Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Hernia repair, Hyperlipidaemia, Hypothyroidism, Insomnia
Clinical narrative: Arm sore, swelling in arm, headache,  fever, chills, body aches, nausea, diarrhea. Missed 3 days of work . Had a telemedicine visit with Dr. on Feb 5. Then arm was still sore and saw Doctor at Medical Center. on Feb 26th and then again saw another Dr. on March 4th and also have a appt on April 1st. The arm is still sore and hurts to move. Have added the additional information page with all the visit summaries from those visits. I have had a x-ray and also taking muscle relaxers, heat, ice and Tylenol still no relief.    Feb 5-HPI Pt. female was scheduled for a video visit-(in response to COVID-19-pandemic ) for. Fatigue, body aches.--needs letter for work.   Patient reports she received her moderna COVID vaccine 1st dose on Monday February 1st, she started to have low-grade fever on Tuesday--99.6. Also had body aches and fatigue. Last night she had 2 episodes of diarrhea. Today her temperature is 96°, but she has severe body aches and her arm from the injection site is still very sore. She has been using ice every couple of hours. She is taking Tylenol 2 tablets every 6 hours for last 4 days. Denies cough, chest pain, change in breathing, sinus congestion, sore throat. Denies known exposure to COVID 19, but in the family has traveled outside. Works at Hospital.   She never had a COVID positive test but she feels in March of 2020 she was sick with symptoms of loss of taste and smell and body aches but never had fever, therefore she did not qualify for COVID-19 testing.   Would like to go back to work on Monday   No vitals were taken since this is a video visit.   Appearance--appears to be alert and oriented, face without gross asymmetry. Patient talks in normal speech and in full sentences, answer to questions appropriately. Mood and affect normal.   Past labs/radiology --reviewed and discussed with patient .   ASSESSMENT AND PLAN:   Diagnoses and all orders for this visit:   Vaccination side effects, initial encounter   Encounter for issue of other medical certificate     Advised to take Tylenol 1-2 tablets every 8 hours Cannot take NSAIDs due to history of allergy. Maintain hydration.   If has fever again tomorrow--should be tested for COVID-19. Advised to call back on Monday to update, if she feels fine no fever for 48 hours then can return to work on Monday  Feb 26th-Progress Notes NP D Cousins at 2/26/2021  5:00 PM Medical Decision Making: Assessment and Plan Diagnoses and all orders for this visit:   Chronic right shoulder pain - XR SHOULDER COMPLETE RIGHT         Symptoms and exam most consistent with shoulder pain.    Signs and symptoms requiring re-evaluation and include follow up care with primary care provider.   Signs and symptoms discussed requiring evaluation in emergency department.    Side effect profile of new medications discussed.   Return for follow up for PCP. .   Subjective:      Chief Complaint Patient presents with ? Shoulder Pain     E. x4weeks, pain right after 1st covid injection       HPI Patient presents with complaints of shoulder pain after 1st covid shot.  Symptoms started about 4 weeks ago Pertinent negatives include numbness / tingling of the lower arm, wrist, or fingers Home treatment has been nothing   ROS negative except as documented in HPI and/or assessment and plan   Chief complaint and all history documented by ancillary staff were reviewed and verified with additions or corrections as appropriate.    Patient allergies, medication list and problem list reviewed.     March 4th-NP A Medical Center at 3/4/2021  8:00 AM  INTERNAL MEDICINE   Medical Decision Making:   Assessment & Plan   Diagnoses and all orders for this visit:   Hyperlipidemia with target LDL less than 100 - CMP (COMPREHENSIVE METABOLIC PANEL); Future - LIPID PANEL; Future - COMPLETE BLOOD COUNT (CBC) WITH DIFF; Future   Hypertriglyceridemia   Hypothyroidism, postsurgical - THYROID STIMULATING HORMONE (TSH); Future - THYROXINE (T4) FREE; Future   Chronic right-sided thoracic back pain - NM HEPATOBILIARY WITH PHARM; Future   Right arm pain - baclofen (LIORESAL) 10 MG Tablet; Take 1 Tablet by mouth 3 times daily as needed for Muscle spasms.   Labs today with gyne labs.  Nuc med scan.  Heat/baclofen to arm. Unlikely to be r/t anything other than the vaccine.  follow up in 6 months, sooner if needed.  Will fill out FMLA paperwork in may when it comes due.    No follow-ups on file.     Subjective   Subjective: HPI: Pt. presents for Arm Pain (right arm) Also here for 6 month follow up. 1. Arm pain: ever since her last COVID vaccine 4 weeks ago. Pain in the deltoid, radiates to the front of the shoulder. No skin changes, no trauma to the joint. Tylenol helps somewhat, difficulty sleeping as a result.  2. Hyperlipidemia: needs follow up labs. 3. Hypothyroid: feeling well, needs follow up labs.  4. Chronic right sided back pain: x several years, when she had hernia repair, surgeon felt like her gall bladder was enflamed. She has had a nondiagnostic gall bladder sono. Would like to look into this further.    Review of Systems  Review of systems was negative, except as documented in HPI.