Age: 72.0
Sex: F
Vaccine: COVID19
Symptoms: Lip swelling, Oedema, Oral mucosal erythema, Paraesthesia, Paraesthesia oral
Clinical narrative: Patient at Covid vaccine drive up clinic  Patient with multiple medication allergies-confirmed with patient  Allergies  Allergen Reactions  ? Levaquin [Levofloxacin] Hives  ? Percocet [Oxycodone-Acetaminophen] Nausea and Vomiting  ? Amoxicillin Nausea and Vomiting  ? Bactrim [Sulfamethoxazole W-Trimethoprim] Other      dizziness  ? Hydrocodone-Acetaminophen Other  ? Keflex [Cephalexin] Other      Severe vertigo  ? Norco [Apap-Fd&C Yellow #10 Al Lake-Hydrocodone] Nausea and Vomiting  ? Oxycodone Nausea and Vomiting  ? Tramadol Nausea and Vomiting  patient reported tingling of face and lips after receiving vaccine @1630  States lips appeared more swollen then prior to vaccine  Denies shortness of breath, wheeze, tongue/ throat swelling, chest pain, palpitation  OBJECTIVE:  Blood pressure :138/ 78 HR 77 Oxygen saturation 99% on room air  Gen: sitting in car. No acute distress  Eyes: Conjunctivae and sclera without injection/icterus and lids and lashes normal.  Oropharynx moist and intact without lesions.  HENT: Atraumatic. No facial droop. Minimal swelling of right upper lip without erythema. Oropharynx moist and intact without lesions.  Neck: supple  Pulm: No tachypnea, retractions or cyanosis. clear to auscultation bilaterally with symmetric air entry in all fields. Speaking in > 5 word sentences without difficulty.  CV: regular rate and rhythm  Psych: Speech fluent with normal volume, rate, and pitch alert and oriented x iii,pleasant affect/mood.  Skin: Exposed areas warm,dry, without rash or jaundice  ASSESSMENT/PLAN:  1. Tingling of face and lips 30 minutes after receiving Covid vaccine. No evidence of hypoxia or respiratory distress/ hemodynamic instability. Patient with history of multiple allergies to medications.  Benadryl 25 mg orally x1 given @ 1640  Lot 201666  Exp 04/2023  Reassess in 15-20 minutes     Addendum  Reassessed at 1700  Patient reports increased swelling/tingling to lips and face right > left  Denies shortness of breath, wheeze, difficulty swallowing , itching, hives  Exam  Gen: sitting in car- appears comfortable  Eyes: Conjunctivae and sclera without injection/icterus and lids and lashes normal.  HENT: Atraumatic. No facial droop  -increased swelling to lips/ perioral right > left  -mild erythema periorally  -Oropharynx moist and intact without lesions.  Neck: supple  Pulm: No tachypnea, retractions or cyanosis. Speaking in > 5 word sentences without difficulty  Psych: Speech fluent with normal volume, rate, and pitch alert and oriented x iii,pleasant affect/mood.  Skin: Exposed areas warm,dry, without rash or jaundice  ASSESSMENT/PLAN:  1. Increased edema and patient reports increased tingling of lips/ face ~ 60 minutes after receiving Covid vaccine. Not improved with benadryl 25 mg x1. Concerning for allergic reaction with history of multiple allergies.  Urgent Care to continued monitoring and treatment  Patient agrees  Husband will transport via private care  Urgent Care notified by clinic:  Patient given EpiPen in case symptoms return.  Instructed patient to go directly to the emergency department for any tongue swelling lip swelling trouble breathing or need to use of EpiPen.  Patient is asymptomatic.  Patient has additional Benadryl or will pick up from the pharmacy.