Age: 30.0
Sex: F
Vaccine: COVID19
Symptoms: Paraesthesia
Clinical narrative: Progress Notes Hastings,(Nurse Practitioner) ? ? Nurse Practitioner MD at 1/17/2021  7:01 AM Expand All Collapse All                                                                   1/15/2021                                                                                              Subjective 30 y.o. female who was seen at Clinic today for her first dose of the COVID 19 vaccination.    She denied any history of previous adverse reactions to vaccines.   She was given the Moderna vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience Right arm pain, numbness/tingling and soreness, note that injection was given in left arm.  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 bay area.   Monitored patient for severe reaction symptoms, including but not limited to abdominal pain, blood pressure abnormality , chest pain, collapse, drooling, hypotension, increased swelling, rapid progression of symptoms, respiratory distress, skin changes, tongue swelling and vomiting.     ALLERGY REVIEW OF SYSTEMS:  Patient complains of muscle aches (Right arm)         Previous Reactions: No previous reactions to vaccines.     Objective    Vitals Vitals:   01/15/21 1239 01/15/21 1248 BP: 137/89 134/89 Pulse: 99 100 SpO2: 100% 100%     Blood Sugar 66 collected at 1236 * Patient given snack (granola bar) just before blood glucose checked.      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is not ill-appearing.  Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.  Musculoskeletal:     Right shoulder: She exhibits pain. She exhibits normal range of motion and no tenderness.     Right elbow: She exhibits normal range of motion and no swelling. No tenderness found.     Right wrist: She exhibits normal range of motion and no tenderness.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.        Assessment/Plan  Treatment included: Ibuprofen/analgesics. Follow up response to treatment: no change. Patient discharge: Stable to go home and follow up with PCP.   Reports that she had work up for Guillain Barre 2.5 years ago but this was ruled out. States that she has had intermittent pain of all extremities since that time and has a handicap parking placard due to this. She denies any pain in right arm prior to the vaccine but states it started just a few minutes after administration. She has full ROM without difficulty and full sensation but reports some numbness and tingling as well as soreness but not necessarily tender to touch. Ibuprofen was administered but shortly after patient requesting to leave and feels this pain is the same as what she's had over the past 2.5 years but wanted to keep us aware. She will be discharging home and states she does not live alone.     Electronically Signed 1/15/2021 1:03 PM