Age: 49.0
Sex: F
Vaccine: COVID19
Symptoms: Rash, Rash pruritic, Urticaria
Clinical narrative: RECEIVED VACCINE AT 11:00 AM.  ABOUT 3:00 PM, ARMS AND HANDS BECAME VERY ITCHY WITH A RASH.  RETURNED TO VACCINE CLINIC TO REPORT REACTION, WAS RECOMMENDED TO SEEK FURTHER TREATMENT AT OUR IN-HOUSE URGENT CARE.  URGENT CARE AT 3:25 pm  Family Medicine Allergic reaction, initial encounter +1 more Dx Hives Reason for Visit Progress Notes  Expand All Collapse All       Subjective   Patient ID:  49 year old female.  Patient seen at clinic Patient came in because of itchy red skin in different parts of the body started today and asked last 2 or 3 hours, patient had Covid vaccine about 4 hours or 5 hours ago, No prior history of hives like this, she had first Covid vaccine without any side effect, Symptoms have been persistent.  Prior h/o similar complain- not sure, may be No new pets/soap/detergents/cream No new meds No insect bites This is a new problem to me.  Review of Systems  With the exception of pertinent +/- in the HPI above, a complete review of systems was reviewed and are negative.  Constitutional: Negative for fever, weight loss, malaise/fatigue and diaphoresis.  HENT: Negative for nosebleeds, congestion, sore throat and ear discharge.  Eyes: Negative for blurred vision, double vision, photophobia, pain, discharge and  redness.  Respiratory: Negative for cough, hemoptysis, Shortness of Breath Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Negative for heartburn, nausea and vomiting.  Genitourinary: Negative for dysuria, urgency, frequency and hematuria.  Musculoskeletal: Negative for myalgias, joint pain and falls.  Neurological: Negative  The following have been updated as appropriate in this visit:-  Tobacco | Allergies | Meds | Problems | Med Hx | Surg Hx |     The following have been reviewed-  Medical History Past Medical History: Diagnosis Date ? Gastroesophageal reflux disease with esophagitis 5/6/2020 ? Generalized anxiety disorder 5/6/2020   has a current medication list which includes the following prescription(s): azithromycin, baclofen, escitalopram, eszopiclone, ibuprofen, methylprednisolone, savella, omeprazole, and topiramate.  Family History Problem Relation Age of Onset ? Hyperthyroidism Mother   ? Bladder cancer Father   ? Breast cancer Aunt   ? Breast cancer Cousin     Social History     Socioeconomic History ? Marital status: Married     Spouse name: Not on file ? Number of children: Not on file ? Years of education: Not on file ? Highest education level: Not on file Occupational History Social Needs ? Financial resource strain: Not on file ? Food insecurity     Worry: Not on file     Inability: Not on file ? Transportation needs     Medical: Not on file     Non-medical: Not on file Tobacco Use ? Smoking status: Current Every Day Smoker     Packs/day: 0.50     Start date: 5/6/2019 ? Smokeless tobacco: Never Used ? Tobacco comment: smoke x 5 years and stop  x 20 years Substance and Sexual Activity ? Alcohol use: Not Currently     Frequency: Monthly or less ? Drug use: Never ? Sexual activity: Yes     Partners: Male Lifestyle ? Physical activity     Days per week: Not on file     Minutes per session: Not on file ? Stress: Not on file Relationships ? Social connections     Talks on phone: Not on file     Gets together: Not on file     Attends religious service: Not on file     Active member of club or organization: Not on file     Attends meetings of clubs or organizations: Not on file     Relationship status: Not on file ? Intimate partner violence     Fear of current or ex partner: Not on file     Emotionally abused: Not on file     Physically abused: Not on file     Forced sexual activity: Not on file Other Topics Concern ? Not on file Social History Narrative ? Not on file      Objective   BP (!) 133/74  | Pulse 92  | Temp 97.4 °F  | Resp 18  | Ht 5' 3" (1.6 m)  | Wt 136 lb (61.7 kg)  | SpO2 99%  | BMI 24.09 kg/m²    Constitutional: oriented to person, place, and time. well-developed, well-nourished and in no distress. HENT:  Head: Normocephalic.  Eyes: Pupils are equal, round, and reactive to light.  Neck: Normal range of motion. No tracheal deviation present.  Ear- Normal  Mouth- Tongue, uvula- Normal, No oral rash Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no  gallop and no friction rub. No murmur heard.  Pulmonary/Chest: Effort normal and breath sounds normal. NO W/R/R Abdominal: Soft. There is no tenderness. S/NT/ND Musculoskeletal: No edema and no tenderness.  Lymphadenopathy: has no cervical adenopathy.  Neurological: Neurological: Pt displays no motor weakness, no tremor, normal facial symmetry, and normal speech. Psychiatric: Affect normal.  Skin,-erythematous skin rash is noted on the chest arm skin, also on the upper back,    Impression/Plan   Patient was seen today for hives.   Diagnoses and all orders for this visit:   Allergic reaction, initial encounter -     famotidine (PEPCID) injection 20 mg -     diphenhydrAMINE (BENADRYL) injection 25 mg -     Sodium Chloride 0.9% infusion 1,000 mL   Thrombocytosis (CMS/HCC) -     famotidine (PEPCID) injection 20 mg -     diphenhydrAMINE (BENADRYL) injection 25 mg   Patient evaluated and worked up for over 50-minute during urgent care visit. Time was spent was for preparing to see the patient by reviewing patient's medical history and previous test results,directly obtaining information regarding today's encounter, evaluating the patient, performing an examination, communicating test results, placing orders.  Patient was seen second time and discussed the finding of lab results and assessment plan is discussed in detail.  Patient was given a liter of IV fluid with Pepcid and Benadryl, and watched for more than 45 minutes, patient's rash improved, still had some rash, advised to take Claritin once a day Pepcid once a day and Benadryl every 4-6 hours, no shortness of breath, New patient complain to me Symptoms improved treatment here,  Stable at d/c- decreased rash, no SOB/Wheezing, No throat swelling,   Cool compresses to the skin will help.  Claritin or Zyrtec once a day Benadryl 25-50 mg every 8 hours for 1st day & then as needed If the symptoms flare again,go to Nearest emergency STAT  Reviewed prior labs, diagnostic test & prior visit notes.     Reviewed current medication and management planned considering current prescription/meds.   Please note this clinic note was performed utilizing voice recognition software.  Due to the voice recognition software there may be grammatical errors inadvertently enclosed that do not reflect the nature of the visit. For worsening of symptoms, Patient is instructed to return sooner either to ER or urgent care/PCP.    Patient is instructed to follow up in 1-2 weeks with PCP I have educated patient on supportive care therapy. Patient agreed with plan and voiced understanding. No barriers to adherence perceived by myself. Department of Urgent Care