Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Blood glucose normal, Dizziness, Headache, Neck pain
Clinical narrative: Progress Notes Expand AllCollapse All    COVID VACCINE CLINIC 2/10/2021   Subjective PT. is a 67 y.o. female who was seen at COVID Vaccine Clinic today for her second  dose of the COVID 19 vaccination.    She was given the Moderna vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience lightheadedness and neck pain.  She denied rash, hives, difficulty breathing, 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, hypotension, rapid progression of symptoms, respiratory distress and tongue swelling.   Medical history includes htn, hld. Takes low dose 10 mg po daily Lisinopril. Last ov with pcp in October, bp normotensive.      Review of Systems  Constitutional: Negative for chills, diaphoresis, fatigue and fever.  HENT: Negative for drooling, facial swelling, sore throat and trouble swallowing.   Eyes: Negative for itching.  Respiratory: Negative for cough, choking, chest tightness, shortness of breath, wheezing and stridor.   Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Negative for abdominal pain, nausea and vomiting.  Musculoskeletal: Positive for myalgias (neck/upper shoulder pain).  Skin: Negative for color change, pallor and rash.  Neurological: Positive for headaches (pressure behind eyes). Negative for dizziness, syncope, facial asymmetry, speech difficulty, weakness and light-headedness.  Psychiatric/Behavioral: Negative for agitation and confusion. The patient is not nervous/anxious.     Previous Reactions: none    Objective    Vitals Vitals:   02/10/21 1108 02/10/21 1111 02/10/21 1153 BP: (!) 199/96 (!) 164/103 (!) 162/80 Pulse: 90 84 74 SpO2: 97% 96%        Blood Sugar 99 collected at 1111 Blood Sugar 99 collected at 1145   Physical Exam Vitals reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing or 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.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds and air entry.  Musculoskeletal:     Cervical back: No swelling.     Comments: ttp over upper trapezius. No cervical spine tenderness.   Skin:    General: Skin is warm.     Coloration: Skin is not pale.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: water, snacks and tylenol 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)   Directed to closely follow up with her primary care provider on her blood pressure. She's aware of what to watch for and when to go to ED. Pt denied wheelchair. She was accompanied out to front assistant.    Dr. at bedside as well.     Electronically Signed 2/10/2021 11:54 AM