Age: 83.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Dyspnoea
Clinical narrative: Progress Notes Expand AllCollapse All    3/12/2021    Patient:                                                             DOB:  4/18/1937  Date:  3/12/2021                                                                                           MRN:     Subjective Patient is a 83 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 right deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience lightheadedness, sensation of sob.  She denied rash, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, 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 blood pressure abnormality , chest pain, increased swelling, rapid progression of symptoms and respiratory distress.    Past Medical History: Diagnosis Date ? Adnexal mass   ? Atrial flutter (HCC)   ? AV nodal ablation on 6/19/14 6/20/2014 ? Biventricular pacemaker (Medtronic) implanted on 6/19/14 6/20/2014 ? Chronic venous insufficiency   ? Glaucoma   ? History of mitral valve replacement 10/10/2006   29 mm Mosaic Porcine Bioprosthesis ? Hypertension   ? Hypothyroidism   ? Long term (current) use of anticoagulants     COUMADIN - HAD TOO MUCH LOVENOX 2011 & HAD BLEED ? Nonischemic cardiomyopathy (HCC)   ? Osteoarthritis   ? PAF (paroxysmal atrial fibrillation) (HCC)   ? PVC's (premature ventricular contractions)   ? Systolic congestive heart failure with reduced left ventricular function, NYHA class 2 (HCC)   ? Varicose vein     Hx of covid, hospitalized for 5 days in December 2020.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of shortness of breath (sensation, briefly)   Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, puffy eyes, eye redness, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, dizziness and headaches    + lightheaded:     Previous Reactions: none    Objective    Vitals Vitals:   03/12/21 0925 03/12/21 0935 03/12/21 0943 BP: (!) 146/75 (!) 157/69 136/78 Pulse: 97 68 68 SpO2: 97% 99% 99%      Physical Exam 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.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     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.     Cranial Nerves: No facial asymmetry.     Sensory: Sensation is intact.     Motor: Motor function is intact.     Coordination: Coordination is intact.     Gait: Gait normal.     Comments: + 5/5 strength to upper and lower extremities.   Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: water and snacks Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns) Lightheaded. Resolved with snacks and water.  Pt to monitor bp at home. Follow up with pcp.   Pt wheeled out to her daughter's car by RN.  Pt and pt's daughter voiced appreciation of care today.