Age: 43.0
Sex: F
Vaccine: COVID19
Symptoms: Aphasia
Clinical narrative: Progress Notes Expand AllCollapse All      Patient:                                                                                                           DOB:   Date:  3/24/2021                                                                                             MRN:     Subjective Patient is a 43 y.o. female who was seen at COVID Vaccine Clinic today for her first  dose of the COVID 19 vaccination.    She was given the Pfizer vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience difficulty speaking.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, dizziness, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and she was then assessed in the emergency area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , rapid progression of symptoms, respiratory distress and tongue swelling.    Past Medical History: Diagnosis Date ? Addison's disease (HCC)   ? Asthma   ? Depression   ? Hypothyroidism   ? Pulmonary HTN (HCC)   ? Restless legs   ? Rheumatoid arthritis(714.0)   ? Sjogren's disease (HCC)     PT on home O2. Followed by medical center. Pt also reports hx of serotonin syndrome.   ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches    + aphasia:     Previous Reactions: none    Objective    Vitals Vitals:   03/24/21 1510 03/24/21 1513 BP: 105/74 123/69 Pulse: 98 96 SpO2: 97% 95%            Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not diaphoretic.     Interventions: Nasal cannula in place.     Comments: Personal O2 via NC  HENT:     Head:     Jaw: Trismus present. No tenderness, swelling or pain on movement.     Comments: aphasia    Mouth/Throat:     Mouth: Mucous membranes are moist. No angioedema.     Pharynx: Oropharynx is clear. Uvula midline. No pharyngeal swelling, posterior oropharyngeal erythema or uvula swelling.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Gait: Gait normal.     Comments: +5/5 strength to upper and lower extremities. No facial drooping. No tongue/throat swelling . Pt points to jaw line and TMJ as the muscles are affected.    Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal. Behavior is cooperative.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: no therapy Follow up response to treatment: no change. Patient discharge: Transported to ED by ambulance.  Differential Diagnosis: Systemic reaction (hypoglycemia, hypotension, generalized rash) and Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   Pt with no other neuro deficits but aphasia is clearly present. Medical team called to have pt brought to ED for further evaluation. Husband will meet her there.