Age: 26.0
Sex: F
Vaccine: COVID19
Symptoms: Nausea, Nervousness, Throat irritation
Clinical narrative: S:The pt walked in, patient is a 26 year old female C/O dizzy after 1st Covid-19 Moderna Vaccine   O: Appearance: alert, well appearing, and in mild distress and oriented to person, place, and time.    A: Pt received  1st Covid-19 Moderna Vaccine about 1440, at 1458 pt stated she felt dizzy after getting the vaccine, stated she also felt like something was stuck in her throat and chest pressure that lasted for 2 minutes and subsided, no other complaints. The patient is in need of an appointment for medical evaluation.  Pt transferred via wheel chair from Covid-19 Vaccine area to 2nd floor MD area.   P: The patient was given an appointment which pt accepted. Appointment with Dr. scheduled for today     Electronically signed by: RN 3/26/2021 3:46 PM   Start Time 3/26/2021  3:34 PM      Filed at 3/26/2021 10:51 PM  Status: Signed    I have reviewed the Chief Complaints and Vital Signs for this encounter as entered by the nurse.    Chief Complaint Patient presents with ? DIZZY     Patient received Covid 19 vaccine today  ? CHEST PRESSURE       SUBJECTIVE:   Patient is a 26 year old female  Complains of of feeling her head warmth, lightheadedness, nausea, like something stuck on her throat and chest pressure after receiving COVID vaccine today.  Symptoms lasted about 20 minutes, feeling well now, symptoms resolved. Patient with history of anxiety and panic attacks, states she nervous with coming to the clinic for vaccine.      Past Medical History: Anxiety       Social History    Tobacco Use Smoking Status Never Smoker Smokeless Tobacco Never Used     Current medication list was reviewed in detail with the patient.    No outpatient medications have been marked as taking for the 3/26/21 encounter (Office Visit) with, M.D..       OBJECTIVE:   The most recent lab test results were reviewed in detail.    HGA1C (%) Date Value 02/23/2021 5.4    ALT (U/L) Date Value 02/23/2021 16    CR (mg/dL) Date Value 02/23/2021 0.57     Review of Systems  Constitutional: Negative for chills, fever, malaise/fatigue and weight loss.  HENT: Negative for sore throat.   Cardiovascular: Negative for palpitations and leg swelling.  Respiratory: Negative for cough and shortness of breath.   Gastrointestinal: Negative for abdominal pain, heartburn and vomiting.  Genitourinary: Negative for dysuria.      BP 119/67 (BP Location: LA-LEFT ARM, BP Patient Position: SITTING, Cuff Size: Large Adult)  | Pulse 82  | SpO2 99%    Physical Exam  Constitutional: She is well-developed, well-nourished, and in no distress.  HENT:  Mouth/Throat: no lip swelling, no tongue swelling, no uvular swelling, moist mucous membranes. Tonsils slight enlarged R>L, no erythema, no exudate.  Cardiovascular: Normal rate and regular rhythm.  Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.  Musculoskeletal:        General: No edema.  Neurological: She is alert.  Nursing note and vitals reviewed.     ASSESSMENT F41.9 ANXIETY  (primary encounter diagnosis) Z23 VACCINATION FOR SARS-COV-2  Comments: no signs of anaphylaxis. Lungs clear, no wheezing, no swelling, no respiratory distress. No rash. Most likely anxiety/panic attack. Patient was observed for a while. Symptoms resolved. Red flag signs given. PLAN: advised patient to finds ways to cope with stress    Follow up with PCP      Please see the orders, patient instructions and follow-up plans for this visit.  CURES reviewed when necessary.  The patient was advised on the nature and expected course of this condition.  Patient was advised to call, return to clinic or go to UC or emergency room if symptoms persist or worsen. Pt voiced understanding.    Electronically signed by: MD Department of Family Medicine Medical Office Building  3/26/2021       ANGIOEDEMA (primary encounter diagnosis)    Plan: METHYLPREDNISOLONE SODIUM SUCC 125 MG/2 ML INJ RECON SOLN  PREDNISONE 5 MG ORAL DOSE PK TAB  FAMOTIDINE 20 MG ORAL TAB  DIPHENHYDRAMINE HCL 25 MG ORAL CAP    Discontinue ace-I, benadryl q-4 hrs prn, pepcid and f/u with pcp, if any swelling of throat, DIB or SOB to ED immediately.    PE: Mouth/Throat: edema of lower lip and chin, no tongue swelling, no uvular swelling or pharyngeal swelling, moist mucous membranes,no erythema,no exudate   S: presents with swelling of lower lip since last night. Per grand-daughter pt's L lower lip was swollen in similar fashion a few months, back, yesterday started again and now spread to entire lower lip and chin. Pt denies any swelling of tongue, throat, no DIB/SOB/CP. Pt is on lisinopril, no new medications.