Age: 35.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Fatigue, Immunisation anxiety related reaction
Clinical narrative: Progress Notes PRN (Nurse Practitioner) Family Medicine    Pt called for follow up s/p covid-19 vaccine done on 02/24/21. She reports doing well just feeling a little tired. She had a few periods of dizziness/lightheadedness yesterday but nothing that lasted long or caused syncope.  She feels better today other than the slight tiredness. She is appreciative of the phone call. Denies any other questions or concerns.  PRN    Progress Notes  APRN (Nurse Practitioner) Family Medicine Cosign Needed Expand AllCollapse All    COVID VACCINE CLINIC  2/24/2021    Patient                                                                           DOB:    Date:  2/24/2021                                                                                                Subjective Pt is a 35 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 left deltoid muscle.   During her 30 minute waiting period after the injection, the patient began to experience lightheadedness and dizziness.  She denied rash, hives, welts, 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 , hypotension, rapid progression of symptoms and respiratory distress.   PMH of vagal symptoms. Not on any medications.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of dizziness   Patient denies chills, fever, malaise/fatigue, facial swelling, itching in ears, sore throat, frequent throat clearing, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, vomiting, abdominal pain, muscle aches and headaches       Previous Reactions: vagal. Allergies to morphine and paxil--breaks out in rash   Pt ate this am around 6 am. She usually eats around 11 am.      Objective    Vitals Vitals:   02/24/21 1058 02/24/21 1114 BP: (!) 134/96 119/74 Pulse: 78 74 SpO2: 100% 100%      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Thyroid: No thyromegaly.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Musculoskeletal:     Cervical back: Neck supple.  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.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: water and snacks 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)    RN Electronically Signed 2/24/2021 1:06 PM