Age: 49.0
Sex: F
Vaccine: COVID19
Symptoms: Dyspnoea, Fatigue, Flushing, Malaise, Nausea
Clinical narrative: Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosign Needed Expand AllCollapse All  Expand All by Default  COVID VACCINE CLINIC  3/16/2021    Patient:                                                                           DOB:  Date:  3/16/2021                                                                                           MRN:      Subjective Patient is a 49 y.o. female who was seen at COVID Vaccine Clinic today for her second  dose of the COVID 19 vaccination.    She was given the Pfizer vaccination in the right deltoid muscle.   She had stayed her 15 minute waiting period after the injection and asked to stay another 5 minutes. She felt fine until she reached the front doors,  she started to feel short of breath, nausea, flushed.   She denied rash, hives, welts, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, 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 ? Asthma   ? Concussion without loss of consciousness 8/27/2019 ? Depressive disorder   ? Esophagitis, reflux   ? Hepatic steatosis 12/7/2018 ? HX OTHER MEDICAL      ? Hyperlipidemia, mixed   ? Hypothyroidism (acquired)   ? Insomnia, unspecified type   ? OSA on CPAP   ? Pulmonary hypertension (HCC)     Noted on CT, echo was normal.  ? Pulmonary nodules 3/28/2015   Follow up with Pulmonary in 3 months for a CT scan      ALLERGY REVIEW OF SYSTEMS:  Patient complains of malaise/fatigue and shortness of breath   Patient denies chills, fever, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, cough, chest tightness, wheezing, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches    +lightheaded:   SOB resolved by time arrival to ED medical bay.    Previous Reactions: none    Objective    Vitals Vitals:   03/16/21 1158 03/16/21 1207 BP: 117/83 (!) 141/91 Pulse: (!) 103 86 Resp: 18 18 SpO2: 96% 97%        Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is morbidly obese. She is diaphoretic.     Comments: Flushed   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.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Gait: Gait normal.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.      Improved in observation bay. Monitored for approx 15 minutes. Pt ambulated but developed chest tightness. Albuterol inhaler provided (2 puffs) via inhalation. Pt reports immediate improvement of symptoms. She was able to ambulate w/o difficulty afterwards.   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)     VS stable. Resolution of diaphoresis and flushed appearance. Pt symptoms resolved with use of albuterol. Suspect exercise induced asthma. Recommend that she use albuterol if needed for wheezing or 30 minutes prior to exercise. Follow up with her pcp otherwise as needed.  Pt voiced appreciation of her care today.    APRN Electronically Signed 3/16/2021 11:52 AM