Age: 34.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoaesthesia, Hypoglycaemia, Hypotension, Pruritus, Rash
Clinical narrative: Progress Notes APRN (Nurse Practitioner) -- Family Medicine Cosign Needed    Called patient for follow up from her visit yesterday here at the vaccine clinic.  Pt states she feels well. She did end up taking another benadryl yesterday evening "more out of precautions" rather than for symptoms. She reports she feels well today and has not had any problems.    APRN    Progress Notes APRN (Nurse Practitioner) -- Family Medicine Cosign Needed Expand AllCollapse All    COVID VACCINE CLINIC  2/24/2021    Patient:                                                                             Date:  2/24/2021                                                                                               Subjective Patient is a 34 y.o. female who was seen at COVID Vaccine Clinic today for her first  dose of the COVID 19 vaccination.    She was given the Pfizer vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience itching and bilateral hand numbness.  She denied rash, difficulty breathing, difficulty swallowing, wheezing, throat tightness, stridor, lightheadedness, dizziness, facial swelling and tongue swelling.   This provider was notified of patient reaction and she was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , hypotension, rapid progression of symptoms, respiratory distress, skin changes and tongue swelling.   She developed more itching later in her visit. Including lip, scalp, ears and ears felt warm.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of itching of skin   Patient denies chills, malaise/fatigue, facial swelling, ear pain, sneezing, sore throat, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, vomiting, abdominal pain, muscle aches, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/24/21 1030 02/24/21 1050 BP: 124/67 113/69 Pulse: 75 72 SpO2: 100% 99%      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not diaphoretic.  HENT:     Head:     Comments: Pt noted to itch neck and scalp region    Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: Clear oral airway No tongue swelling. Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Thyroid: No thyromegaly.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Skin:    General: Skin is warm and dry.     Comments: Injection site w/o erythema or swelling.   Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: antihistamines and water Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Systemic reaction (hypoglycemia, hypotension, generalized rash)   Initially with zyrtec, she was not seeing improvement. Two doses of 25 mg of benadryl of 15 minutes within each other, pt was able to see improvement. Pt aware of when she is able to take more benadryl if needed. If symptoms worsen or do not respond to benadryl, pt aware to go to ED.    APRN Electronically Signed 2/24/2021 11:14 AM