Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Tachypnoea, Unresponsive to stimuli, Urticaria, Wheezing
Clinical narrative: pt was sent to Er for hives and anylphatic response see discharge summaryDate Type Department Care Team Description 03/20/2021 Emergency  Anaphylaxis, initial encounter (Primary Dx) Allergies Active Allergy Reactions Severity Noted Date Comments Adenosine Unknown  03/20/2021  Barium Iodide Unknown  03/20/2021  Codeine Unknown  03/20/2021  Epi E-Z Pen   03/20/2021  Influenza Virus Vaccines Unknown  03/20/2021  Iodinated Contrast Media   03/20/2021  Iodine Unknown  03/20/2021  Lidocaine Unknown  03/20/2021  Morphine Unknown  03/20/2021  Penicillins Unknown  03/20/2021  Propofol Unknown  03/20/2021  Ketorolac Unknown  03/20/2021  Tramadol Unknown  03/20/2021  documented as of this encounter (statuses as of 03/23/2021) Medications Not on filedocumented as of this encounter (statuses as of 03/23/2021) Active Problems Not on file  documented as of this encounter (statuses as of 03/23/2021) Social History Tobacco Use Types Packs/Day Years Used Date Never Assessed     Sex Assigned at Birth Date Recorded Not on file  Job Start Date Occupation Industry Not on file Not on file Not on file COVID-19 Exposure Response Date Recorded In the last month, have you been in contact with someone who was confirmed or suspected to have Coronavirus / COVID-19? No / Unsure 3/20/2021 11:25 AM EDT documented as of this encounter Last Filed Vital Signs Vital Sign Reading Time Taken Comments Blood Pressure 159/80 03/20/2021 12:10 PM EDT  Pulse 98 03/20/2021 12:10 PM EDT  Temperature 36.1 °C (97 °F) 03/20/2021 11:14 AM EDT  Respiratory Rate 18 03/20/2021 12:10 PM EDT  Oxygen Saturation 98% 03/20/2021 12:10 PM EDT  Inhaled Oxygen Concentration - -  Weight 85 kg (187 lb 6.3 oz) 03/20/2021 11:14 AM EDT  Height 162.6 cm (5' 4") 03/20/2021 11:14 AM EDT  Body Mass Index 32.17 03/20/2021 11:14 AM EDT  documented in this encounter Discharge Summaries Not on filedocumented in this encounter Discharge Instructions Instructions:  You can take benadryl for itching at home.   Attachments: The following attachments cannot be sent through Care Everywhere.  Anaphylactic Reaction documented in this encounter ED Notes Patient arrives from Vaccine clinic where she received her second Covid immunization. Prior history of allergic reaction to other vaccines and history of asthma. Patient is alert and following instructions but has labored breathing and expiratory wheezing and is not verbally answering questions. Received Epi 0.3mg IM pta. Ems unable to obtain IV acce Associated Order(s): Critical Care  Formatting of this note might be different from the original. Emergency Department Encounter Note   History of Present Illness  Chief Complaint Patient presents with Allergic Reaction  HPI:  This is a 67yoF with pmhx asthma and multiple allergies who presents today after her second Pfizer COVID-19 vaccination. She received the dose, and while under observation in the waiting area she started having itching and wheezing. 911 was called.  EMS reports arrival and patient tachypneic, obvious hives. They gave IM epi for presumed allergic reaction and transported immediately.  ROS:  Review of Systems Unable to perform ROS: Acuity of condition  Remaining ROS are as documented in HPI.  Previous History  Past Medical History: No past medical history on file. Allergies  Past Surgical History: No past surgical history on file.  Medications: Patient's Medications No medications on file   Allergies: Adenosine, Barium iodide, Codeine, Epi e-z pen, Influenza virus vaccines, Iodinated contrast media, Iodine, Lidocaine, Morphine, Penicillins, Propofol, Toradol [ketorolac], and Tramadol  Social and Family History: Social History  Tobacco Use Smoking status: Not on file Substance Use Topics Alcohol use: Not on file  No family history on file.  Physical Exam  Vitals: 03/20/21 1210 BP: 159/80 Pulse: 98 Resp: 18 Temp: SpO2: 98%  Pulse ox Normal as interpreted by me.  Physical Exam Constitutional: General: She is not in acute distress. Appearance: Normal appearance. She is not toxic-appearing or diaphoretic. Comments: Actively itching at her skin on her back and stomach HENT: Head: Normocephalic and atraumatic. Comments: No airway edema Nose: No congestion or rhinorrhea. Mouth/Throat: Mouth: Mucous membranes are moist. Eyes: Extraocular Movements: Extraocular movements intact. Pupils: Pupils are equal, round, and reactive to light. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Wheezing (scattered inspiratory and expiratory wheezes in all fields) present. Abdominal: Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Skin: General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Findings: Rash present. Comments: Diffuse hives Neurological: General: No focal deficit present. Mental Status: She is alert. Comments: Not speaking but able to communicate and breath without difficulty Psychiatric: Mood and Affect: Mood normal.    ED Results:  EKG: Time: 1124, Rate: 112 , Rhythm: SInus , ST segments: Nonspecific ST changes without acute signs of ischemia. Comparison EKG was not available and unable to compare to a prior EKG.      ED Labs:  Labs Reviewed - No data to display  ED Radiology:  XR Chest 1 View Final Result  1. Low lung volumes with minimal bibasilar atelectasis. Mild interstitial prominence in the lower lungs, which may be secondary to bronchovascular crowding and/or mild interstitial edema.    Reviewed and electronically signed by : 3/20/2021 11:51 AM -------- FINAL REPORT -------- Transcribed By: Self Edit Transcribed Date: 03/20/2021 11:50   The laboratory results, imaging results and other diagnostic exam results related to this ED encounter were reviewed in the EMR.  ED Procedures:  Critical care provider statement: Critical care time (minutes): 32 Critical care time was exclusive of: Separately billable procedures and treating other patients and teaching time Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Respiratory failure and circulatory failure Critical care was time spent personally by me on the following activities: Development of treatment plan with patient or surrogate, evaluation of patient's response to treatment, examination of patient, interpretation of cardiac output measurements, obtaining history from patient or surrogate, ordering and performing treatments and interventions, pulse oximetry and re-evaluation of patient's condition Comments: Anaphylaxis management, two doses of epi and multiple re-evaluations    ED Administered Mediations:  Medications methylPREDNISolone sodium succ (SOLU-Medrol) injection 125 mg (125 mg intravenous Given 3/20/21 1115) famotidine (PF) (PEPCID) injection 20 mg (20 mg intravenous Given 3/20/21 1113) diphenhydrAMINE (BENADRYL) injection 50 mg (50 mg intravenous Given 3/20/21 1111) EPINEPHrine (ADRENALIN) injection 0.3 mg (0.3 mg intramuscular Given 3/20/21 1110) sterile water injection - ADS Override Pull (2 mL intravenous Given 3/20/21 1115)  ED Pre-Disposition Vitals: Vitals: 03/20/21 1210 BP: 159/80 Pulse: 98 Resp: 18 Temp: SpO2: 98%  Medical Decision Making, ED Course  MDM:  MDM Number of Diagnoses or Management Options Anaphylaxis, initial encounter Diagnosis management comments: This is a 67-year-old female who presents for chief complaint of anaphylaxis  On arrival patient's vital signs include tachycardia and tachypnea. S diffuse wheezing, he was not hypoxic. Exam significant for diffuse urticaria, no angioedema  This is a patient received 1 dose of IM epi in route. Reevaluated immediately upon arrival and she is still having significant symptoms. Patient given a second dose of epi and Pepcid, Solu-Medrol, Benadryl. Maintaining her airway Without difficulty.  Chest x-ray without acute process. patient reevaluated in the trauma bay and no longer having wheezing.  Patient reevaluated at the 4-hour mark, she is feeling much improved and no longer has any urticaria. She has no wheezing. She feels great and would like to go home. We discussed that she needs to keep her EpiPen in her purse, she states that she just changed her purse for the new season and that she will member in the future. She states that she just picked up this new EpiPen prescription she declines an additional epi prescription today.  Diagnosis is anaphylaxis, disposition is discharged with PCP follow-up. I also gave her allergist follow-up given her multiple allergies multiple anaphylactic reactions. I discussed the results of the work-up and evaluation done today, answered her questions, she is given return precautions for any worsening or concerning symptoms. She is in agreement with the plan.  Diagnosis 1. Anaphylaxis  Please see ED Course below for updates regarding ED results and course of the ED visit.  ED Course:  Clinical Impressions as of Mar 20 1507 Anaphylaxis, initial encounter   ED Prescriptions:  ED Prescriptions None   Disposition: Discharge  Condition: Stable  Diagnosis / Impression:  Final diagnoses: Anaphylaxis, initial encounter  Attending Supervisory Note: I have performed a history and physical examination of the patient and discussed the management of the patient with the residen. I was personally present for, observed, and participated in the critical portion of the procedure(s): critical care.  Patient presents from COVID vaccination with anaphylactic reaction. Patient required a second dose of epi while here but then improved markedly. Patient observed x4 hours with no worsening, will d/c for outpatient f/u. Given steroids while here, will recommend PRN benadryl at home..  documented in this encounter Plan of Treatment Pending Results Name Type Priority Associated Diagnoses Date/Time ECG 12 lead ECG STAT  03/20/2021 11:24 AM EDT documented as of this encounter Procedures Procedure Name Priority Date/Time Associated Diagnosis Comments XR CHEST 1 VIEW STAT 03/20/2021 11:47 AM EDT   Results for this procedure are in the results section.  ECG 12-LEAD STAT 03/20/2021 11:24 AM EDT   HC CRITICAL CARE 30-74 MINUTES Routine 03/20/2021 11:03 AM EDT   Results for this procedure are in the results section.  PR CRITICAL CARE 30-74 MINUTES Routine 03/20/2021 11:03 AM EDT   Results for this procedure are in the results section.  documented in this encounter Results XR Chest 1 View (03/20/2021 11:47 AM EDT): Specimen Impressions Performed At 1. Â Low lung volumes with minimal bibasilar atelectasis. Mild interstitial prominence in the lower lungs, which may be secondary to bronchovascular crowding and/or mild interstitial edema. -------- FINAL REPORT -------  Signed Date: 03/20/2021 11:51  Transcribed By: Self Edit  Transcribed Date: 03/20/2021 11:50  REASON FOR EXAM: Â Wheezing  VIEWS: 1, IMAGES: 1  COMPARISON: Â Chest x-ray 7/20/2016  POWERSCRIBE  Procedure Note Interface, Incoming Ancillary Results - Imaging Results Ps360 - 03/20/2021 11:54 AM EDT  XR CHEST 1 VIEW  COMPLETED DATE: 3/20/2021 11:39 AM  REASON FOR EXAM: Wheezing  VIEWS: 1, IMAGES: 1  COMPARISON: Chest x-ray 7/20/2016   IMPRESSION:  1. Low lung volumes with minimal bibasilar atelectasis. Mild interstitial prominence in the lower lungs, which may be secondary to bronchovascular crowding and/or mild interstitial edema. -------- FINAL REPORT -------- Dictated Date: 03/20/2021 11:50 Transcribed By: Self Edit Transcribed Date: 03/20/2021 11:50  Critical Care  Critical care provider statement:  Â Critical care time (minutes): Â 32  Â Critical care time was exclusive of: Â Separately billable procedures and  treating other patients and teaching time  Â Critical care was necessary to treat or prevent imminent or  life-threatening deterioration of the following conditions: Â Respiratory  failure and circulatory failure  Â Critical care was time spent personally by me on the following  activities: Â Development of treatment plan with patient or surrogate,  evaluation of patient's response to treatment, examination of patient,  interpretation of cardiac output measurements, obtaining history from  patient or surrogate, ordering and performing treatments and  interventions, pulse oximetry and re-evaluation of patient's condition  Comments:  Â  Anaphylaxis management, two doses of epi and multiple re-evaluations  documented in this encounter Visit Diagnoses Diagnosis Anaphylaxis, initial encounter - Primary  documented in this encounter Discharge Diagnoses Not on file documented in this encounter Administered Medications Inactive Administered Medications - up to 3 most recent administrations Medication Order MAR Action Action Date Dose Rate Site diphenhydramine (BENADRYL) injection 50 mg  50 mg, intravenous, Once, Sat 3/20/21 at 1107, For 1 dose  Given 03/20/2021 11:11 AM EDT 50 mg   EPINEPHrine (ADRENALIN) 1 mg/mL injection - ADS Override Pull  Starting Sat 3/20/21 at 1107, For 1 dose, Created by cabinet override,  EPINEPHrine (ADRENALIN) injection 0.3 mg  0.3 mg, intramuscular, Once, Sat 3/20/21 at 1108, For 1 dose  Given 03/20/2021 11:10 AM EDT 0.3 mg  Left Deltoid famotidine (PF) (PEPCID) injection 20 mg  20 mg, intravenous, Administer over 2 Minutes, Once, Sat 3/20/21 at 1107, For 1 dose  Given 03/20/2021 11:13 AM EDT 20 mg   methylPREDNISolone sodium succ (SOLU-Medrol) injection 125 mg  125 mg, intravenous, Once, Sat 3/20/21 at 1107, For 1 dose, Reconstitute each 125 mg vial with 2 mL sterile water for injection to a concentration of 62.5 mg/mL.,  Given 03/20/2021 11:15 AM EDT 125 mg   sterile water injection - ADS Override Pull  Starting Sat 3/20/21 at 1108, For 1 dose, Created by cabinet override,  Given 03/20/2021 11:15 AM EDT 2 mL   documented in this encounter  documented as of this encounter Advance Directives Documents on File