Age: 21.0
Sex: F
Vaccine: COVID19
Symptoms: Throat tightness
Clinical narrative: Progress Notes (Nurse Practitioner) ? ? Family Medicine Cosign Needed Expand AllCollapse All    COVID VACCINE CLINIC 2/24/2021                                                                Date: 02/24/2021                                                                                              Subjective Patient is a 21 y.o. adult who was seen at COVID Vaccine Clinic today for patients first  dose of the COVID 19 vaccination.    Patient was given the Pfizer vaccination in the left deltoid muscle.   During patient's 30 minute waiting period after the injection, the patient began to experience throat tightness and itching.  Patient denied rash, difficulty breathing, difficulty swallowing, wheezing, hoarseness, stridor, itching, lightheadedness, dizziness, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and patient was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , drooling, increased swelling, rapid progression of symptoms, respiratory distress, skin changes and tongue swelling.   PMH: includes peanut allergy, carries epi-pen. She takes 75 mg of benadryl nightly to help with insomnia and seasonal allergies.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of itching of skin   Patient denies chills, malaise/fatigue, facial swelling, itching in ears, sore throat, frequent throat clearing, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, abdominal pain, muscle aches, dizziness and headaches       Previous Reactions: she was brought back to bay intially for observation as she reported to pass out when she gets shots. Shortly after injection, she developed symptoms above. No vagal issues arose.     Objective    Vitals Vitals:   02/24/21 1048 02/24/21 1100 02/24/21 1136 BP: (!) 153/85 106/76 124/72 Pulse: (!) 101 86 81 Resp: (!) 22 16   SpO2: 99% 100% 100%        Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: Patient is not in acute distress.    Appearance: Normal appearance. Patient is well-developed. Patient is obese. Patient is not diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: Clear oral airway  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  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.     Capillary Refill: Capillary refill takes less than 2 seconds.     Comments: Injection site without rash, erythema or swelling  Neurological:     General: No focal deficit present.     Mental Status: Patient 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: antihistamines Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Vaccine-Related Anxiety (include misc mental health) and Anaphylaxis (dyspnea, stridor, drooling, tongue swelling)   Close monitoring. Pt improving. Doing well with medication intervention. Pt has ride. Pt wheeled out to the front. Pt ambulates without difficulty. No dizziness. Instructions given on when she can take her next benadryl dose.    APRN Electronically Signed 2/24/2021 11:25 AM