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Write-up: Allergic reaction to vaccine +1 more Dx Referred by MD Reason for Visit Progress Notes PA-C (Physician Assistant) ? ? Physician Assistant Cosign Needed ? Patient was seen at COVID Vaccine Clinic today for her first dose of the COVID 19 vaccination. She denied any history of previous adverse reactions to vaccines. ? She was given the Pfizer-Biontech (lot: EH9899) vaccination in the left deltoid muscle. ? During her 15 minute waiting period after the injection, the patient began to experience oral tingling (upper lip and then into the lower lib) It then progressed to the tongue and she reported tingling to the tip of the tongue and further back to the middle of tongue. She thought there might be some mild swelling to the tip of the tongue. She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, dizziness, facial swelling and lip swelling. ? This Staff member was notified of patient reaction and she was then assessed in the emergency bay area. ? PMH: Hx hypertension but did not take her medication today. Patient had recovered from the COVID-19 virus about 2 weeks ago. ? Vitals Time 1130 BP 170/90 HR 86 s/r RR 14 nl O2 97 % ? Physical Exam Constitutional: She is oriented to person, place, and time. She appears well-developed and well-nourished. No distress. HENT: Head: Normocephalic and atraumatic. Right Ear: Hearing and external ear normal. Left Ear: Hearing and external ear normal. Eyes: Conjunctivae are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Normal range of motion. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Pulmonary/Chest: Effort normal and breath sounds normal. No stridor. No respiratory distress. She has no wheezes. She has no rales. Musculoskeletal: Normal range of motion. Neurological: She is alert and oriented to person, place, and time. No sensory deficit. Gait normal. Skin: Skin is warm and dry. She is not diaphoretic. Psychiatric: She has a normal mood and affect. Her behavior is normal. Judgment and thought content normal. Cognition and memory are normal. Vitals reviewed. ? ? Treatment included antihistamines. Patient was given 50 mg of benadryl at 1138. ? Vitals Time 1147 BP 160/100 HR 90 S/R RR 14 nl O2 98% ? Response to care: Patient states the upper lip resolved but the lower lip and tongue sensations remained but did not worsen. Patient was recommended to go to the hospital given her sudden response with concern of tongue swelling. Patient did agree to this. COVID staff was made aware that the patient would be leaving her SUV in the parking lot. ? Patient was transfer by Response team to the hospital at 11:53 AM. ? ?
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