Age: 40.0
Sex: M
Vaccine: COVID19
Symptoms: Cardiac monitoring, Cold sweat, Cough, Dysphagia, Erythema
Clinical narrative: ER Nursing Intervention/Reassessment [Charted Location:   EMR-Emergency Rm Service] [Authored: 04/16/2021 15:18]- for Visit: 004092726008, Complete, Revised, Signed in Full, General  IV:   IV Intervention: ? IV IV INTERVENTION/REASSESSMENT ? IV 1 Date 04/16/2021 ? IV 1 Time 14:25    ? IV IV 1 ? IV 1 Size 20G ? IV 1 Type peripheral iv ? IV 1 Inserted By inserted per RN ? IV 1 Side right ? IV 1 Right antecubital ? IV 1 Actions flushes easily  labs obtained ? IV 1 Dressing needleless valve placed, catheter secured, transparent dressing applied with date/time/initials  transparent semi-permeable dressing applied ? IV 1 Response pt. tolerated well  pt instructed to call RN for problems ? IV 1 Total Attempts 1  COVID Screening Questions:   COVID Screening Questions: ? Have you had a COVID-19 vaccine in the last 7 days? Yes (1) ? Was this COVID-19 vaccine your: First dose (1)    Assessment Date / Time: ? Date/Time 04/16/2021 14:25     History of Present Illness:   Chief Complaint: ? History of Present Illness allergic reaction ? Onset Time/Last Seen Normal 04/16/2021 13:15  Skin Assessment:   Skin Assessment: ? Skin cool  diaphoretic ? Mucous Membranes moist  intact    COVID Screening Questions:   COVID Screening Questions: ? Have you had a COVID-19 vaccine in the last 7 days? Yes ? Was this COVID-19 vaccine your: First dose    ER Triage Note: ? Triage Date/Time 04/16/2021 14:21 ? Triage Chief Complaint medical,  Allergic Reaction to Covid Vaccine ? Additional Triage Comments Pt states he went home after receiving his Covid Vaccine (Phizer) when he noticed he was itching on his back.  Pt arrived to ED with generalized erythema, skin cool and clammy, and wheezing.  Pt denies contact with chemicals or anything else. ? Have you been sexually assaulted? no ? Stroke Screening no ? Pregnant/Could be pregnant not applicable ? LMP not applicable ? Tetanus <5 years ago ? Immunization up to date yes ? CDC Early Warning Symptoms None Identified ? CDC Precautions standard precautions  mask applied  Infectious Disease:   Infectious Disease: ? Have you traveled recently? No ? Do you have any of the following symptoms? none    Mode of Arrival: ? Mode of Arrival private auto  Height/Length - Weight for Calculation:   Weight for Med Calculation: ? Height (ft) 6 Feet ? Height (remainder in inches) 0 Inch ? Height (cm) 182.8 cm ? Body Measurements stated ? Weight for Calculation (kg) 108 Kg ? Weight Method stated ? BSA (m2) 2.29 M2 ? BMI (kg/m2) 32.3 kg/m2    Triage Vital Signs: ? Temp (degrees F) 97.1 degrees F    ? Temp (degrees C) 36.1 degrees C    ? Method skin/temporal ? Heart Rate (beats/min)   118 bpm    ? Respiration (breaths/min) 18 ? BP Systolic (mm Hg)   156 mm Hg ? BP Diastolic (mm Hg)   103 mm Hg ? Sitting BP right upper arm ? SpO2 Patient On room air ? SpO2 (%) 98 %   Treatment Prior to Arrival: ? Treatment Prior to Arrival none  Allergies:  Allergies/Intolerances:       Allergies: ?? Pfizer-BioNTech COVID-19 Vaccine: Anaphylaxis ?? tramadol: Hives  Home Medications - OMR:  Home Medications - OMR:  * Patient Currently Takes Medications as of 04/16/2021 15:11 documented in Structured Notes ?? losartan 50 mg oral tablet: None, 1 tab(s) orally once a day, Hx, Status: Active, Quantity: 0, Refills: None, Last Dose Taken:   ?? Albuterol (Eqv-ProAir HFA) 90 mcg/inh inhalation aerosol: None, 2 puff(s) inhaled every 6 hours, Hx, Status: Active, Quantity: 0, Refills: None, Last Dose Taken:      Patient Seen Time:  ? Patient Seen Time 04/16/2021 14:21    ? LMP not applicable ? Tetanus <5 years ago ? Immunization up to date yes   Triage Vital Signs: ? Temp (degrees F) 97.1 degrees F ? Temp (degrees C) 36.1 degrees C ? Method skin/temporal ? Heart Rate (beats/min)   118 bpm ? Respiration (breaths/min) 18 ? BP Systolic (mm Hg)   156 mm Hg ? BP Diastolic (mm Hg)   103 mm Hg ? Sitting BP right upper arm ? SpO2 Patient On Pulseox: 98   % on RA @ bedside monitor -- normal ? SpO2 (%) 98 % ? Acuity Level 3   Preferred Pain Scale: Preferred Pain Scale Numeric Pain Scale© Numeric Pain Score - Rest© 0 - No Pain Numeric Pain Score - Activity© 0 - No Pain    Treatment Prior to Arrival: ? Treatment Prior to Arrival none    Nursing Documentation Review: ? Triage Review I have reviewed the above Vital Signs, Nursing Documentation and Triage Assessment.  Arrived From:  ? Arrived From home  home after leaving vaccination clinic  HPI:  ? HPI CC: rash/itching  HPI: history from patient  He describes Covid just after receiving the Pfizer vaccine, his initial dose.  By the time that he returned home he had opened up a soft drink was having some slight cough, trouble swallowing and had sensation of itching on his back.  He asked his mother to check his back and it was discovered that he was starting to have rash over his body.  This seemed to be persistent and he returned to ER for further evaluation/treatment.  He has not had reaction to vaccination in the past.  He does have allergy to tramadol.  He denies having any allergy to soap, detergent, or other chemicals.  He denies having exposure to any chemical, fume, dust, plant material after receiving the vaccination.  He denies having any new foods or drinks recently.  He is not having any nausea or vomiting.  He has felt somewhat sweaty.   Allergy: tramadol H/O LE muscle weakness/atrophy , COPD  ROS  Const:  No fever, chills, sweats.  No unusual weakness (he does note "my leg is atrophying" when he is speaking about his LLE) HEENT:  No  runny nose, congestion, ear ache.  Perhaps some odd sensation in the throat due to swollen uvula. CV:  No chest pain, palpitations. No unusual shortness of breath.  No edema to the ankles / legs.  No pain with breathing. Abdom: No nausea, vomiting, diarrhea, or constipation.  No abdominal pain. Lymph:  No swelling to glands.    Physical Exam:  ? Physcial Exam A&O, nontoxic. Pleasant. No pain distress. Mild physiologic distress. Appears to be overwt adult with component of chronic illness and with acute allergic reaction/process_. Eyes: EOMI, nonicteric, conjunctiva clear. Throat: Moist mucous membranes.  Symmetric rise of palate.  No pharynx erythema.  Tonsils normal size and without erythema or exudate. His uvula is moderately edematous and elongated.  He is managing his secretions well.  There is no angioedema of the tongue, soft palate, lips.  No stridor.  No blood in the oropharynx.  No rhinitis/runny nose. Neck:  supple, normal ROM, nontender. trachea midline. No cervical or supraclavicular lymphadopathy. Thyroid nontender and normal size. Back:  No pain on percussion.  No muscle spasm. Nontender palpation.  No kyphosis. Lungs: fair to good air movement with quiet, fine primarily inspiratory wheezes in the mid to lower lung fields.   nl effort, no rales, crackles, rhonchi.  Normal resonance on percussion.  Cough clear. Cardiac:  borderline tachy RRR S1, S2, without murmur or rub.  Posterior tibial, Pedal pulses 2/4  bilaterally.  No ankle or pretibial edema. Skin: cool & dry extermities.  cool & moist (not diaphoretic) back skin.  Normal turgor. He does have confluent macular rash to the neck, (somewhat on face), arms, back/chest/abdomen.  Some mild hyperemia to the legs/ankles.  No urticaria. The right deltoid injection site is involved with the hyperemia/macular rash but no urticaria at this location right now Abdom: Bowel sounds present   x 4 Quadrants.  Normal tympany to percussion.  Soft.  Non-distended. Nontender.  Nonsurgical. Good muscle tone and moves all extremities.   He notes he has his chronic weakness in his left lower extremity.      Medical Decision Making: ? Discussed with another healthcare provider Discussed case with another healthcare provider ? Consultation Consultation 1, Consultation 2 ? Consultation 1 04/16/2021 15:54 ? Consultation 1 Comments discussed with  RPh.  He will come to ER to obtain additional information from patient.  This is the hospital's first presumptive Pfizer vaccine reaction. ? Consultation 2 04/16/2021 15:41 ? Consultation 2 Comments discussed with Dr.  we discuss presentation.  he agrees pt will need monitoring with the persisting symptom/findings and the H/O COPD.  1617 Dr has been to ER and completed eval.  pt to be placed on 2nd floor med/tele for additional monitoring and treatment.  pt did have labs yesterday.    ? Decision to Admit Based On  1446 Based on his symptoms and presentation presumptive acute anaphylaxis to component of the Pfizer Covid vaccine.  We will begin treatment with 0.3 mg epinephrine IM once as well as dexamethasone, famotidine, diphenhydramine IV. We will continue to monitor with cardiac telemetry and pulse oximetry.  He does have slight wheezing but this may be related to his chronic COPD.  No respiratory distress at this time, but his symptoms seem to have been mildly progressive over the past hour (per his report).  I believe inclusion of the epi to be prudent based on his presentation. Additionally, I will inform the vaccination clinic of this reaction.  he agrees pt will benefit from continued monitoring and repeated IV antihistamine and IV steroid treatment.  Pt will need IVFluid for hydration as well.   Recheck: ? Recheck Recheck 1, Recheck 2, Recheck 3 ? Time 14:55 ? Recheck patient stable  patient improving with treatment ? Comments He is improving.  His skin is now warm and moist (not sweatty , not diaphoretic).  The rash is receeding from the arms. Good coloration to the legs/ankles.  Back & torso rash starting to recede.  no nausea/vomiting. no difficulty breathing. still with fading macular rash on the torso and upper back. Lungs: improved air movement compared to the initial exam, nl effort, no rales, crackles, rhonchi.  He has lower field (only) quiet fine inspiratory wheezes.  Normal resonance on percussion.  Cough mildly wheeze @ bases, with improved airflow. Cardiac: borderline tachy RRR S1, S2, without murmur or rub.  Posterior tibial, pedal pulses 2/4 bilaterally.  No ankle or pretibial edema. ? Time #2 15:05 ? Recheck #2 patient stable  patient improving with treatment ? Comments #2 man from pharmacy is here and recognizes patient from the vaccination clinic.  Patient rash has faded from his extremities fully and appears to have faded from his abdomen still somewhat at the malar area of the cheeks as well as the neck and torso portion of the chest.  His pulse is 98?99 continues to have elevated blood pressure.  Pulse oximetry 98-100% on room air, normal.  Pharmacist will enter the reaction into the CDC/FDA/Pfizer database. Overall pt notes he feels tired (probably related to hydration & benadryl).  He notes he has returned to home about 2 weeks ago after spending some time on the road in mountains playing guitar / touring with a small band , playing music. ? Time #3 15:37 ? Recheck #3 patient stable ? Comments #3 He has been resting.  No respiratory distress.  His blood pressure and pulse and pulse oximetry are reviewed at bedside and they are nonfocal at this time.  Overall he is improving.  He notes he still has malaise and feels about the same with itching in his back and the sensation in his throat.  When I evaluate his back there is hyperemia/some macular rash that is in approximately the distribution of the trapezius muscle of the back this is where he notes he has the itching.  Additionally when I evaluate his throat there is still some presence of uvula edema.  There is no other angioedema.  Perhaps he does have some mild hyperemia to the uvula and soft palate at this time.  He is clinically improving but his symptoms have not resolved fully.  Skin warm and dry normal turgor. No diaphoresis Lungs initially some coarseness/mucousy breath sounds to the mid lower fields but this clears after he coughs.  Good air exchange at this time.  No rales rhonchi wheezes or crackles.  Cough initially mucousy then clear. managing secretions well. no stridor. no respiratory distress.  Critical Care Times:  ? Critical Care Time of minutes excluding, separately billable procedures 35  Disposition Summary:  Arrival 04/16/2021 14:21 Disposition to be admitted Disposition Decision Date/Time 04/16/2021 15:54 Does an Emergency Medical Condition Exist at the time of D/C? yes Condition at Disposition Stable  Alert and Oriented  Guarded   Emergency Diagnosis:  ?? History of COPD (Z87.09): Entered Date: 04/16/2021 15:59, ICD-10: Z87.09 ?? Anaphylaxis due to immunization (T80.52XA): Entered Date: 04/16/2021 15:59, ICD-10: T80.52XA ?? Drug reaction, initial encounter (T50.905A): Entered Date: 04/16/2021 15:59, ICD-10: T50.905A  PCP Summary:  ? PCP ,    ? Select Follow-up Physician Follow Up Physician #1  Follow Up Physician #2 ? Follow-Up MD  ? Group Name Primary Care ? Specialty  ? Follow-Up MD  ? Fax Number ? Follow Up In 04 days    Instructions: ? Other Instructions Return to ER for worsening symptoms or other concerns ? Additional Instructions  Patient has had clinical improvement and stabilization although he is not fully resolved of his symptoms.  He is placed into the hospital for further evaluation and management under Dr.  Note Complete:  Note Complete This document is complete. Affix my electronic signature.     Last Updated: 04/16/2021 16:19 by (MD)  References: 1.  Data Referenced From "ER MD Exam and Disposition" 04/04/2021 17:40 2.  Data Referenced From "1. Vital Signs - Adult" 04/16/2021 14:30