Age: 97.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness
Clinical narrative: Pt called to follow up on covid-19 vaccine done on 02/26/21.  Denies any reoccurrence of lightheaded. Felt fine at home and over the weekend. He has chronic itching, not new after vaccine. Plans to call his pcp today to get scheduled to manage this further. Denies any further questions or concerns.   Pt is appreciative of phone call.      a 97 y.o. male who was seen at  Clinic today for his first  dose of the COVID 19 vaccination.    He was given the Pfizer vaccination in the left deltoid muscle.   During his 15 minute waiting period after the injection, the patient began to experience lightheadedness.  He denied rash, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and he was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , chest pain, hypotension, rapid progression of symptoms, respiratory distress and vomiting.   PMH includes htn and DM (diet controlled). Reports he ate breakfast around 7 am today. He had cheerios, cantaloupe, and coffee.    He arrives to the bay using his own motorized wheelchair.    ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, malaise/fatigue, facial swelling, itching in ears, sore throat, frequent throat clearing, 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    Negative for nausea:  + lightheaded.:       Previous Reactions: none    Objective    Vitals Vitals:   02/26/21 1131 02/26/21 1138 02/26/21 1155 BP: (!) 175/79 (!) 144/82 132/80 BP Location: Right arm     Pulse: 89   64 SpO2: 98%          Physical Exam Constitutional:      General: He is not in acute distress.    Appearance: Normal appearance. He is well-developed. He is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     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:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Mental Status: He 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: Systemic reaction (hypoglycemia, hypotension, generalized rash)   Great response to eating and drinking. Symptoms resolved. Pt monitored for total of 30 minutes. He feels well to go home. Wife with him. He was able to operate his electric wheelchair out accompanied by his wife. Follow up with pcp as needed.