP I have educated patient on supportive care therapy. Patient agreed with plan and voiced understanding. No barriers to adherence perceived by myself. Department of Urgent Care