Age: 78.0
Sex: M
Vaccine: COVID19
Symptoms: Condition aggravated, Hypersensitivity, Pruritus
Clinical narrative: Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/9/2021  9:00 AM Expand AllCollapse All    COVID VACCINE CLINIC  3/8/2021    Patient:   Date:  3/8/2021                                                                                             MRN:  9750775     Subjective Patient is a 78 y.o. male who was seen at COVID Vaccine Clinic today for his first  dose of the COVID 19 vaccination.    He was given the Pfizer vaccination in the left deltoid muscle.   During his 30 minute waiting period after the injection, the patient began to experience itching.  He denied rash, difficulty breathing, difficulty swallowing, wheezing, throat tightness, lightheadedness, dizziness, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and he was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to rapid progression of symptoms and skin changes.   PMH: idiopathic anaphylaxis in 1995. Hx of copd, a-fib (on eliquis) and hypothyroidism.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of itching of skin   Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, dizziness and headaches       Previous Reactions: none to vaccines. Unknown cause of his anaphylaxis in 1995. At that time he developed rash/hives and it progresses quickly.  He's had itching off/on chronically. He doesn't think the itching today changed from baseline. His wife would like him to be checked out.    Objective    Vitals Vitals:   03/08/21 0338 03/08/21 1555 BP: (!) 133/93   Pulse: 93 73 SpO2: 99% 99%        Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is not ill-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds and air entry.  Skin:    General: Skin is warm.     Coloration: Skin is not pale.     Findings: No rash (visual exam of abdomen, chest, back and groin and upper extremities w/o evidence of rash/hives.).  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: antihistamines benadryl Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Systemic reaction (hypoglycemia, hypotension, generalized rash) Itching.    Chronic vs new itching. He reports immediately upon getting back to the bay that he doesn't think it's anything but his chronic itching that he gets.  He declines feeling like this is an allergic response like he's had in the past.  Benadryl given as requested by pt's wife for comfort measures. This request was reasonable. Pt's wife will be driving. They both are aware of what to monitor for and when to call 911.  Pt's exam is unremarkable. VS stable. Follow up with pcp otherwise.    APRN Electronically Signed 3/8/2021 3:48 PM