Age: 52.0
Sex: M
Vaccine: COVID19
Symptoms: Chills, Dyspnoea, Electrocardiogram normal, Erythema, Feeling jittery
Clinical narrative: Patient is a 52 y.o. male. Chief Complaint Patient presents with ? Allergic reaction     Reaction to Covid Vaccine        Is patient concerned about a specific cause for the current symptoms? Yes Covid Vaccine Onset of symptoms: 0830. Symptoms include: difficulty breathing and/or wheezing, rapid heart rate or palpitations and generalized redness. Rash distribution:  Face. How are symptoms changing over time? improving.   Patient describes symptoms as moderate. Has patient tried any treatment for these symptoms?No What makes the symptoms better?   Rest and time What makes the symptoms worse? Nothing   Patient states that the shortness of breath and the increased heart rate started after about 4 minutes - then went away but came back much stronger at 10 minutes post vaccination   No itching, wheezing, cough - just flushed and chilled Increased HR and jittery   Did have surgery recently    Did have Moh's procedure in the fall and had a reaction to the lidocaine - increased heart rate, increased blood pressure    Associated symptoms:   o Fever No   o Sore throat No   o Recent illness No   o Exposure to person(s) with similar rash No   Patient has flu vaccine documented this season.  Patient Active Problem List Diagnosis ? Migraine ? Obstructive sleep apnea syndrome ? Calculus of gallbladder without cholecystitis without obstruction ? Hemiplegic migraine without status migrainosus, not intractable ? Low HDL (under 40) ? History of nonmelanoma skin cancer ? Encounter for screening colonoscopy ? Essential tremor   Medical History Past Medical History: Diagnosis Date ? Acquired hypothyroidism   ? Chronic kidney disease     Stage 2 ? Chronic migraine with aura 01/04/2013 ? Colon polyps   ? Color blind   ? Enlarged prostate   ? GERD (gastroesophageal reflux disease)   ? Hemiplegic migraine   ? Hx of febrile seizure   ? Kidney stones     x 1 - 2001 ? Nodular basal cell carcinoma (BCC) 09/08/2020   bcc nod, rt cheeck and rt medial cheek ? Obstructive sleep apnea syndrome 11/04/2013   Home sleep testing on 10/31/13 with apnea/hypopnea index = 9 and low oxygen saturation = 90%. Auto-PAP titration pending.    Surgical History Past Surgical History: Procedure Laterality Date ? Colonoscopy   04/10/2020   ksc ? Hx lap cholecystectomy N/A 12/23/2020   LAPAROSCOPIC CHOLECYSTECTOMY  ? Hx of mohs/skin cancer surgery and repair   09/08/2020   bcc nod, rt cheek ? Hx of mohs/skin cancer surgery and repair   09/08/2020   bcc nod, rt medial cheek ? Hx wisdom teeth extraction     ? Upper gi endoscopy   04/10/2020   ksc  Objective: BP 116/74  | Pulse 84  | Temp 97.9 °F (36.6 °C) (Oral)  | Resp 18  | SpO2 97%    General:well-hydrated, well nourished, no acute distress HEENT: ENT exam normal, no neck nodes or sinus tenderness Lung: clear to auscultation bilaterally  Heart: regular rhythm, tachycardia noted and no murmurs, clicks, or gallops. Extremities: extremities normal, atraumatic, no cyanosis or edema Skin: flushed (face and neck and chest primarily) , no hives  Neuro: alert, orientation normal, speech normal   9:30 AM  Improving symptoms  Decreased HR, although patient states if feels like it is cycling, flushing is almost resolved No hives or shortness of breath  Mild jittery feeling