Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Paraesthesia
Clinical narrative: Notes APRN (Nurse Practitioner) ? ? Pediatrics Cosigned by: MD at 12/20/2020 11:30 AM Expand All Collapse All      COVID VACCINE CLINIC 12/18/2020    Patient:      DOB:   Date:  12/18/2020                                                                                         MRN:  10148412     Subjective Patient is a 48 y.o. female who was seen at Vaccine Clinic today for her first dose of the COVID 19 vaccination.    She denied any history of previous adverse reactions to vaccines.   She was given the Pfizer vaccination in the right deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience tingling in hands and feet.  She denied rash, hives, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, lightheadedness, dizziness and tongue swelling.   This provider was notified of patient reaction and she was then assessed in the emergency bay area.   Patient with PMH of fibromyalgia and rheumatoid arthritis No history of vaccine or medication reaction previously   Review of Systems  Constitutional: Negative for chills and fatigue.  HENT: Negative for congestion, facial swelling, rhinorrhea, sinus pain, sneezing, sore throat and trouble swallowing.   Respiratory: Negative for cough and shortness of breath.   Musculoskeletal: Negative for back pain, myalgias and neck stiffness.  Skin: Negative for rash.  Neurological:       Tingling in hands and feet bilaterally         Objective    Vitals Vitals:   12/18/20 1255 12/18/20 1318 12/18/20 1345 BP: (!) 143/86 (!) 129/91 131/83 BP Location: Left arm Left arm Left arm Pulse: 79 72 69 SpO2: 100% 100% 100%       Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing or diaphoretic.  HENT:     Head: Normocephalic.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Cardiovascular:     Rate and Rhythm: Normal rate.  Pulmonary:     Effort: Pulmonary effort is normal.  Musculoskeletal: Normal range of motion.     Comments: C/o tinglinig to feet and hands bilaterally Normal ROM  Grip strength equal bilaterally No lightheadedness or weakness  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is not pale.     Findings: No erythema or rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.         Assessment/Plan    Treatment included antihistamines. Follow up response to treatment:good Patient discharge:  Stable to go home and follow up with PCP   Benadryl given at 1314 At 1330 reports significant reduction to tingling in hands and resolved in feet 1340 - tingling has resolved 1350 - Escorted by pharmacist out of building.  VSS   Patient provided with paperwork about immunization Strict instruction to go to the ED if shortness of breath, cough, difficulty swallowing, tingling/weakness, or other allergic symptoms occur. Patient verbalized understanding APRN Electronically Signed 12/18/2020 2:00 PM     Division of Health       3 of 3