Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Fibromyalgia, Mobility decreased, Mouth ulceration, Nausea
Clinical narrative: 03/12/2021: Discussion/Summary: Called Patient's Wife regarding Patient's Alprazolam 0.5mg and advised her the Prior Authorization has been completed. And that Insurance responded "Available without Prior Authorization." Also that this page was printed out and faxed to Patient's Pharmacy. Patient's wife stated she greatly appreciated this.   Patient's wife went on to say the both she and Patient received their 1st Covid 19 Vaccine (Pfizer) on 3/5/21. An when Patient left the Pharmacy he was fine. But a little later his Tongue started to swell and the next day his mouth was covered in Blisters. She stated his breathing was okay, but he also had a fever, diarrhea and generalized fatigued. She went on to say that Patient has laid in the bed from Friday night 3/5/21  straight through to Wednesday 3/10/21. She stated has decreased appetite as well.   Inquired of patient's wife if she called to have Patient tested for the Covid 19 virus. She stated "nobody tole me to." Advised patient's wife was just inquiring about that and if she had called to see if Patient could be seen for these symptoms. She replied no.   Advised patient's wife to watch Patient and if needed she can call the clinic After hours Nurse Line or call back on Monday if he continues to be so Fatigued that all he can do is lay around. Patient's wife did state some of the other symptoms have resolved, the blisters in the mouth, swollen tongue, but Patient did experience these for 3 to 4 days after being vaccinated with his 1st Covind 19 (Pfizer) vaccine.  Patient's wife asked should Patient get second one, and the Pharmacist told her "no." Advised patient's wife, Patient needs to discuss this with Dr., or PA.   Advised patient's wife to call if needed for Patient and to please follow up on this Covid 19 after effects on Patient.  Patient's wife voiced understanding. Dr.   03/16/2021: Discussion/Summary: Called back today for follow up with Patient for his reported 1st Covid Vaccine Reaction. (See Care Team Note dated 3/12/21 for documentation).  Spoke with Wife, first. advised her per Nursing Supervisor, even if Patient is better, he needs to come in and have his reaction documented for the Adverse Reporting for the Covid 19 Vaccine. Patient's wife stated she would hand the phone over to Patient.  Inquired of Patient how he was doing and if the "fatigue" he reported from his 1st Covid 19 vaccine had resolved. He stated "I'm always tired, but I am able to go to the Eye doctor this morning." Advised Patient even though he is feeling better and his symptoms he reported (swollen tongue, mouth covered in blisters, so fatigued unable to get out of bed, fever, diarrhea, but breathing was ok), he needs to come in and have this documented so it can be reported to the Adverse Reporting for the Covid 19 Vaccine. Offered Patient appointment today or tomorrow with PA.  He stated he will come in today @ 1:45pm for this visit.   Patient is scheduled for 1:45pm today to follow up on Adverse Reaction to 1st Covid 19 vaccine, per Patient & Wife's reported symptoms. Dr.   03/16/2021: History of Present Illness:  Patient received his first COVID 19 vaccine on March 5.  He had the Pfizer vaccine around 5:00 that afternoon. He was in bed-by 9:00 that evening. He remained in bed through March 7. He developed some nausea,  swelling of his tongue, and mouth ulcers. The tongue swelling resolved by March 10. He also was aware of some palpitations the night after his vaccine. He had no swelling of his airways, shortness of breath, wheezing, fever, chills, headache or increased body aches. He has fibromyalgia, and did not notice any changes in his chronic pain. He complains of ongoing fatigue, but the other symptoms have resolved. He has a history of pulmonary fibrosis which is managed by his pulmonologist, Dr. He was told by Dr. he should not take the second vaccine because of his symptoms following the first vaccine.   Patient had swollen tongue, Blisters in his mouth, Diarrhea, Fatigue, Fever had resolved.   Two weeks ago Patient had "red raised areas wit a clear head," come up on both legs. The left is much worse than Right. No itching, burning, just the raised areas. Patient did "pop" one of them and it still didn't dry up.  Still dealing with Severe Fatigue and this reaction has caused his Fibromyalgia to Flare.   Feels sure he had Fever on 4/13/21. Offered Appointment (See documentation) Seeing Primary Care Provider on 5/3/21.   Advised to call this office with, continued or worsening symptoms.  Patient did voice understanding.