Age: 35.0
Sex: F
Vaccine: COVID19
Symptoms: Facial pain, Feeling jittery, Hypersensitivity, Neck pain, Pain in extremity
Clinical narrative: o Complaint The patient is a 35 year(s) old Female complaining of allergic reaction, reactive to COVID vaccine. o Chief Complaint Quote Per triage note: Patient states she received her first COVID vaccine injection and started to feel pain/tingling down right arm/face and neck. Patient was given one IM epi at site. Patient states she now feels jittery only. o Time Seen 02-17-2021 13:54 o Historian patient o Objective Statement 35-year-old female presents the emergency department for an allergic reaction.  Patient received her first dose of the Covid vaccination in her right deltoid and shortly after receiving the vaccination she began having tingling in the right arm extending down the right hand and up to the right neck and face.  She was given epinephrine and sent to the emergency department.  On arrival to the emergency department, she says the tingling in her arm has improved but she now feels "jittery ".  She denies any headache, visual change, throat tightness, chest pain, difficulty breathing, abdominal pain, nausea, vomiting, rash.  Says she had an anaphylactic reaction to bee stings in the past and is also allergic to Motrin.  Review of Systems   Constitutional: Negative for chills, diaphoresis and fever.   HENT: Negative for congestion, facial swelling and rhinorrhea.    Eyes: Negative for discharge and visual disturbance.   Respiratory: Negative for cough, chest tightness and shortness of breath.    Cardiovascular: Negative for chest pain and leg swelling.   Gastrointestinal: Negative for abdominal pain, diarrhea, blood in stool and vomiting.   Endocrine: Negative for cold intolerance and polydipsia.   Genitourinary: Negative for difficulty urinating, dysuria and hematuria.   Musculoskeletal: Negative for arthralgias, joint swelling and myalgias.   Skin: Negative for rash.   Neurological: Negative for speech difficulty, numbness and headaches.  Physical Exam Nursing notes and vital signs reviewed.  GENERAL: No distress  HEAD: normocephalic, atraumatic  EENT: PERRL, EOMI. Conjunctivae normal color, sclerae non-icteric; moist mucous membranes.  NECK: Supple, non-tender; no meningismus  LUNGS: Lungs CTA, breathing even and unlabored. Normal air movement.  HEART: Regular rate and rhythm, no murmur  CHEST: No deformity; non-tender  ABDOMEN: The abdomen is soft, and non-tender, no masses or bruits.  EXTREM: Normal ROM; no deformity, no calf tenderness. Normal pulses palpable in all extremities. There is no pedal edema.  SKIN: No rash; no diaphoresis  NEURO: Alert; normal speech and cognition; CN's grossly intact; strength grossly intact without focal deficit.  BACK: No CVA TTP. o ED Course 1620: Repeat evaluation, patient resting comfortably in the room.  Her vital signs remained stable.  She was given steroids, Pepcid and Benadryl and has been monitored in the ED with no incident.  She having any numbness or tingling in her right arm.  She is still not having any shortness of breath or throat tightening.  We will discharge the patient home.  Patient will be given a prescription for an EpiPen.  Did tell the patient to follow-up with primary care physician to discuss whether or not she should receive the second dose.  Patient given warnings indications to return the ED.  Patient understands and agrees the plan.