Age: 56.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dyspnoea, Paraesthesia, Tremor
Clinical narrative: Progress NotesFamily Medicine Cosigned/8/2021 10:39 AM  COVID VACCINE CLINIC     a 56 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 tingling/shaking, short of breath.  She denied rash, hives, welts, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, 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 , rapid progression of symptoms and respiratory distress.   PMH: depression, takes Abilify and Cymbalta. GERD on Protonix. Lipitor for cholesterol.     ALLERGY REVIEW OF SYSTEMS:  Patient complains of chills ("shaky") and shortness of breath   Patient denies fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, wheezing, rash, hives, eczema, itching of skin, abdominal pain, muscle aches, joint pain, dizziness and headaches    tingling in hands.:     Previous Reactions: none    Objective    Vitals Vitals:   03/08/21 0833 03/08/21 0851 BP: 133/78 123/71 BP Location: Left arm   Patient Position: Sitting   Pulse: 95 81 SpO2: 99% 98%      Blood Sugar 117 collected at 0839     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.     Comments: intially hyperventilating but improved after removal of mask. Eupnea at discharge.  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.     Gait: Gait normal.  Psychiatric:        Mood and Affect: Mood is anxious.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.     Comments: Hyperventilating upon arrival to bay. Mask taken off to assist with this along with instructions on deep breathing.          Assessment/Plan  Treatment included: water, snacks and pepcid 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)   Pt observed in the bay for approx. 15 minutes. Pt greatly improved with treatments above.  Pt encouraged to eat 30 minutes prior to next vaccine.  She reports that she is appreciative of her care today. F/up with pcp as needed.