Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Dyspnoea, Fatigue, Hyperhidrosis, Malaise
Clinical narrative: Progress Notes HCP; APRN (Nurse Practitioner) ? ? Family Medicine    Pt called to follow up on covid-19 vaccine done on 02/26/21.  She reports no reoccurence of hypotension. She states she felt tired for the rest of Friday into Saturday. Fatigue has resolved. She denies any other symptoms. Doing well now.  Denies any further questions or concerns.   Pt is appreciative of phone call.    HCP; APRN      Progress Notes HCP, APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/4/2021  8:26 AM Expand AllCollapse All         Subjective Patient is a 38 y.o. female who was seen at clinic, COVID Vaccine Clinic today for her first  dose of the COVID 19 vaccination.    She was given the Pfizer vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience lightheadedness, sob and diaphoresis.  She denied rash, 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 , collapse, hypotension, rapid progression of symptoms and respiratory distress.   Pt wheeled back in wheelchair. She was pale diaphoretic with slow to response to questions. She was alert and oriented x 3. She was assisted by two nurses into the bed and placed in trendelenburg.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of malaise/fatigue, shortness of breath and dizziness   Patient denies facial swelling, sore throat, frequent throat clearing, cough, chest tightness, wheezing, rash, itching of skin, vomiting, abdominal pain, muscle aches and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/26/21 1318 02/26/21 1333 02/26/21 1337 02/26/21 1405 BP: 100/64 117/70 115/76 112/59 BP Location:       Left arm Patient Position: Trendelenburg     Sitting Pulse:       66 SpO2:              Blood Sugar 97 collected at 1313     Physical Exam Constitutional:      General: She is in acute distress.     Appearance: She is diaphoretic.  Neck:     Thyroid: No thyromegaly.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Tachypnea present. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Musculoskeletal:     Cervical back: Neck supple.  Skin:    General: Skin is warm.  Neurological:     Mental Status: She is alert, oriented to person, place, and time and easily aroused.     Pt monitored closely by RN and this provider. Pt able to demonstrate improvement after being placed in trendelenburg position. Slowly in 5-10 min increments we raised her hob up and seen improvement. She was given water and snack.    01:55 pm: She was able to demonstrate ambulation around medical bay without assistance, dizziness/lightheadedness.    Assessment/Plan  Treatment included: water, snacks and body position, ice packs Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Systemic reaction (hypoglycemia, hypotension, generalized rash)   She has recovered well after almost an hour of observation/intervention. VS stable, normotensive, normal heart rate and rhythm, dry skin, a &O x 4. She had a hypotensive response to the vaccine. Suggest that she lay down for her next vaccine out of precaution.  She did eat a turkey sandwich prior to coming and had water as well.  She is pleased with her care.  She was walked out to the front with RN.    HCP, APRN Electronically Signed 2/26/2021 1:32 PM