Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Hyperventilation
Clinical narrative: Patient was seen date:  3/8/2021 Subjective is a 66 y.o. female who was seen at 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.  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. Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality, chest pain, rapid progression of symptoms and respiratory distress. Past Medical History: Diagnosis  Date: Depression, Dysplasia of cervix, GERD (gastroesophageal reflux disease), Headache, Incontinence of urine, Insomnia, Interstitial cystitis, Rash. ALLERGY REVIEW OF SYSTEMS: Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, vomiting, abdominal pain, dizziness, and headaches; lightheaded: Previous Reactions: none. Objective Vitals: 03/08/21 1101 - 03/08/21 1106 BP: 130/66 - 135/63 BP Location: Left arm Patient Position: Sitting Pulse: 56  64 SpO2: 96% 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. Comments: Pt with slight hyperventilation when arrived to the bay. Pt asked to take off mask and take deep breaths in/out. Reports great improvement in symptoms. Mask placed back on. Eupneic breathing noted on discharge. 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. Assessment/Plan Treatment included: water 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). Anxiety Pt monitored in the bay for approx 15 minutes.  Pt improved with treatment as described in physical exam and with water.  Pt denies issues with dizziness/lightheadedness in standing up from wheelchair here in the bay.  She feels well and is ready to go home. Husband with her. Pt accompanied out by pharmacist. Electronically Signed 3/8/2021 11:10 AM.