Age: 39.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Dyspnoea, Hypoaesthesia, Injection site pain
Clinical narrative: Patient:  Date: 06 Jan 2021 1307  Appt Type: EROOM Treatment Facility:  Clinic: EMERGENCY ROOM FAX  Provider:  Patient Status: Outpatient Clinic Phone:  Autocites Refreshed by 06 Jan 2021 1335 Allergies o Penicillins: Urticaria (patient states hives) Labs No Labs Found. Rads No Rads Found. Vitals No Vitals Found. Appointment Comments: Last Updated by 06 Jan 2021 1332  XROOM 09 = Poss Covid vaccine reaction Questionnaire Autocites Refreshed by Jan 2021 1335  Questionnaires S/O Note Written by 06 Jan 2021 1357  Chief complaint The Chief Complaint is:Chief complaint The Chief Complaint is: COVID vaccine reaction. History of present illness The Patient is a 39 year old male. Patient is a 39-year-old male who presents to the emergency department after receiving the COVID vaccine today. The patient states that he began noticing shortness of breath, pain at the injection site, and numbness down his arm. He was told to report to the emergency department for evaluation. The patient denies fever, loss of consciousness, or other symptoms. The symptoms have been constant. Nothing is making the symptoms better. Past medical/surgical history Reported: No significant past medical history. Surgical / Procedural: No significant past surgical history. Personal history Behavioral: Not a current smoker. Drug Use: Not using drugs. Family history No significant family history. Review of systems A 10 point review of systems was conducted, which is negative except as stated in the history of present illness. Physical findings Vital Signs: ° Current vital signs reviewed. General Appearance: ° Well-appearing. Ears, Nose, Throat: ° ENT: normal. Pharynx: Mucosal: ° Pharynx was moist. Lungs: ° Normal. ° Respiration rhythm and depth was normal. ° Clear to auscultation. Cardiovascular: ° System: normal. Heart Rate And Rhythm: ° Normal. Neurological: ° Level of consciousness was normal. Sensation: o Sensory exam abnormalities were noted Patient states that he has sensation along the left arm and fingers, but that it feels different compared to the right arm, especially in the ulnar distribution. Motor: ° A motor exam demonstrated no dysfunction. Skin: ° Intact. A/P Written by 06 Jan 2021 1348  1. Encounter for other specified special examinations Plan/Comment(s): - 39-year-old male with reaction following receipt of the COVID vaccine. Physical exam reveals normal vital signs. Heart and lungs are clear. Mild tenderness in the injection site on the arm without findings of erythema, cellulitis, or other mild numbness subjectively compared to right arm and fingers on the left hand, but full motor strength of medial, radial, and ulnar intact. Low suspicion for cellulitis, abscess formation, pneumonia, pneumothorax, or more serious pathology to symptoms. Plan to discharge with return precautions. Disposition Written by 06 Jan 2021 135 Disposition: Released w/o Limitations Follow up: as needed in 2 day(s) with PCM or sooner if there are problems. Discussed: Diagnosis, Medication(s)/Treatment(s), Alternatives, Potential Side Effects with Patient who indicated understanding. Signed By MD, (Emergency Physician, Hospital) @ 06 Jan 2021 1357  As of 13 Jan still having pain, numbness, and swelling in left arm and left hand also has shortness of breath after walking a distance more than 200 yards. Some days are worse than others.