Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: Contusion, Dizziness, Dyspnoea, Fatigue, Fibrin D dimer
Clinical narrative: ** Backache - As of this visit today, April 21, 2021, pt still has c/o continuous back pains all down her spine since receiving the Johnson & Johnson COVID-19 Vaccine on March 31, 2021. patient continues to report pain in her neck (cervical), thoracic, and lumbar spine. She insists that the cervical pain radiates into both shoulders and down to her arms bilaterally. She states these pains started almost immediately after receiving the vaccine and persists as of today. On a scale of 0-10, patient rates her spine and shoulder pains at 3 continuously.     -- I've added methocarbamol 750mg tid for muscle relaxant with ibuprofen 400mg q6h. ** Severe headache - As previously noted in my previous findings with patient she reported having moderate headaches for two days after receiving the J&J COVID-19 Vaccine on March 31, 2021 but she states her headaches have now subsided.  *** Other: On my first visit with patient on April 6, 2021, she was very concerned about a sudden loss of hair since taking the J&J Vaccine in addition to the spine pains and bruising.  ** Leg swelling - patient reported both leg and hand swelling for 2 days after receiving J&J COVID-19 Vaccine with some new neurologic symptoms as noted below: ** New neurologic symptoms -patient continues to report significant weakness and fatigue.     -- Her headaches that were present after receiving the vaccine have subsided after the first two days following the vaccine being administered.     -- She reported new numbness x 2 days in both fingers and toes bilaterally with both hands and legs swelling immediately after receiving the vaccine.     -- She also reported 2 hours of dizziness immediately after receiving the vaccine on March 31, 2021.    -- patient reported a new onset of hand tremors that suddenly came on a week ago Sunday, April 11,       2021 while fishing that lasted for a few hours. She stated that the tremors would come and go for a while.    -- patient has been and is currently negative for loss of consciousness, seizures, and migraines. ** Severe abdominal pain - patient initially reported episodic sharp shooting pains in abdominal area on multiple occasions after receiving the vaccine but have mostly now subsided. However, today, April 21, 2021 she reports more abdominal shooting "Sharp Pains" in her RUQ this morning that she rated 3/10 pain, and LLQ "Sharp Shooting" pain last Friday, 4/16/21. She states that the shooting pains last approximately 3 minutes in duration. ** Shortness of breath ? patient has continuous episodic shortness of breath complaints that have persisted since receiving the vaccine on March 31, 2021. Her last episode was again this morning, April 21, 2021 and she also states she is feeling like she is having trouble breathing during the exam today. Her SaO2 is 98% on Room Air during triage. She also reported yesterday, the same at the Clinic. She reported being at work on Monday, April 19, 2021 and became short of breath and had to lay down on the floor to breath easier. patient is a Kindergarden teacher. She also became short of breath Monday evening while at home while cleaning her closet.     -- Yesterday, April 20, 2021 at Clinic  I added a rescue inhaler for her shortness of breath. ** Petechiae (tiny red spots on the skin) - patient reported a new eruption on her upper back and shoulders after receiving J&J Vaccine. While the red spots are not bleeding, there was a significant notable rash to bilateral shoulders and upper back when I last saw her a week ago on April 13, 2021 at the Clinic. Today, the rash has cleared significantly. She was prescribed TRIAMCINOLONE 0.025% (80GM) OINT,TOP  in Urgent Care last week, when I referred her to Dr. in the ER. ** New or easy bruising - multiple new bruising noted today on her left bicep arm. Yesterday, April 20, 2021 at the Clinic, I noted new bruising on lower extremities in addition to the bruising noted the week prior. The bruising started after receiving the J&J COVID-19 Vaccine that I noted in my previous findings last week.