Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dry mouth, Dysphonia, Eye discharge, Eye swelling
Clinical narrative: Chief Complaint: ? Care Coordination ? Immunization/Vaccine Administration ? Tongue Swelling a 59 y.o. female with PMHx of HTN, Anxiety, well controlled T2DM and obesity who presented today to receive her first COVID Vaccine. Denies hx of anaphylaxis due to any cause.  First COVID Vaccine administered in RD at 9:53 AM   13 min after the vaccine was administered she informed my CMA that she was having throat thickness, tongue swelling and watery eyes. I immediately completed vitals:  BP: 178/100 Pulse: 76 RR 16 SpO2: 97%    10:13 am I moved her into my exam room. She stated that within 2-3 min of receiving the vaccine she began experiencing "throat thickness", dry mouth and tongue "thickness" but the symptoms had not progressed. She also c/o postnasal drip and a horse voice. She also c/o watery eyes and swelling around eye but states she had the watery eyes this morning prior to the vaccine. She also c/o numbness of a small area of her left wrist. She has significant environmental seasonal allergies for which she takes Claritin each morning and uses Flonase and montelukast each evening. She ran out of Claritin so she did not take one this morning.    All of her symptoms are consistent with her normal environmental allergy symptoms she has been having off and on the last few weeks. She states they just all flared up about 2 min after the vaccine was given.    She also states she did not take her BP medication this morning. She states she was very stressed out getting her today because she got lost and thought she would be late. Admits to feeling anxious.    Denies hives, itching, difficulty swallowing, throat closing sensation, shortness of breath, chest pain, difficulty breathing, lightheadedness, dizziness, n/v/d, abdominal pain, wheezing, headache.    10:22 am  States she has a slight headache but otherwise symptoms are stable  Completed physical exam - unremarkable. No stridor, no lip/tongue/posterior pharynx swelling I reviewed her medication list   10:27 am  Repeat vitals:  BP: 178/102 Pulse: 72 RR 16 SpO2: 99%    10:36 am  I continued to monitor her, I completed serial vitals and physical exams as well as continuously asked how she was feeling and doing. She denied difficulty breathing, wheezing, worsening of symptoms, chest pain, lightheadedness, palpitations.    I advised giving her liquid benadryl only if she could have someone come pick her up. She declined stating that she did not have someone that could drive her home. She lives 20 min away   10:40 am  She states that the eye swelling has resolved and the throat thickness was improving. Her slight headache has resolved. I advised we monitor for another 30 min here in the clinic.    11:10 am She states she is feeling much better. She reports her tongue and throat feel back to normal. Headache has resolved. She denies any difficulty breathing, wheezing, lightheadedness, dizziness, n/v/d, hives, itching, palpitations, throat/tongue itching. Rechecked vitals and physical exam.    Vitals (75 min after vaccination)  BP: 176/98 Pulse: 78 RR 12 SpO2: 98%             ROS:  Constitutional: Negative for fatigue, diaphoresis and weakness.  Eyes:  Negative for blurred vision, eye pain and photophobia.       Watery eyes  E/N/T:  Positive for congestion and hoarseness. Negative for rhinorrhea, odynophagia, stridor and tinnitus.        Throat and tongue thickness  Cardiovascular:  Negative for chest pain, palpitations, tachycardia, edema, dyspnea on exertion, irregular heartbeat and near-syncope.  Respiratory:  Negative for cough, shortness of breath, wheezing and sputum production.   Gastrointestinal:  Negative for abdominal pain, diarrhea, stool changes, nausea and vomiting.  Integumentary:  Negative for dry skin, pruritus, rashes, dry skin and flushing.  Neurological:  Positive for headaches. Negative for dizziness, weakness, focal weakness, light-headedness and vertigo.  Allergic/Immunologic: Positive for environmental allergies. Negative for frequent illnesses, urticaria, hives and persistent infections.      PMH: Diagnosis Date ? Abnormal mammogram   ? Anxiety   ? Essential hypertension, benign   ? High cholesterol      I reviewed the following historical information during this visit:   Tobacco | Meds | Problems | Med Hx | Surg Hx | Fam Hx | Soc Hx        OBJECTIVE:   Vitals (75 min after vaccination): BP: 176/98 Pulse: 78 RR 12 SpO2: 98%  Temp: 97.1             PHYSICAL EXAM CONSTITUTIONAL Vitals reviewed.  GENERAL APPEARANCE: Well-developed and obese.  GROOMING: Well groomed.  LEVEL OF DISTRESS: The patient is nervous/anxious. The patient is not distressed or diaphoretic. She appears to be well. The patient is not lethargic or toxic. The patient does not appear tired.  EYES:  LIDS/CONJUCTIVA:Positive for Bilat/clear eye drainage.Negative for eye lid edema. No lid edema, no surrounding facial edema Conjunctiva are minimally pink, no erythema   PUPILS/IRIS:  extraocular movement intact. ENT EXTERNAL EARS/NOSE: External ears and nose are normal. SEPTUM/MUCOSA: Turbinates are mildly swollen. Negative for edematous mucosa, sinus tenderness and pale, boggy nasal mucosa. LIPS/TEETH/GUMS: Normal lips, teeth and gums. No lip edema. OROPHARYNX: Oropharynx normal. Mucosa:  Mucosa appears normal. No tongue edema, erythema or rash noted No oropharynx or posterior pharynx swelling noted She is swallowing and breathing normally No stridor  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 inspiratory wheezes, expiratory wheezes or stridor. 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. No supraclavicular or submandibular nodes.Supraclavicular INTEGUMENTARY SKIN INSPECTION: Normal.  ECZEMA/PRURITIC CONDITIONS: Negative for urticaria. Skin temp and color normal, no flushing, no diaphoresis, no urticaria Injection site is unremarkable NEUROLOGICAL CRANIAL NERVES: Cranial nerves normal.  CN grossly normal  GAIT, COORDINATION, REFLEXES  Gait: normal PSYCHIATRIC ORIENTATION: She is alert and oriented to person, place and time. MOOD/AFFECT: Appears anxious. Does not appear agitated or depressed. She is not argumentative. She does not act disrepectful, act distrustful or have a flat affect. INSIGHT/JUDGEMENT: Normal insight/judgement. The patient has good insight with good judgment.            ASSESSMENT/PLAN:    Environmental allergies - Symptoms were consistent with her normal environmental allergy flare ups.  - She did not take claritin this morning as usual so this may be why the allergies flared up  - Symptoms resolved within 70 min of giving the vaccine without any therapy   - I recommended giving liquid benadryl and having someone come pick her up and monitor her at home. She declined stating that she did not have someone who could pick her up and stated that she would rather take benadryl at home.    - She stated she felt safe to drive home. I gave strict warnings that if any sx recurred or if any new or concerning symptoms developed that she should call 911. Reviewed signs and symptoms of anaphylaxis.  - I advised she take liquid benadryl when she got home and have someone monitor her for the next 4 hours.   Essential hypertension               - elevated today likely due to increased stress/anxiety and not taking BP medication this morning              - I advised that she monitor her BP closely at home. I advised she take her BP medication when she got home if her throat felt normal.               - recommended f/u with PCP    Encounter for administration of vaccine First Pfizer COVID Vaccine given today I recommended she consult with her PCP about the second vaccine.    She expressed understanding and all questions answered.    ----------------------------------- Called patient at 2:10 pm to check up on her. She states that she took liquid benadryl about 40 min ago and that all of her symptoms have completely resolved. She states that she is feeling great now. She denies difficulty breathing, throat  swelling/tighntess/thickness, tongue swelling, wheezing, headache, n/v/d, lightheadedness, hives, itching, palpitations or chest pain.  She states she took her BP medications but has not checked her BP at home yet.    I recommended she continue taking benadryl as needed and recommended she follow up with her PCP in 1-2 days.    --------------------------------- Patient's PCP)    I wanted you to be aware that your patient had a mild reaction vs flare up of her environmental allergies after her first COVID Vaccine today. I called her 4 hours after the vaccine. She had taken benadryl at home and her symptoms had resolved. I was hoping to consult with you about her receiving her second vaccine.    Her BP was elevated. She had not taken her BP medication this AM. I recommended she also f/u with you on that as well.     --------------------------------- Dr's response "People react to making antibodies.  The serious anaphylaxis is rare.  Most are having general side affects and flu-like symptoms   I would like you to administer the 2nd vaccine.     Notes seen on morning of April 20.  Responded."