Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Immunisation anxiety related reaction, Paraesthesia oral, Tongue discomfort
Clinical narrative: Progress Notes (Nurse Practitioner)  - - Family Medicine    Attempt to call patient for follow up via phone. No answer.  Progress Notes APRN (Nurse Practitioner)  - - Family Medicine Cosign Needed Expand AllCollapse All    COVID VACCINE CLINIC 2/24/2021    Patient:                                                                            Date:  2/24/2021                                                                                           MRN:  1356120     Subjective Patient is a 58 y.o. female who was seen at COVID Vaccine Clinic today for her first  dose of the COVID 19 vaccination.    She was given the Pfizer vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience tip of tongue tingling/burning.  She denied rash, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, dizziness, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and she was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to drooling, rapid progression of symptoms, respiratory distress, tongue swelling and vomiting.   Pt reports that she may have burned the tip of her tongue this am after eating hot oatmeal. She wanted to be evaluated to be sure if that was the issue and not an allergic reaction.    PMH includes HTN: takes 10 mg of Lisinopril     ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, cysts, muscle aches, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/24/21 0912 02/24/21 0920 02/24/21 0927 BP: (!) 144/79 126/82 132/71 Pulse: 75   67 SpO2: 99%   100%      Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: No visible burn noted to tip of tongue. No swelling or discoloration noted.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Thyroid: No thyromegaly.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: water Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Vaccine-Related Anxiety (include misc mental health)   Encouraged to monitor symptoms at home. She is aware of f/up care with ED if she does progress in symptoms of allergic reaction.  This time I think she has the burnt tip of her tongue sensation.  F/up with pcp otherwise.      APRN Electronically Signed 2/24/2021 9:40 AM