Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site erythema, Injection site swelling, Local reaction
Clinical narrative: 1. Local reaction to COVID-19 vaccine Active T88.1XXA 999.9     Plan: Mild erythema at the left deltoid injection site as expected.  There is also mild swelling.  Patient has been reassured this is a normal Covid vaccine local reaction 48 hours after her Covid vaccine injection.  Patient has been reassured no oral antibiotics are indicated at this time.   No antibiotics are dispensed today.  ED Prescriptions    None     Follow-up: No follow-up provider specified.  Subjective: Patient ID:  Patient is a 65 y.o. female who presents today with a chief complaint of: No chief complaint on file. 65-year-old female patient presents to express care with concerns about redness at her Covid injection site.  Patient's fourth Covid booster was administered on Friday.  Patient states she is "had this happen before, my last Covid vaccine did the same thing."  Patient referencing erythema at the injection site.  This time is different for her.  She has had some localized swelling.  Patient states that her last COVID injection reaction, she was given oral antibiotics.  Patient is insistent she needs antibiotics again this time. HPI Review of Systems  Constitutional: Negative for chills, fever and malaise/fatigue.     Patient Reported Taking    No current medications.     History  Reviewed and updated this visit:                 Objective:   There were no vitals taken for this visit.   Physical Exam Constitutional:  Well-nourished, well-developed female  HENT:  Normocephalic, atraumatic.  Eyes:  PERRL, EOMI, anicteric, conjunctivae normal.  Extremities: No edema Integument: skin warm and intact, localized erythema left deltoid.  There are no lesions or blistering noted. Neurologic: Alert and oriented x4 Psychiatric: Affect is normal, appropriate, cooperative   Ortho Exam    Prior to Admission medications  Medication Sig Start Date End Date Taking? Authorizing Provider acyclovir (ZOVIRAX) 400 MG tablet Take 1 tablet by mouth 3 times daily as needed for up to 5 days. 4/8/22 4/13/22   PA-C calcium carbonate (TUMS) 500 mg chewable tablet Take 1 tablet by mouth Daily.       Historical Provider, MD cyclobenzaprine (FLEXERIL) 5 MG tablet Take 1-2 tablets by mouth every 8 hours as needed for Muscle spasms. 8/31/21     PA-C DULoxetine (CYMBALTA) 30 mg DR capsule Take 1 capsule by mouth Daily. 1/7/22 1/7/23   PA-C estradiol (YUVAFEM) 10 mcg vaginal tablet Place 1 tablet vaginally Daily for 14 days, THEN 1 tablet Twice a week for 76 days. 2/3/22 5/4/22   PA-C levothyroxine (SYNTHROID) 50 mcg tablet Take 1 tablet by mouth every morning (before breakfast) Take 5 days/week.. 1/7/22     PA-C levothyroxine (SYNTHROID) 75 mcg tablet Take 2 days/week when not taking the 50 mcg dose.. 1/7/22      PA-C Nutritional Supplements (MENOPAUSE FORMULA PO) Take  by mouth. occasionally       Historical Provider, MD   No results found. No results found for this or any previous visit (from the past 24 hour(s)).        PA-C       PA-C 04/10/22 1022   1. Local reaction to COVID-19 vaccine Active T88.1XXA 999.9     Plan: Mild erythema at the left deltoid injection site as expected.  There is also mild swelling.  Patient has been reassured this is a normal Covid vaccine local reaction 48 hours after her Covid vaccine injection.  Patient has been reassured no oral antibiotics are indicated at this time.   No antibiotics are dispensed today.  ED Prescriptions    None     Follow-up: No follow-up provider specified.  Subjective: Patient ID:  Patient is a 65 y.o. female who presents today with a chief complaint of: No chief complaint on file. 65-year-old female patient presents to express care with concerns about redness at her Covid injection site.  Patient's fourth Covid booster was administered on Friday.  Patient states she is "had this happen before, my last Covid vaccine did the same thing."  Patient referencing erythema at the injection site.  This time is different for her.  She has had some localized swelling.  Patient states that her last COVID injection reaction, she was given oral antibiotics.  Patient is insistent she needs antibiotics again this time. HPI Review of Systems  Constitutional: Negative for chills, fever and malaise/fatigue.     Patient Reported Taking    No current medications.     History  Reviewed and updated this visit:                 Objective:   There were no vitals taken for this visit.   Physical Exam Constitutional:  Well-nourished, well-developed female  HENT:  Normocephalic, atraumatic.  Eyes:  PERRL, EOMI, anicteric, conjunctivae normal.  Extremities: No edema Integument: skin warm and intact, localized erythema left deltoid.  There are no lesions or blistering noted. Neurologic: Alert and oriented x4 Psychiatric: Affect is normal, appropriate, cooperative   Ortho Exam    Prior to Admission medications  Medication Sig Start Date End Date Taking? Authorizing Provider acyclovir (ZOVIRAX) 400 MG tablet Take 1 tablet by mouth 3 times daily as needed for up to 5 days. 4/8/22 4/13/22   PA-C calcium carbonate (TUMS) 500 mg chewable tablet Take 1 tablet by mouth Daily.       Historical Provider, MD cyclobenzaprine (FLEXERIL) 5 MG tablet Take 1-2 tablets by mouth every 8 hours as needed for Muscle spasms. 8/31/21     PA-C DULoxetine (CYMBALTA) 30 mg DR capsule Take 1 capsule by mouth Daily. 1/7/22 1/7/23   PA-C estradiol (YUVAFEM) 10 mcg vaginal tablet Place 1 tablet vaginally Daily for 14 days, THEN 1 tablet Twice a week for 76 days. 2/3/22 5/4/22   PA-C levothyroxine (SYNTHROID) 50 mcg tablet Take 1 tablet by mouth every morning (before breakfast) Take 5 days/week.. 1/7/22     PA-C levothyroxine (SYNTHROID) 75 mcg tablet Take 2 days/week when not taking the 50 mcg dose.. 1/7/22      PA-C Nutritional Supplements (MENOPAUSE FORMULA PO) Take  by mouth. occasionally       Historical Provider, MD   No results found. No results found for this or any previous visit (from the past 24 hour(s)).        PA-C       PA-C 04/10/22 1022   1. Local reaction to COVID-19 vaccine Active T88.1XXA 999.9     Plan: Mild erythema at the left deltoid injection site as expected.  There is also mild swelling.  Patient has been reassured this is a normal Covid vaccine local reaction 48 hours after her Covid vaccine injection.  Patient has been reassured no oral antibiotics are indicated at this time.   No antibiotics are dispensed today.  ED Prescriptions    None     Follow-up: No follow-up provider specified.  Subjective: Patient ID:  Patient is a 65 y.o. female who presents today with a chief complaint of: No chief complaint on file. 65-year-old female patient presents to express care with concerns about redness at her Covid injection site.  Patient's fourth Covid booster was administered on Friday.  Patient states she is "had this happen before, my last Covid vaccine did the same thing."  Patient referencing erythema at the injection site.  This time is different for her.  She has had some localized swelling.  Patient states that her last COVID injection reaction, she was given oral antibiotics.  Patient is insistent she needs antibiotics again this time. HPI Review of Systems  Constitutional: Negative for chills, fever and malaise/fatigue.     Patient Reported Taking    No current medications.     History  Reviewed and updated this visit:                 Objective:   There were no vitals taken for this visit.   Physical Exam Constitutional:  Well-nourished, well-developed female  HENT:  Normocephalic, atraumatic.  Eyes:  PERRL, EOMI, anicteric, conjunctivae normal.  Extremities: No edema Integument: skin warm and intact, localized erythema left deltoid.  There are no lesions or blistering noted. Neurologic: Alert and oriented x4 Psychiatric: Affect is normal, appropriate, cooperative   Ortho Exam    Prior to Admission medications  Medication Sig Start Date End Date Taking? Authorizing Provider acyclovir (ZOVIRAX) 400 MG tablet Take 1 tablet by mouth 3 times daily as needed for up to 5 days. 4/8/22 4/13/22   PA-C calcium carbonate (TUMS) 500 mg chewable tablet Take 1 tablet by mouth Daily.       Historical Provider, MD cyclobenzaprine (FLEXERIL) 5 MG tablet Take 1-2 tablets by mouth every 8 hours as needed for Muscle spasms. 8/31/21     PA-C DULoxetine (CYMBALTA) 30 mg DR capsule Take 1 capsule by mouth Daily. 1/7/22 1/7/23   PA-C estradiol (YUVAFEM) 10 mcg vaginal tablet Place 1 tablet vaginally Daily for 14 days, THEN 1 tablet Twice a week for 76 days. 2/3/22 5/4/22   PA-C levothyroxine (SYNTHROID) 50 mcg tablet Take 1 tablet by mouth every morning (before breakfast) Take 5 days/week.. 1/7/22     PA-C levothyroxine (SYNTHROID) 75 mcg tablet Take 2 days/week when not taking the 50 mcg dose.. 1/7/22      PA-C Nutritional Supplements (MENOPAUSE FORMULA PO) Take  by mouth. occasionally       Historical Provider, MD   No results found. No results found for this or any previous visit (from the past 24 hour(s)).        PA-C       PA-C 04/10/22 1022   1. Local reaction to COVID-19 vaccine Active T88.1XXA 999.9     Plan: Mild erythema at the left deltoid injection site as expected.  There is also mild swelling.  Patient has been reassured this is a normal Covid vaccine local reaction 48 hours after her Covid vaccine injection.  Patient has been reassured no oral antibiotics are indicated at this time.   No antibiotics are dispensed today.  ED Prescriptions    None     Follow-up: No follow-up provider specified.  Subjective: Patient ID:  Patient is a 65 y.o. female who presents today with a chief complaint of: No chief complaint on file. 65-year-old female patient presents to express care with concerns about redness at her Covid injection site.  Patient's fourth Covid booster was administered on Friday.  Patient states she is "had this happen before, my last Covid vaccine did the same thing."  Patient referencing erythema at the injection site.  This time is different for her.  She has had some localized swelling.  Patient states that her last COVID injection reaction, she was given oral antibiotics.  Patient is insistent she needs antibiotics again this time. HPI Review of Systems  Constitutional: Negative for chills, fever and malaise/fatigue.     Patient Reported Taking    No current medications.     History  Reviewed and updated this visit:                 Objective:   There were no vitals taken for this visit.   Physical Exam Constitutional:  Well-nourished, well-developed female  HENT:  Normocephalic, atraumatic.  Eyes:  PERRL, EOMI, anicteric, conjunctivae normal.  Extremities: No edema Integument: skin warm and intact, localized erythema left deltoid.  There are no lesions or blistering noted. Neurologic: Alert and oriented x4 Psychiatric: Affect is normal, appropriate, cooperative   Ortho Exam    Prior to Admission medications  Medication Sig Start Date End Date Taking? Authorizing Provider acyclovir (ZOVIRAX) 400 MG tablet Take 1 tablet by mouth 3 times daily as needed for up to 5 days. 4/8/22 4/13/22   PA-C calcium carbonate (TUMS) 500 mg chewable tablet Take 1 tablet by mouth Daily.       Historical Provider, MD cyclobenzaprine (FLEXERIL) 5 MG tablet Take 1-2 tablets by mouth every 8 hours as needed for Muscle spasms. 8/31/21     PA-C DULoxetine (CYMBALTA) 30 mg DR capsule Take 1 capsule by mouth Daily. 1/7/22 1/7/23   PA-C estradiol (YUVAFEM) 10 mcg vaginal tablet Place 1 tablet vaginally Daily for 14 days, THEN 1 tablet Twice a week for 76 days. 2/3/22 5/4/22   PA-C levothyroxine (SYNTHROID) 50 mcg tablet Take 1 tablet by mouth every morning (before breakfast) Take 5 days/week.. 1/7/22     PA-C levothyroxine (SYNTHROID) 75 mcg tablet Take 2 days/week when not taking the 50 mcg dose.. 1/7/22     PA-C Nutritional Supplements (MENOPAUSE FORMULA PO) Take  by mouth. occasionally       Historical Provider, MD   No results found. No results found for this or any previous visit (from the past 24 hour(s)).        PA-C       PA-C 04/10/22 1022