Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Chest discomfort, Dyspnoea, Productive cough, Stridor, Throat clearing
Clinical narrative: Progress Notes Nurse Practitioner COVID VACCINE CLINIC   Subjective Patient is a 48 y.o. female who was seen at SVH COVID Vaccine Clinic today for her second  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 breathing, and chest tightness and phlegmy throat. .  She denied rash, hives, welts, difficulty swallowing, wheezing, 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 , collapse, drooling, hypotension, increased swelling, rapid progression of symptoms, respiratory distress, skin changes, tongue swelling and vomiting.         ALLERGY REVIEW OF SYSTEMS:  Patient complains of frequent throat clearing, chest tightness and shortness of breath       Previous Reactions: Covid shot : Muscle ache and headaches for 2 days.     Objective    Vitals Vitals:   03/17/21 1603 03/17/21 1639 03/17/21 1650 BP: 109/88   (!) 146/104 Pulse: (!) 117 (!) 107   SpO2: 99% 97% 99%            Physical Exam Constitutional:      Appearance: Normal appearance. She is well-developed.  HENT:     Head: Normocephalic.     Right Ear: Hearing normal.     Left Ear: Hearing normal.     Nose: Nose normal.     Mouth/Throat:     Lips: Pink.     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. Uvula midline.  Eyes:     General: Vision grossly intact.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Decreased air movement present. Examination of the right-upper field reveals decreased breath sounds and wheezing. Examination of the left-upper field reveals decreased breath sounds and wheezing. Decreased breath sounds and wheezing present. No rhonchi or rales.     Comments: Tight wheeze in lungs  Cleared after 2 puffs of albuterol inhaler, symptoms reoccurred within 10 min of use. Neurological:     Mental Status: She is alert.  Psychiatric:        Behavior: Behavior is cooperative.    Pt was given albuterol inhaler 2 puffs,Pepcid,  Benadryl IM and Solumedrol 125 mg IM. Pt initially clears for about 10 minutes, then airways tighten up again after inhaler use. Epinephrine 0.3 given and pt sent by AMR to hospital. O2 started at 2L at 4:50.      Assessment/Plan  Treatment included: albuterol, antihistamines, oral steroids, water and pepcid Follow up response to treatment: poor. Patient discharge: Transported to ED by ambulance.  Differential Diagnosis: Anaphylaxis (dyspnea, stridor, drooling, tongue swelling) and Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns) 5:05 left for ER.  Update given to AMR and SV ER.        Electronically Signed 3/17/2021 4:56 PM