Age: 42.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dizziness, Presyncope
Clinical narrative: Date:  3/24/2021                                                                                            Subjective Patient is a 42 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 right deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience lightheadedness.  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  and rapid progression of symptoms.   PMH: asthma r/t seasonal allergies     ALLERGY REVIEW OF SYSTEMS:  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, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches    + lightheaded:     Previous Reactions: none that she is aware of.  Had dizziness/lightheaded with ear piercing.     Objective    Vitals Vitals:   03/24/21 0951 03/24/21 0955 03/24/21 0959 BP: (!) 166/111 (!) 150/100 (!) 142/72 Pulse: 66 57 63 Resp: 18 14   SpO2: 100% 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.     Pharynx: Oropharynx is clear.  Eyes:     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.     Comments: Speaking full sentences 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 is anxious (slight).        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.     Improved with rest/reclined.  Pt able to sit up and stand w/o dizziness/lightheadedness.     Assessment/Plan  Treatment included: water and close monitoring 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 Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)     Anxiety mixed with pseudo mild vasovagal syndrome. Pt improved and did well. Pt aware of option of getting her vaccine done here in the bay next time if she would like. Recommend 30 minute observation.   F/up with pcp otherwise.     3/24/2021 9:48 AM