Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Glycosylated haemoglobin, High density lipoprotein decreased, Low density lipoprotein
Clinical narrative: R.N. at 4/22/2021  4:19 PM   Status: Addendum    Situation: received report from RN at 4:13 pm.  patient c/o chest tightness and extreme fatigue 5 min post covid vaccine #1 Pfizer   Background : patient 1st covid vaccine today.  Patient with h/o DVT. BP 134/77 (BP Location: RA-RIGHT ARM)  | Pulse 94  | SpO2 100%            Outpatient Medications Marked as Taking for the 4/22/21 encounter (Office Visit) M.D. Medication Sig ? Dabigatran Etexilate (PRADAXA) 150 mg Oral Cap Take 1 capsule by mouth 2 times a day for DVT      Assessment: patient is alert and oriented.  Reports chest pain 5/10.  Patient with clear speech.     Recommendation: ECG, same day appointment with MD for further assessment.    Electronically signed by: RN 4/22/2021 4:22 PM   R.N.    Start Time 4/22/2021  4:08 PM      Filed at 4/22/2021  4:32 PM  Status: Signed    Patient received first covid pfizer vaccine 5 minutes after she felt chest tightness pain level 5/10.  Patient complaining of feeling very tired.  Patient has a hx of DVT of left leg and is taking blood thinners.  Report given to RN Appointment given to see Dr.   M.D.    Start Time 4/28/2021 12:06 PM      Filed at 4/28/2021 12:08 PM  Status: Signed    Chief Complaint Patient presents with ? CHEST TIGHTNESS     post covid vaccine ? FATIGUE     "extreme"   I was called down to evaluate patient who experiences some chest tightness and rapid heart rate within a few minutes of receiving covid vaccine. By the time I came down sxs had resolved (within 30 min). No shortness of breath,doe, dizziness, headaches.   ekg reviewed :" no change from prior (2019) did have some evidence of possible old infarct age undetermined. Patient does not recall every being told she had an MI       Outpatient Medications Marked as Taking for the 4/22/21 encounter (Office Visit) with M.D. Medication Sig Dispense Refill ? VITAMIN B-2 100 mg Oral Tab Take 2 tablets by mouth 2 times a day 100 tablet 0 ? magnesium oxide 400 mg magnesium Oral Cap Take 1 tablet by mouth daily 90 capsule 0 ? Dabigatran Etexilate (PRADAXA) 150 mg Oral Cap Take 1 capsule by mouth 2 times a day for DVT 180 capsule 2 ? Clindamycin Phosphate (CLEOCIN) 1 % Top Soln Apply to affected area(s) 2 times a day 60 mL 3       CHOL                        178        01/05/2021 TRIG                        118        01/05/2021 HDL                          47        01/05/2021 LDL CALC                   107 (H)      01/05/2021 LDL                            80      11/07/2019 CHOL/HDL                    3.8        01/05/2021 TRIGLYCERIDE, NONFASTING      109      11/07/2019     GLUC        141 (H)      07/15/2019 GLUC            78      09/15/2006 GLUC FAST       82      10/10/2007 HGBA1C         5.1      01/05/2021 HGBA1C         4.8      08/14/2019 HGBA1C         5.4      09/15/2017       Review of Systems :   General ROS: No acute distress. Cardiovascular ROS: no chest pain or dyspnea on exertion Respiratory ROS: no cough, shortness of breath, or wheezing   Physical exam:    The physical exam is generally normal.  Patient appears well, alert and oriented x 3, pleasant, cooperative.  Vitals are as noted.  Heart sounds are normal, no murmurs, clicks, gallops or rubs.  Lungs are clear to auscultation.   Extremities are normal, no edema       ASSESSMENT/PLAN:   CHEST PRESSURE Note: after covid vaccine. Resolved.  Plan: EKG 12 OR MORE LEADS W INT & RPT Reassurance.   RTC/UC/ER if sxs worsen or do not improve. PT VOICED UNDERSTANDING.     MD