Age: 23.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Nausea, Retching
Clinical narrative: Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosign Needed Expand AllCollapse All    COVID VACCINE CLINIC 3/17/2021    Patient:                                                                                 Date:  3/17/2021                                                                                             Subjective The patient is a 23 y.o. female who was seen at  COVID Vaccine Clinic today for her second  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 lightheadedness, dizziness and nausea.  She denied rash, hives, 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 area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , hypotension, rapid progression of symptoms and vomiting.   PMH not significant.     ALLERGY REVIEW OF SYSTEMS:  Patient complains of vomiting and dizziness   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, abdominal pain, muscle aches, joint pain and headaches    +lightheadedness:     Previous Reactions: none    Objective    Vitals Vitals:   03/17/21 0853 03/17/21 0942 BP: 129/75 117/70 Pulse: 80 86 Resp:   14 SpO2: 100% 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. PND NOTED     Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.   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 normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.    08:53Pt with several bouts of emesis, clear/mucous. Pt given zofran 4 mg x 2. Pt reports that she deals with chronic PND that typically is worse in the mornings and gets better after 30 minutes of waking up. Denies hx of acid relfux but has occassional heart burn.  Pt has a few spare times of dry heaving.  Zyrtec 10 mg given.    0935: pt with reported improvement of dizziness/lightheadeness. Still having nausea and urges to vomit. Pepcid 20 mg given.    0942: Pt reports improvement and no nausea.  She appears to feel better. Pt asked to drink some water and observed for a little bit longer to see that she does well.     Assessment/Plan  Treatment included: water and zofran, pepcid, zyrtec and ice pack Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   She greatly improved by the end of her stay. She denies nauseas. No more emesis. She was able to stand w/o dizziness/lightheadedness.  She's to gradually advance diet as tolerated. Follow up with pcp as needed. We discussed reasons to go to the ED. She's grateful for her care today. Pt ambulated out of medical center w/o assistance.      APRN Electronically Signed 3/17/2021 9:30 AM