Age: 44.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Headache
Clinical narrative: Progress Notes  (Nurse Practitioner) ? ? Family Medicine Cosign Needed Expand AllCollapse All    COVID VACCINE CLINIC  3/16/2021     Date:  3/16/2021                                                                                               Subjective a 44 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, dizziness, 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 , chest pain, collapse, rapid progression of symptoms and respiratory distress.    Past Medical History: Diagnosis Date ? Allergy   ? Anxiety   ? GERD (gastroesophageal reflux disease)     occasional ? Nextgen PMH Comments     MVA with nose and facial lacerations  06/29/2012;Acne Vulgaris   Not on any medications currently Ate breakfast sandwich and drank coffee this am.      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, eczema, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches     + dull headache to back of head developed about 10 minutes into her stay here in the medical bay. Tylenol 1000 mg given.    Previous Reactions: none    Objective    Vitals Vitals:   03/16/21 0930 BP: (!) 151/73 Pulse: (!) 104 Resp: 18 SpO2: 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:     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.  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, snacks and tylenol Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Systemic reaction (hypoglycemia, hypotension, generalized rash)   More likely a dip in her blood sugar and lack of water intake.  Pt improved with observation and interventions. She is appreciative of care today.    Electronically Signed 3/16/2021 9:34 AM