Age: 50.0
Sex: F
Vaccine: COVID19
Symptoms: Trismus, Wheelchair user
Clinical narrative: flushing, weakness, LE cramping 50 year old female seen today for first COVID vaccine. Pt states that ten minutes post vaccination she began to feel lightheaded, unsteady, and bilateral leg cramps. She denies weakness, headache, dizziness, nausea, blurred vision, tongue swelling, difficulty swallowing, SOB, abd pain, numbness, tingling, paresthesias. She states that she had eaten oatmeal and a boiled egg with 16 ounces of water earlier this morning. She states she did a high intensity workout prior to arrival. VS: BP 120/81, HR 69, O2 97% RA, Temp 98.6, POC 112 exam benign. Other provider taking over care: Upon evaluation, Patient appeared in mild distress. She had been able to consume apple juice w/o issue. Vital signs were stable, although initial BP cuff used was too large for her arm. She was speaking in full sentences w/o increased WOB and able to stand on her own, but not walk to examination room. Staff assisted in her transfer to a wheel chair so that she could be seen in a private exam room. Patient stated she felt complete body flushing and warmth all over, muscle cramps - mostly over b/l LE, jaw cramping (akin to past TMJ experiences), lightheadedness, weakness, and nausea. She had exercised that morning, ate at typical healthy breakfast, and was feeling well prior to the vaccination. Denied pruritus, angioedema/swelling, confusion, SOB/wheezing, tachycardia/palpitations, need to vomit, abdominal cramping. O: repeat vitals HR 71 BP 120/84 with peds cuff RR 10 SpO2 99% on RA Gen: laying down on exam table, mild distress, non-toxic in appearance, answering questions appropriately, pleasant HEENT: atraumatic/normocephalic, PERRL, nares patent, throat-non- erythematous/no exudate Neck: no swelling CV: regular rate and rhythm, normal S1/S2, no murmurs Pulm: clear to auscultation bilaterally with no wheezes/rales/rhonci Abd: soft, non-tender/non-distended, +NBS in all 4 quadrants Ext: moves all 4 spontaneously, no edema. B/l LE with visible cramping/shaking when knees were asked to be bent Skin: no lesions or rashes, paw print tattoos on either shoulder Neuro: CN II-XII grossly intact, 5/5 strength UE and LE Psych: appropriate, thoughts linear and non-tangenital A/P: 5- yo patient with reaction to vaccination concerning for immediate allergic reaction (not anaphylaxis). Provider continued interview, provided reassurance, water and healthy snack for consumption and monitored patient for another ~20 minutes. RN stayed with patient for another ~20 minutes - for total obs time of over and hour after vaccination. Upon re- evaluation, Patient still with mild HA, but felt well enough to drive. Discussed other s/sx of immediate allergic reaction/anaphylaxis and when to seek emergent care. She is able to rest for the remainder of the day and has a partner at home who is able to keep an eye on her. Also reviewed that given concern for immediate allergic reaction - that she would need referral from PCP for allergist appt prior to receiving 2nd dose. Discussed that facility is already aware that patients may be referred for allergy needs and that consult could potentially be done over the phone, but that would be up to the provider. If cleared for 2nd dose, noted that allergist may recommend pre- or post-tx medications or nothing at all, but that she should please consider having someone drive her to/from the appointment. Patient stated verbal understanding and was visualized ambulating out of clinic on won with steady gait.