Age: 23.0
Sex: F
Vaccine: COVID19
Symptoms: Fatigue, Feeling abnormal, Hypoglycaemia, Hypotension, Rash
Clinical narrative: Progress Notes  APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/23/2021  1:26 PM Expand AllCollapse All    COVID VACCINE CLINIC  3/19/2021      Date:  3/19/2021                                                                                           MRN:  8812976     Subjective Patient is a 23 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 anxiety.  She denied rash, hives, welts, difficulty breathing, 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  and rapid progression of symptoms.   PMH: not significant.      ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   03/19/21 1355 03/19/21 1413 BP: 95/62 92/63 Pulse: 99   SpO2: 100%          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.  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. Affect is flat.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.    1415: attempt to stand patient up after she finished eating and drinking. She reports her legs feel weird and felt weak. + dizziness/lightheadedness when standing. Pt sat back down and laid back in recliner, blanket given. Monitor at this time.    1422: pt bp rechecked with new bp cuff. Still in the 90's systolic. Pt feels okay. Pt sat up in recliner. Plan to recheck bp.    1428: pt bp rechecked, still in the 90's systolic.  Pt feels tired. No other new symptoms reported.  Pt given another snack.    1440: pt reports feeling a little better.  Repeat bp still in the 90s systolic.  Pt able to stand up w/o dizziness.  She was ambulated around the bay w/o assistance. States she feels as well as she did when she first got here.     Assessment/Plan  Treatment included: water, snacks and blanket 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 Systemic reaction (hypoglycemia, hypotension, generalized rash)   Decreased bp (questionable if this is her baseline), and anxiety. Pt w/o known hx of what her bp normally runs.  Monitored in bay.  Improved with water, snack and time.  Pt able to leave w carrying her instrument w/o issues and feels well. Walked out accompanied by RN.         APRN Electronically Signed 3/19/2021 2:03 PM