Identifying Data:
Full Name: Mrs. T.B
Address: Queens, NY
Date of Birth: 7/22/1951
Date & Time: 3/16/2021
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Chief Complaint: “My arm is swollen after getting the COVID vaccine”. x 4 days
History of present Illness:
69 year old female with PMH of hypertension, hypercholesterolemia and no history of COVID presented to ED with a 4 day history of pain and swelling of her left upper arm. The pain and swelling started 9 days after receiving her first dose of Moderna COVID vaccine. Swelling had begun around the injection site and expanded to include the entire lateral side of her left upper arm. Pain was described as dull, constant, and localized to the arm, with an intensity of 4/10. Patient didn’t take anything for the swelling, and nothing made it better or worse. She also reported rash over her chest that started on the first day of receiving her vaccine. She took Tylenol on the first day and the rash went away. She also had chills, generalized fatigue and occasional headache since she got the vaccine. Denied fever, recent trauma, or recent exposure to allergens. No chest pain, palpitation and SOB. Patient stopped taking all her medications 4 days ago because she didn’t know if they will exacerbate the swelling or not.
Past Medical History:
Hypertension x 20 years, well controlled on medications
Hypercholesterolemia x 20 years, well controlled on medications
Constipation – 3 month ago
Immunization – Up to date including flu shot
Screening Test – Colonscopy 2019, one polyp was removed.
Mammogram 2018, found a nodule in left breast and was followed up with a biopsy, was a benign nodule and didn’t proceed to surgery
Past Surgical History:
Left breast biopsy in 2018
Medications:
Livalo (Pitavastatin) 2 mg PO once daily for hypercholesterolemia. Last dose taken on 3/12/2020
Cartia XT (Diltiazem hydrocholoride) 120 mg PO twice daily for hypertension. Last dose taken on 3/12/2020
Linzess (Linaclotide) PO once daily for constipation (patient doesn’t remember the dosage). Last dose taken on 3/12/2020
Multivitamin PO once daily for general health (patient doesn’t remember the dosage). Last dose taken on 3/12/2020
Allergies:
Sulfa, selfish, cats
Family History:
Mother – Deceased at age 93, natural causes. Had history of hypertension
Father – Deceased at age 85, kidney failure
Brother – 60, alive and diagnosed with leukemia
Daughter – 37, alive and well
Denies family history of diabetes
Social History:
Mrs. T.B is a married female living with her husband.
Habits – Denies alcohol and tobacco use. Denies history of substance abuse and illicit substance use. She drinks coffee occasionally.
Travel – Denies recent travel.
Sexual Hx – Not sexually active. Menopause at age 55. Denies history of sexually transmitted disease.
Review of Systems:
General – Generalized fatigue and chill after receiving COVID vaccine (x13 days)
Denies recent weight loss or gain, loss of appetite, fever and night sweats.
Skin – Erythema, pain and swelling of her left arm, started from injection site and expanded to the entire lateral side of her left upper arm (x4 days). Denies moles/rashes, change of skin texture, pigmentation, excess dryness or sweating, open wound, itchiness.
Head – Has headache once or twice a week since she got the COVID vaccine. Headache lasts about half hour each time, goes away on its own. Headache is occasional, around temporal and occipital areas, with an intensity of 2/10. Patient didn’t take anything for it, and nothing makes it worse. Denies light-headedness, recent head trauma, sinus pain or nasal congestion.
Eyes – Patient is myopic, wears glasses. Last eye exam on 10/27/2020, does not know her intraocular pressure or visual acuity. Denies other visual disturbances, photophobia, redness, discharge and tearing.
Ears – Patient notices constant tinnitus in both ears for a long time. Tinnitus doesn’t interfere with her daily life. Denies deafness, pain, discharge, or use of hearing aids.
Nose – Denies discharge, obstruction, epistaxis, loss of smell, recent trauma to nose, itchiness.
Mouth/throat – Last dental exam in Jan, 2021, normal. Denies sore throat, bleeding gum, mouth ulcers, voice change or use of dentures.
Neck –Denies localized swelling/lumps, decreased range of motion.
Breast – Benign nodule in left breast. Mammogram and biopsy of left breast done in 2018. Denies pain, and nipple discharge.
Pulmonary system – Denies cough, sputum, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, hemoptysis and cyanosis.
Cardiovascular system – HTN x 20 years. Hypercholesterolemia x20 years. Occasional edema/swelling of her ankles. Denies heart murmur, chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.
Gastrointestinal system – Constipation 3 months ago. Occasional diarrhea. Colonoscopy done in 2019, one polyp was removed. Denies nausea or vomiting, loss of appetite, abdominal pain, rectal bleeding, dysphagia, hemorrhoids and jaundice.
Genitourinary system –Denies urinary frequency, urgency, oliguria and incontinence. Monogamous, not sexually active. Denies history of STI.
Menstrual/Obstetrical – G1 P1 (NSVD X1). Menarche age 15. Menopause at age 55. Denies abnormal vaginal discharge, itching, pain of vagina.
Nervous system – Denies seizure, weakness, sensory disturbances, memory change, and ataxia.
Musculoskeletal system – Pain and swelling of left upper arm x 4 days. Denies back pain, joint pain or varicose vein.
Hematological system –Denies history of clots, easy bruising or bleeding, anemia, blood transfusion, lymph node enlargement.
Endocrine system –Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating or hirsutism.
Psychiatric –Denies history of depression, anxiety, feeling of helplessness, hopelessness, lack of interest in activity, suicidal thoughts, hallucination, and obsessive/compulsive disorder.
Physical Examination:
Vitals:
Temp: 36.7 degree C
BP: 146/83 sitting up
Pulse: 76, regular
RR: 18/min, unlabored
O2: 98% Room air
General – Slender female, sitting up in bed, well groomed and in gown.
Skin – Left upper arm is swelling and warm to the touch. Poor turgor. Nonicteric, no lesions noted, no scars, tattoos
Hair – average quantity and distribution
Nails – no clubbing, capillary refill <2 seconds
Head – normocephalic, atraumatic, non-tender to palpation throughout
Ear – Symmetrical and appropriate in size. No lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals. TM is pearly white, intact with light reflex. Weber midline/Rinne reveals AC>BC in both ears.
Nose – Symmetrical, no masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally. Nasal mucosa pink. No foreign bodies
Sinuses – Non-tender to palpation over bilateral frontal, ethmoid and maxillary sinuses
Eyes – Symmetrical OU, No strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink.
Visual acuity corrected – 20/20 OS, 20/20 OD, 20/20 OU
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy – Red reflex intact OU. Cup to disk ratio < 0.5OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Lips – Pink, moist, no cyanosis or lesions.
Mucosa – Pink, well hydrated, No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Palate – Pink; well hydrated. Palate intact with no lesions, masses, scars.
Teeth – Good dentition. No obvious dental caries noted.
Gingivae – Pink, moist. No hyperplasia, masses, lesions, erythema or discharge.
Tongue – Pink, well papillated. No masses, lesions or deviation.
Oropharynx – Well hydrated. No injection, exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions.
Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills. Bruits noted bilaterally, no cervical adenopathy noted.
Thyroid – Non-tender. No palpable masses, no thyromegaly, no bruits noted
Chest –Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxic respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout
Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart – JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdomen – Flat and symmetric with no scars, striae, or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness
