| Days after vaccination:||0
|Vaccination / Manufacturer
||Lot / Dose
||Site / Route|
|COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH
||- / UNK
||- / -
Administered by: Private Purchased by: ?
Symptoms: Computerised tomogram normal,
Laboratory test normal,
SMQs:, Oropharyngeal conditions (excl neoplasms, infections and allergies) (narrow), Guillain-Barre syndrome (broad), Noninfectious encephalitis (broad), Noninfectious meningitis (broad), Hearing impairment (broad)
Life Threatening? No
Birth Defect? No
Permanent Disability? No
Office Visit? Yes
ER Visit? No
ER or Doctor Visit? Yes
Other Medications: PrEP (Emtricitabine/Tenofivir) Albuterol inhaler Fluticasone/Salmeterol inhaler Montelukast Fexofenadine Cyclobenzaprine Fluoxetine
Current Illness: none
Preexisting Conditions: Mild persistent asthma Obesity Pre-diabetes Back pain Non-alcoholic fatty liver Adjustment disorder/depression
Allergies: Clindamycin - rash
Diagnostic Lab Data: HIV/RPR pending (though he is already monitored closely while on PrEP).
CDC Split Type:
Write-up: Onset of tongue numbness a few hours after vaccination, which was gone the next day. Vaccinated on 12/16 - 10 days later on 12/26/20 tongue numbness recurred & he developed (R) facial droop - seen in ER on 12/17 had normal head CT, negative work up for stroke. Seen in clinic on 12/28 - diagnosed with Bells palsy, started on Valacyclovir. Patient will hold PrEP x7 days (precautionary), no sexual activity during that time.