Age: 33.0
Sex: M
Vaccine: COVID19
Symptoms: Erythema, Pruritus, Rash maculo-papular, Somnolence, Vaccination complication
Clinical narrative: Progress Notes R.N. (REGISTERED NURSE) ? ? Urology  Patient is a 33 yr old male on 03/13/21 approximately 17:35 PM for 1st covid Pfizer vaccine Reviewed allergies and vaccine covid vaccine information provided to member.   Allergies: Seafood, general rash, itchy and hives  . 1st dose Pfizer given IM at 17:42 PM via left deltoid 5 minutes later started itching, redness bilateral hands   Gen: Alert nontoxic No chest pain or dyspnea  Pt denies Resp Distress Wheezing: no No SOB,tongue or Throat Swelling: no   At :17:43 PM;  25 mgl/10 ml  liquid Benadryl given PO NDC # 0121-0978-10 Lot # 4EF Expired Date: 11/21 At 17:45 PM second dosef 25 mg /10 ml liquid Benadryl given  PO Lot # C4EF EXP: 11/21   Blood pressure : 151/101, sat 98%, RR 16. (left arm)   At 18:00 PM; Blood pressure 144/104, hr 79, rr 16. Sat 97%. Right arm blood pressure 140/94 No sob or wheezing, no chest pain  No Throat swelling At 18:15 PM: developed macular/Papular rash through out upper and lower ext, with severe itching At 18:25 PM, Accompanied  member to ER, report given to ER charge nurse Pt registered via call center staff at PM. Pt in room 7,ER waiting to be seen per ER provider Approximately 19:15 PM  Report given to ER provider.  Approximately 19:45 PM member moved to room 8, resting,on cardiac monitor, states feeling sleepy now.  Mother and sister waiting in the waiting area in ER, they both were made awarded.  Completed by: RN, March 14, 2021, 12:46 PM 20:00 PM  Primary Director was informed  Completed by: March 14, 2021, 12:48 PM    Allergic Reaction    SUBJECTIVE Patient is a 33 yr old male presenting with allergic reaction for approximately 30 min. Accompanied by nurse upstairs that administered vaccine and gave 50 mg of benadryl as well.    o Associated sx: rash o SOB, Tongue or Throat Swelling: No o Exposure/Trigger:  covid vaccine 5 minutes later started itching and with rash o Any treatment prior to arrival:  antihistamines   Relevant medical history reviewed/updated.    ROS All other aspects of the 10 point ROS performed and negative other than the pertinent positives and negatives listed below and in the HPI    GENERAL No fever, weight loss CARD No chest pain or dyspnea on exertion    PHYSICAL EXAM   Vitals: BP (!) 148/96  | Pulse 83  | Temp 98.8 °F (37.1 °C) (Tympanic)  | Resp 16  | Ht 5' 6" (1.676 m)  | Wt 182 lb (82.6 kg)  | SpO2 98%  | BMI 29.38 kg/m²     GEN Alert, nontoxic  EYES   PERRL, EOMI, anicteric  HEENT     Lingual edema:  No Hydropic Uvula: No Airway Patent:  Yes Mucosal Lesions:  No NECK    Supple, FROM CARD   RRR, No murmurs RESP RR nl, No Resp Distress Wheezing:  none EXT Well perfused, no deformity  NEURO A&Ox3, moving all ext  SKIN Rash: Macular/Papular through out upper and lower ext Skin Desquamation:  No      ASSESSMENT/PLAN Evaluation most supportive of allergic reaction.   o Evidence of anaphylaxis, respiratory distress or airway compromise:  No o Concern for Stevens-Johnson Syndrome or Erythema Multiforme Major  No     Tx/Plan: o Benadryl 50 mg given immediately after vaccine administration  o Solumedrol given here with improvement in rash and redness after 1 hour o Discussed taking prednisone for the next 5 days and benadryl q6 at home.  o Do not get second vaccine.                     03/13/21 2025    Other Notes All notes  ED Notes from  L.P.N. (Hematology and Oncology)  ED Notes from  L.P.N. (Hematology and Oncology)  ED Notes from  R.N. (z Urgent Care Facility)  ED Notes from  L.P.N. (Hematology and Oncology)  ED Notes from  L.P.N. (Hematology and Oncology) Additional Orders and Documentation   Results    Meds    Orders Procedures   Flowsheets   Encounter Info:   Detailed Report, History, Allergies, AVS, Mark As Reviewed This Encounter  Vitals Recorded in This Encounter   3/13/2021  1824 3/13/2021  1825 3/13/2021  1917 3/13/2021  1952 3/13/2021  1953 BP: 163/102Abnormal  148/96Abnormal  138/88 133/91Abnormal  ? Pulse: 83 ? 62 69 ? Resp: 16 ? 18 22Abnormal  21Abnormal  Temp: 98.8 °F (37.1 °C) ? ? ? ? Temp src: Tympanic ? ? ? ? SpO2: 98 % ? 100 % 98 % ? Weight: 182 lb (82.6 kg) ? ? ? ? Height: 5' 6" (1.676 m) ? ? ? ? All Flowsheet Templates (all recorded)  Acuity/Destination Custom Formula Data ED Assess ED Reassessment MD Initial Contact Neurologic  Respiratory Assessments ER All Flowsheet Data  ER All Flowsheet Data Results for all Tests ordered in this Encounter  Results for all Tests ordered