Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Rash pruritic, Swelling, Weight
Clinical narrative: itchy rash; Allergic skin reaction/allergic skin rashes; polyarthralgia/ joint and muscle pain/ swelling of left foot; Worsended on receiving second dose; series of adverse reactions, both allergic and inflammatory; series of adverse reactions, both allergic and inflammatory; increased temperature/ super high fever temperatures; joint and muscle pain; no longer lead an active; chronic idiopathic urticaria/ extreme red rashes all over the body; swelling; nerve pains; depression; This is a spontaneous report received from contactable reporter(s) (Consumer or other non HCP and Physician) from legal division. The reporter is the patient.  A 48-year-old female patient received bnt162b2 (BNT162B2), on 21May2021 as dose 2, single (Batch/Lot number: unknown) at the age of 46 years for covid-19 immunisation. The patient's relevant medical history included: "Known allergies: Chocolate" (unspecified if ongoing); "smoker" (unspecified if ongoing), notes: smoked a brief amount in her teen years. The patient's family history included: "HTN (hypertension)" (unspecified if ongoing), notes: Mother: HTN, Father: HTN; "Angioplasty" (unspecified if ongoing), notes: Father: Angioplasty; "Cancer" (unspecified if ongoing), notes: Uncle: Cancer. The patient's concomitant medications were not reported. Vaccination history included: Covid-19 vaccine (DOSE 1, SINGLE. Unspecified manufacturer), for COVID-19 immunisation. The following information was reported: RASH PRURITIC (medically significant), outcome "not recovered", described as "itchy rash"; DERMATITIS ALLERGIC (medically significant), outcome "unknown", described as "Allergic skin reaction/allergic skin rashes"; ARTHRALGIA (non-serious), outcome "unknown", described as "polyarthralgia/ joint and muscle pain/ swelling of left foot"; CONDITION AGGRAVATED (non-serious), outcome "not recovered", described as "Worsended on receiving second dose"; HYPERSENSITIVITY (non-serious), INFLAMMATION (non-serious), outcome "unknown" and all described as "series of adverse reactions, both allergic and inflammatory"; BODY TEMPERATURE INCREASED (non-serious), outcome "not recovered", described as "increased temperature/ super high fever temperatures"; MYALGIA (non-serious), outcome "not recovered", described as "joint and muscle pain"; LOSS OF PERSONAL INDEPENDENCE IN DAILY ACTIVITIES (non-serious), outcome "unknown", described as "no longer lead an active"; CHRONIC SPONTANEOUS URTICARIA (non-serious), outcome "unknown", described as "chronic idiopathic urticaria/ extreme red rashes all over the body"; SWELLING (non-serious), outcome "unknown"; NEURALGIA (non-serious), outcome "not recovered", described as "nerve pains"; DEPRESSION (non-serious), outcome "unknown". The patient underwent the following laboratory tests and procedures: Blood pressure measurement: 104/55; 120/58; 120/71; 123/60; 99/59; 108/58; 116/55; 103/52; Body mass index: 28.09, notes: +3.11 from 24.98 on 09Jun2023; 24.98, notes: 0.59 from 25.57 on 23May2023; 25.57, notes: +2.93 from 22.64 on 17Oct2022; 22.64, notes: +1.01 from 21.63 on 31Aug2022; 21.63, notes: -2.58 from 24.21 on 10Aug2022; 24.48, notes: -0.75 from 25.23 on 07Jun2022; 25.23; Body temperature: 98.5 Fahrenheit; 97.6 Fahrenheit; 98.8 Fahrenheit; 99 Fahrenheit; 98 Fahrenheit; Heart rate: 71; 117, notes: low 1ODs on my exam; 77; 80; 70; 68; 100; 78; Weight: 153.6 lbs, notes: +17 from 136.6 lbs on 09Jun2023; 136.6 lbs, notes: -3.2 from 139.8 lbs on 23May2023; 139.8 lbs, notes: +16 from 123.8 lbs on 17Oct2022; 123.8 lbs, notes: -10.2 from 134 lbs on 31Aug2022; 134 lbs, notes: -16 from 150 lbs on 10Aug2022; 147 lbs. Therapeutic measures were taken as a result of arthralgia, hypersensitivity, depression.  Clinical course: On 21May2021, after taking the second dose of the COVID-19 Vaccine from the Pfizer laboratory, and on 21May2021, at the pharmacy application site, patient developed a series of adverse reactions, both allergic and inflammatory. patient have a history of adverse reactions described by the doctors who evaluated patient, including allergic skin rashes and increased temperature, both in the lesion and in the body, accompanied by joint and muscle pain. With all these reactions patient can no longer lead an active. The patient provided with allmedical reports and skin photos . She was also undergoing treatment in HEALTH: with a rheumatologist and dematologist. The patient was asking financial help to survive. She can not work. She does not want to harm the laboratory. She was already evicted and couldn't pay the rent. She has financial needs. She wanted to receive an amount per month. If she needs it, she has a lawyer. The patient requested help. Roughly a year and seven months ago, on 21May2021; I took the second dose of the COVID- 19 vaccine. The COVID-19 vaccine was fabricated by PFIZER and administered at a local (withheld) location. Immediately after returning home from the vaccine, I began to feel adverse reactions to it. I consulted a doctor immediately due to extreme red rashes all over the body, super high fever temperatures, muscle pain and nerve pains. To this day I still suffer these reactions and issues. I had never experienced them previously, until I took the PFIZER COVID-19 vaccine. Today I find myself unable to have a normal life, I am unable to work, move around, drive, or do anything that I previously could do. I am in bed all day; I need help to be able to take a bath/shower due to the strong muscle and nerve pain. I am having to take and pay out of pocket the following medications. Montelukast - for the allergies Prednisone 20 mg twice a day-for the pains Sertraline 100 mg twice a day- for the emotional and physiological issues derived from the change in my life Metocarbamol four times a day- for the pains. It is extremely uncomfortable having to leave the house and be seen with huge red rashes all over my skin. To request aid to be able to do simple tasks such as go do groceries or move anywhere. Over this last nearly two years I have had to go to various doctors and clinics. Such as: (withheld). I come to you through this letter with a plea of aid. I am unable to work as previously mentioned, had to spend a lot of money out of pocket. I must request money and aid from friends and family on a nearly daily basis. Every diagnosis I had has confirmed I had extreme adverse reactions to the vaccine and that all the issues I deal with now were a side effect and derived from the PFIZER COVID-19 vaccine. I no longer have the mental health, the physical health I had before the vaccine after dealing with all the issues above. I have been dealing with severe depression, I must see a therapist and psychoanalyst on a weekly basis to help combat this depression. Below will be attached various images taken throughout these last two years of the noticeable reactions I suffered. Patient Demographic Information: Past Medical History: None. Past Surgical History: None. Reviewed vaccine: Vaccine type: Covid-19 Mrna, LNP-S , PF, 30 MCG/0.3 ML dose (Pfizer-BioNTech): 21May2021. 47-year-old Female presents to day with the recurrence of an itchy rash. She has been dealing with this problem on/off of the last year. It was gone over the winter but returned last week, covers majority of body, little to no rash upon waking in the morning but gets worse throughout the day, states the rash appeared after having her first COVID vaccine injection and worsened after the 2nd dose, has swelling of left foot that appears with the rash which causes increased pain to WB, no known exposure or symptoms of COVID- Date of Encounter: 03Nov2023. Exam Reason (CC): Annual Physical Exam - Needs PHQ/ GAD. Problem: patient presents for physical. Agency recommendations reviewed with patient. Patient had not completed labs prior to visit. Will draw today. interpreter utilized during encounter. Unfortunately patient was late to encounter and some topics had to be deferred. Currently seeing Rheum and Dermatology for further evaluation and management of urticaria and polyarthralgia. Being treated for suspected rheumatoid arthritis with methotrexate. Currently taking 20 mg methotrexate weekly, prednisone 10 mg daily and folic acid daily. On OCP to prevent pregnancy. Next appointments are in December. Discontinued Sertraline a month ago. Felt like it helped with her mood but wanted to take a break on the medication. Currently frustrated by her health condition because she is unable to work. Reports that she will have difficulty with her hands locking up on her. Pfizer emailed her and requested a copy of her records. Asked if she could email this to us for help. PHQ-9 score: not completed due to time GAD-7 score: not completed due to time. Diet: Breakfast: coffee, scrambled eggs/ toast Lunch: grilled meat, rice. Dinner: soup. Snacks: yogurt and fruit Drinks: juice, water. Supplements: Vitamin D Caffeine: 2 cups of coffee ETOH: none. Sleep: 4-5h, struggles with ins. mnia due to pain and worrying about her medical conditions Exercise: walking, biking, weight, 3 days a week. Smoking hx: smoked a brief amount in her teen years. Gyn GOPO. Menarche: 16. LMP: 11Oct2023 still having regular periods Contraception: OCP. Preventative: Mammogram: has not had baseline mammogram Colonoscopy: due, has not had. Pap smear: thinks last one was about 5 years ago, due Vitals: BP: 120/58 HR: 71, Temp: 98.5 °F, Wt: 153.6 lbs. [+17 from 136.6 lbs on 09Jun2023], BMI: 28.09 [+3.11 from 24.98 on 09Jun2023]. PE: General: NAD EYES: EOMI, no conjunctivitis or obvious drainage HENT: NA/AT NECK: Supple RESP: Normal WOB. CVS: RRR no m/r/g. Normal pulses. Normal skin color MSS: Grossly normal ROM. NS: Nonfocal and grossly intact PSYCH: Normal affect. Assessment: Cervical cancer screening [Z12.4]: Due, will schedule for Pap smear. Breast cancer screening [Z12.39]: Due, will order screening mammogram Rheumatoid arthritis [M06.9]: Currently managed by Rheumatologist. Taking 20 mg methotrexate weekly, prednisone 10 mg daily and folic acid daily. Suspect will likely need biologic given reported limited response to MTX. Chronic idiopathic urticaria [L50.1]: Currently undergoing work-up and evaluation with Derm. Will need to review records on database Adjustment disorder with depressed mood [F43.21] Insomnia [G47.00]. Suspect insomnia is exacerbated by underlying depression. Patient discontinued sertraline 100 mg although it sounds like it worked well. Discussed trialing trazodone 50 mg nightly to help with sleep. Counseled on common side effects. Plan: Standard labs ordered. Will need to perform more detailed at exam at Pap visit. Orders: order comprehensive metabolic panel, tsh w/reflex to ft4, hemoglobin a1c with eag, lipid panel with reflex to direct ldl, cbc (includes diff/plt). Follow-up 2 months for Pap Signed electronically by (Name withheld), DO on 04Nov2023 10:34 am in (Name withheld). Date of Encounter: 09Jun2023, Exam Reason (CC): Office Visit - adverse drug reaction. Problem: patient presents for acute visit for adverse drug reaction. interpreter utilized during encounter. Patient saw Rheum for office visit on 30 May and was diagnosed with atypical rheumatoid arthritis based on findings on wrist x-ray which are suggestive of underlying inflammatory process. Per records, patient was advised to start methotrexate 15 mg weekly, folic acid daily and continue prednisone 20 mg daily. However, patient states her understanding what that she needed to discontinue the prednisone all together before starting the methotrexate. States her last dose of prednisone was Friday 02Jun. Took her first dose of methotrexate on Tuesday June 6. States she had some diarrhea and felt fatigued, but noticed improvement in her wrist pain that day. On Wednesday, she states she developed severe fevers (Tmax 41 degrees Celsius) and joint pain so severe she was unable to get out of bed. States her muscles felt so tight she could not straighten her legs. Also developed a diffuse pink rash across her face and extremities. Attempted to contact Rheumatology office but was not sure what number to call so she contacted our office after hours. States she understood that she was advised to go to the hospital by ambulance, but was afraid to go to the hospital alone, because her friend had to leave for work early in the morning so she stayed at her friend's house. Reports she still had fevers Wednesday but her temp was not as high (37-38 degrees Celsius. No longer having fevers today. States her joint pain has improved some. Able to ambulate, but it is painful. Rash has improved a little but is still present on her arms and legs. Denies vomiting or abdominal pain. Currently denies shortness of breath. Vitals: BP: 120/71, HR: 117 (low 1ODs on my exam), Wt: 136.6 lbs. [-3.2 from 139.8 lbs on 23May2023], BMI: 24.98 [-0.59 from 25.57 on 23May2023]. Objective: Skin: diffuse pink maculopapular rash across extremities. No visible bullae noted. PE: General: Nad EVES: EOMI, no conjunctivitis or obvious drainage HENT: NA/AT NECK: Supple RESP: Normal WOB CVS: Tacychardic no m/r/g. 2+ radial pulses. ABDOM: NTND MSS: Grossly normal ROM NS: Nonfocal and grossly intact PSYCH: Normal affect. Assessment: Adverse drug reaction [T50.905A]: Improving. Suspect patient likely had severe reaction to methotrexate. Symptoms may have been worsened by abruptly discontinuing steroid. Discussed with patient that goal is to start a medication like methotrexate so that she can gradually wean off steroid due to long-term risks with daily steroid use. Reviewed risks of immediately discontinuing steroid after chronic long-term use. Will resume prednisone. Advised to take 20 mg BID for three days as a burst and then decrease to 10 mg BID. Counseled to continue folic acid but discontinue methotrexate at this time. Provided Rheum clinic number to patient so she is able to contact them for future acute concerns regarding medication. I called Rheum this morning and informed nurse of patient's adverse reaction who stated she would inform patient's rheumatologist. CMP and CBC ordered. Rheumatoid arthritis [M06.9]: Recently established with Rheumatology and diagnosed based on imaging findings of wrist consistent with inflammatory arthritis. Started on methotrexate, but will likely need alternative therapy. Follow-up 6 weeks Signed electronically by (Name withheld), DO on 10Jun2023 11:18 am in (Name withheld) Date of Encounter: 23May2023. Exam Reason (CC): Office Visit - paperwork for rhuem appt Problem: presents for f/u. interpreter utilized during encounter. Polyarthralgia: Reports taking prednisone 10 mg twice daily. Overall pain is well-controlled on this dose. Recently went without prednisone for 4 days and had worsening symptoms. Has Rheum appt May 30. Initial appt had to be rescheduled. Has noticed some swelling in her face and wondering if this is due to prednisone. Doing well on Sertraline 100 mg daily. Currently not in counseling due to cost, but is getting support from family and friend. Notes rash on her arms and eyes. Sensitive and almost burning pain. States Xyzal seems to help rash some. Pain seem to be in her wrists and goes up her arms into her elbows. Completed initial claim for Program through agency but has not heard any updates in months. Vitals: BP: 123/60. HR: 80, Wt: 139.8 lbs. [+16 from 123.8 lbs on 17Oct2022], BMI: 25.57 [+2.93 from 22.64 on 17Oct2022]. Assessment: Polyarthralgia [M25.50] / Chronic idiopathic urticaria [L50.1]: Suspect potential underlying autoimmune condition may have been triggered by Pfizer COVID-19 vaccine as symptoms developed immediately after vaccine was received and worsened on receiving second dose. Previous CRP/ESR elevated although ANA IFA with reflex titer and pattern was negative. Anti-DS Ab and Rheumatoid factor also negative. Previously provided information for Program through agency. Has had difficulty with follow-up due to limited transportation. Refill Prednisone 10 mg BID, currently is at minimum dose patient has been able to wean to. CBC, CMP, lipids ordered today. Counseled on light stretching and low-impact exercise including walking, swimming, and lateral recumbent biking. Would have ideally liked to repeat some rheum labs prior to Rheum appt but patient has need to cancel multiple appointments. Will defer further work-up to Rheum at this time. Refill xyzal since it seems to help with urticaria -Discussed trialing gabapentin from nerve pain described by patient. Counseled on common side effects of med. Provided paper copy of records to patient for her to take to appt. Depression [F32.A]: Stable on Sertraline 100 mg. Currently not in counseling but connected with counselor if she decides to resume her sessions. Follow-up 2 months or sooner if needed. Signed electronically by DO on 24May2023. Date of Encounter: 03Feb2023. Exam Reason (CC): Office Visit - med check and follow-up- Ask about balance!! Problem: patient presents for f/u. interpreter utilized during encounter. Polyarthralgia: Reports taking prednisone 10 mg twice daily. State on this dose pain is well-managed in her feet. Has some pain in her hands and intermittently has area of swelling on right wrist. States if she runs out of steroid she develops severe pain in her joints. Mentioned she has noticed some puffiness in her face but otherwise steroid has been well-tolerated. Has initial Rheum appointment scheduled 12Apr2023. Has also completed initial claim for Program through agency. Patient pulled up an email from agency stating that all medical records a year prior to vaccine and all records after vaccine was needed. States she did receive a release form but was not sure of the best next step. States she has previously had x-rays of her feet but not her wrist. Has not noticed any rash in the last two months. Depression/ Anxiety: Currently taking Sertraline 100 mg daily. Has also started weekly counseling sessions, a therapist that speaks her native language. Has noticed significant improvement with both counseling and medication. Has also started exercising daily. States prior to onset of symptoms after vaccine she was very active at baseline. Is excited that she has been able to be more active. Patient showed a picture of her right wrist. Visible swelling noted over what appears to be first CMP joint. No other concerns reported today. Vitals: BP: 99/59, HR: 70, Temp: 97.6 °F, Objective: MSK: No visible swelling or bogginess noted of DIP, PIP, MCPS b/1. Skin: No visible rash on exposed skin. PE: General: Nad, Eyes: Eomi, no conjunctivitis or obvious drainage Hent: Naat. NECK: Supple RESP: Normal WOB. CVS: RRR Normal skin color MSS: Grossly normal ROM. NS: Nonfocal and grossly intact PSYCH: Normal affect. Assessment: Polyarthralgia [M25.50) / Chronic idiopathic urticaria [L50.1): Suspect potential underlying autoimmune condition may have been triggered by Pfizer COVID-19 vaccine as symptoms developed immediately after vaccine was received and worsened on receiving second dose. Previous CRP/ESR elevated although ANA IFA with reflex titer and pattern was negative. Anti-DS Ab and Rheumatoid factor also negative. Previously provided information for Vaccine Injury. Compensation Program through agency. Refill Prednisone 10 mg BID, currently is at minimum dose patient has been able to wean to. CBC, CMP, lipids unable to be performed today, will perform at next visit for monitoring. Counseled on light stretching and low-impact exercise including walking, swimming, and lateral recumbent biking. Given initial rheum labs performed in 6/2022 and rheum appointment not until 4/2023 would benefit from further lab work-up to clarify diagnosis. Discussed ordering repeat rheum labs. Vit D Insufficiency: Recheck level with other rheum labs, Adjustment disorder with depressed mood [F43.21]: Improved on Sertraline 100 mg. Also in counseling with therapist in patient's native language. Suspect ability to be more active has also greatly supported patient mood. Follow-up 1 month for labs and flu Signed electronically by (Name withheld), DO on 03Feb2023 6:02 pm in Date of Encounter: 17Oct2022 Exam Reason (CC): Office Visit - needs interpreter Problem: patient presents for follow-up. interpreter utilized during encounter. Polyarthralgia: Reports taking prednisone 10 mg twice daily. State on this dose pain is well-managed in hands, wrists, shoulders. Still having pain in knees and feet especially left midfoot but states pain is currently tolerable and reports improved function. No known hx of trauma or injury to left foot. Used to be very active, but has been limited by pain. Also reports pain due to tight muscles in back of legs. Has started walking to increase daily activity, but wearing sandals because she cannot tolerate sneakers. Taking Calcium and Vitamin D supplement daily. Contacted Rheumatology and was scheduled for appointment 17Apr2022. Was informed this is the earliest she could be seen. Has also intermittently experienced a diffuse rash on her trunk on extremities that began after her first COVID immunization. States first reaction after immunization was a rash and arthralgia symptoms developed later. Depression/ Anxiety: Currently taking Sertraline 50 mg daily. Has noticed some improvement in her mood since starting medication especially reduced anxiety. Still feels sad and reports crying often due to frustration of not being able to work or be active. Vitals: BP: 108/58, HR: 68, Temp: 98.8 °F, Ht: 62 in. Wt: 123.8 lbs. [-10.2 from 134 lbs on 31Aug2022]. BMI: 22.64 [+1.01 from 21.63 on 31Aug2022]. Objective: MSK: tenderness to palpation on dorsal aspect of left midfoot. No visible swelling or deformities appreciated on exam. Tenderness to palpation around both knee joints. No visible swelling or bogginess noted of DIP, PIP, MCPS b/1. Skin: No visible rash on exposed skin. PE: General: And Eyes: Eomi, no conjunctivitis or obvious drainage Hent: Na/At. NECK: Supple RESP: Normal WOB CVS: RRR. MSS: Grossly normal Rom. NS: Nonfocal and grossly intact PSYCH: Normal affect. Assessment: Polyarthralgia [M25.50] / Chronic idiopathic urticaria [L50.1]: Suspect potential underlying autoimmune condition may have been triggered by Pfizer COVID-19 vaccine as symptoms developed immediately after vaccine was received and worsened on receiving second dose. Previous CRP/ESR elevated although ANA IFA with reflex titer and pattern was negative. Anti-DS Ab and Rheumatoid factor also negative. Previously provided information for Compensation Program through agency -Refill Prednisone 10 mg BID, currently is at minimum dose patient has been able to wean to. CBC, CMP, lipids ordered for monitoring. Trial of Robaxin 750 mg prn for potential underlying muscle spasms. Counseled on light stretching and low-impact exercise including walking, swimming, and lateral recumbent biking. Advised to send pictures of rash and discussed potential biopsy to assist with clarifying diagnosis. Given initial rheum labs performed in Jun2022 and rheum appointment not until Apr2023 would benefit from further lab work-up to clarify diagnosis. At next appt will discuss repeating following labs: ESR, CRP, ANA with reflex and consider additional testing. Vit D Insufficiency: Clarify Vit D dose patient is supplementing with. Re-check level when repeating additional autoimmune testing. Adjustment disorder with depressed mood [F43.21]: Improving, but not at goal. Increase Sertraline to 100 mg daily. Provided multiple resources for counseling in patient's native language. Advised to contact office if referral needed. Pain of left midfoot [M79.672]: Suspect is associated with underlying rheumatologic condition. 01Jul22 x-ray of left mid¬ foot showed no evidence of fracture or dislocation. Given pain is significantly impacting patient mobility and quality of life discussed podiatry referral to determine if there may be alternative cause to pain. Follow-up 4-6 weeks. Signed electronically by (Name withheld), DO on 18Oct2022 9:25 am in Date of Encounter: 31Aug2022. Exam Reason (CC): Office Visit - follow up. Problem: (Name withheld) presents for follow-up of diffuse polyarthralgia. interpreter used during encounter. States she was not able to tolerate lower dose of prednisone. Reports her pain had worsened so much she went to Urgent Care on 21Aug2022 where she received a prescription for tramadol and an injection of Toradol. Thinks those meds helped some. Since starting the prednisone 10 mg BID a few days ago she feels she is able function and her pain is much more manageable. (Name withheld) has wondered if she might qualify for compensation from a vaccine injury program. States prior to receiving COVID vaccines she lived a very active and fulfilling life. States she has not been able to work since developing her health complications and feels frustrated by how much it has negatively impacted her quality of life. (Name withheld) reports taking Sertraline 25 mg daily. States med is well-tolerated and she thinks it is helping some. States when her pain was previously uncontrolled she was having passive SI, but denies currently having SI. States her faith is very important to her and her relationship has also been a large source of social support. Vitals: BP: 104/55, HR: 77, Ht: 66 in. Wt: 134 lbs. [-16 from 150 lbs on 10Aug2022]. BMI: 21.63 [-2.58 from 24.21 on 10Aug2022]. PE: General: Nad EYES: EOMI, no conjunctivitis or obvious drainage HENT: NA/AT NECK: Supple RESP: Normal WOB. CVS: RRR Normal skin color MSS: Grossly normal ROM. NS: Nonfocal and grossly intact PSYCH: Normal affect. Plan: Chronic urticaria/joint swelling: seems to be autoimmune in etiology, previous CRP/ESR elevated although ANA IFA with reflex titer and pattern was negative. Anti-DS Ab and Rheumatoid factor also negative. Continue Prednisone 10 mg BID, has not responded to attempts to wean dose. Previously referred to Rheum, but unfortunately practice not accepting self-pay patients at this time. Secondary referral has been placed to Rheum, provided patient with phone number to contact office. Provided links and phone number to Compensation Program through agency, discussed possibility that patient may need to look into attorney to assist with process of pursuing compensation. Depending on when Rheum appt is scheduled, it may be beneficial to consider repeat autoimmune w/u Adjustment disorder with depressed mood Increase Sertraline to 50 mg daily. Will look into options for counseling for patient in native language. Follow-up 1 mth or sooner if needed Signed electronically by (Name withheld), DO on 05Sep2022. Patient Name: (Name Withheld) D.O.B.: (DOB Withheld); 47 yrs, 1 mo at the time of visit Seen by (Name Withheld) Date of Encounter: 17Jun2022 Exam Reason (CC): Walk-in - Jaw and ear pain as well as ankle pain. Problem: (Name Withheld) presents for a reoccurrence of joint pain in her ankles and wrists as well as facial pain and swelling which began several days ago. This is also accompanied by skin irritation but not itching. All of this feels familiar to a prior episode of discomfort/pain which then evolved into an urticaria! rash and was treated successfully with prednisone by urgent care. She states the pain is severe. She is very frustrated that her recurring pattern of pain/discomfort has begun to interfere with her daily life. Of note, she does endorse fever at home which she states did get up to 39C (102F). No URI sx, N/V. Vitals: BP: 116/55, HR: 100, Temp: 99 F, Wt: 142.6 lbs. [-4.4 from 147 lbs on 07Jun2022], BMI: 24.48 [-0.75 from 25.23 on 07Jun2022] 02: 99 PE: General: Nad. Eyes: Eomi, no conjunctivitis or obvious drainage. HENT: NA/AT. Puffiness noted to cheeks bilaterally. OP erythematous w/ clear PND. TMs w/ clear effusion and slight bulge, EACs clear and non-erythematous. No LAD noted. NECK: Supple RESP: Normal WOB, CVS: mild tachycardia. MSS: Grossly normal ROM, no edema noted, no joint swelling or erythema NS: Nonfocal and grossly intact PSYCH: Normal affect. Plan: Suspect rheumatic process given previously positive CRP/sed rate, neutrophilia and now reoccurring joint pain. Will draw rheumatic panel Monday (lab not available today) and reassess. Pred burst provided to pt today for inflammatory relief. Fever is concerning but do not suspect infectious process based on her other symptoms; likely that previous neutrophilia was related to recent steroid use. However, instructed pt and SO to contact us over the weekend if sx worsened. Consider relapsing/remitting fever DO (though no known hx tick-borne illness signs or sx) as cause. Orders: New prednisone 20 mg Tab 2 tablets orally daily for 5 days #10 tablet RFx0 Signed electronically by (Name withheld) on 07Jun2022 2:11 pm in (Name Withheld). Patient Name: (Name Withheld) D.O.B.: (DOB Withheld); 47 yrs, 1 mo at the time of visit Seen by (Name Withheld). Date of Encounter: 07Jun2022. Problem: (Name withheld) presents to establish care. Due to technical difficulties, our interpreting services were not available today. Her boyfriend (name withheld) provided some of her HPI today. Intake paperwork was not completed prior to this visit, but pt was able to take it home with her and planned to have her niece help her fill it out prior to her next visit. Allergic skin reaction started first Apr2021 after first Covid shot (Pfizer, also got 2nd dose May2021). Had severe reaction after second dose also. The reaction consists of an itchy rash- pt brought photos to demonstrate which show disseminated urticaria. She endorses flares about every 3 months which are severe. While she was waiting for a visit with our office, she sought out care sooner at Urgent Care and was given prednisone which helped quite a lot. Also cetirizine, famotidine. So far, the rash has not returned since then (see note in chart; was seen about a week ago). She was working with medical facility last year- from there was set up with Allergist-- had taken antihistamine prior to allergy testing, so the initial result was not conclusive. Today she presents a rx sheet with a lab order: CBC, ESR, CRP, LFTs, vit D. Fax to #. She is still interested in completing her evaluation with allergists and finding out what she may be reacting to. Vitals: BP: 103/52, HR: 78, Temp: 98 F, RR: 17, Ht: 64 in. Wt: 147 lbs. BMI: 25.23. 02: 97. PE: General: nad Eyes: eomi, no conjunctivitis or obvious drainage Hent: na/at Neck: supple Resp: normal wob Cvs: regular rate Mss: grossly normal rom Ns: nonfocal and grossly intact Skin: no rash noted today Psych: normal affect. Plan: -Update wellness labs plus lab order today; will fax to AP office per pt request. -APE and lab review in 2 weeks; will use interpreter at that visit. -Sent pt home with intake form to bring back with her at next visit to more fully review her medical history. -Continue famotidine and cetirizine Signed electronically by (Name Withheld) on 08Jun2022 8:51 am in (Name Withheld). Patient Name: (Name Withheld). D.O.B.: (DOB Withheld); 47 yrs, 1 mo at the time of visit Seen by (Name Withheld) Date of Note: 11Aug2022. Received call in PM on 8/10 regarding Rx for prednisone. I stated patient had two refills prescribed by previous PCP available for pick-up and to call again if Rx could not be filled. Signed electronically by (Name Withheld) on 11Aug2022 8:51 am in (Name Withheld). Patient Name: (Name Withheld). D.O.B.: (DOB Withheld); 47 yrs, 2 mo at the time of this note Date of Note: 29Jul2022 The Rheumatology clinic called back they said that they had received the referral and it was just waiting for approval on their. I did inform them that when they reach out to the patient they will need a interpreter. Documented by (Name Withheld) on 29Jul2022. Patient Name: (Name Withheld) D.O.B.: (DOB Withheld); 6 mo at the time of printing this document. Gender: Female. Patient ID: # Cared for by (Name Withheld) Test Name: Tsh W/Reflex To Ft4, Tsh W/Reflex To Ft4. Value: 1.28 Reference Range: mlU/L. Reference Range: >or= 20 Years 0.40-4.50. Pregnancy Ranges: First trimester 0.26-2.66,