| Days after vaccination:||2
|Vaccination / Manufacturer
||Lot / Dose
||Site / Route|
|COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN
||1808982 / 1
||- / IM
Administered by: Private Purchased by: ?
C-reactive protein normal,
Full blood count normal,
Metabolic function test,
Red blood cell sedimentation rate normal,
SMQs:, Severe cutaneous adverse reactions (broad), Anaphylactic reaction (broad), Angioedema (narrow), Peripheral neuropathy (broad), Neuroleptic malignant syndrome (broad), Anticholinergic syndrome (broad), Oropharyngeal allergic conditions (narrow), Guillain-Barre syndrome (broad), Accidents and injuries (narrow), Hypersensitivity (narrow), Drug reaction with eosinophilia and systemic symptoms syndrome (broad)
Life Threatening? No
Birth Defect? No
Permanent Disability? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Other Medications: Flintstone multiple vitamins with iron, vitamin D 3125 mcg daily.
Current Illness: UTI 3/9/21 Ciprofloxacin 500 mg 1 twice daily for 6 days. Vitamin D insufficiency 3/9/21 ?vitamin D 3 125 mcg 1 p.o. daily. Anxiety- No medication issued.
Preexisting Conditions: Generalized anxiety, multiple sclerosis, persistent anxiety, spinal stenosis of the cervical foramina, overweight, status post bariatric surgery, adjustment disorder with anxiety, hyperlipidemia.
Allergies: Latex and morphine derivatives.
Diagnostic Lab Data: CBC, CMP, C-reactive protein, erythrocyte sedimentation rate That were drawn on 4/15/21 at 12:19 PMwere all within normal limits. Patient was notified of the results but stated that she was still not feeling well so she was instructed to proceed to the emergency room and did so at 17:46 on April 15, 2021. She was seen and evaluated by emergency room personnel. Given epinephrine 0.3 mg IM x1, dexamethasone 8 mg IV x1 diphenhydramine 25 mg IV x1 and famotidine 20 mg IV x1. She was diagnosed with drug rash and angioedema. She was instructed to have close follow-up with her PCP. The patient has not returned to clinic or called expressing any additional concerns.
CDC Split Type:
Write-up: The patient began to notice that her face/eye was swollen/finger tingling. She then proceeded to have an itchy and scratchy and burning sensation. Her fever increased to 101.6. During her telehealth evaluation on April 14, 2021 8 macular papular rash that was not deemed to be proper was noted on the lower extremities. They were nonblanchable and no pain was elicited with palpation by the patient under my direction.