Age: 51.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue
Clinical narrative: (Nurse Practitioner)  Family Medicine at 3/1/2021 10:50 AM    Pt called to follow up on covid-19 vaccine done on 02/24/21.  She reports that she got home that day and slept until the next day.  Fatigue resolved.  No other issues noted with vaccine otherwise.  Denies any further questions or concerns.   Pt is appreciative of phone call.      Progress Notes     2nd Attempt to call patient for follow up via phone. No answer.    Progress Notes ? Family Medicine at 2/28/2021  7:28 AM    Attempt to call patient for follow up via phone. No answer.    Progress Notes (Physician Assistant) ? ? Family Medicine Cosigned by: MD at 2/28/2021  7:29 AM   STORMONT VAIL COVID VACCINE CLINIC   Patient:                                                                 Date:  2/24/2021                                                                                              Patient is a 51 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, headache, vision changes and increased respirations.  She denied rash, hives, difficulty swallowing, wheezing, throat tightness and hoarseness. She has a history of asthma often triggered by stress. She does have albuterol inhaler on hand, but has not used today. Denies frequent use of albuterol inhaler.   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 rapid progression of symptoms, respiratory distress and skin changes.     ALLERGY REVIEW OF SYSTEMS:  Patient complains of shortness of breath, dizziness and headaches   Patient denies chills, fever, facial swelling, cough, chest tightness and wheezing       Previous Reactions: Denies    Objective    Vitals Vitals:   02/24/21 1155 BP: (!) 126/92 Pulse: 64 SpO2: 100%      Physical Exam Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic and atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear. No posterior oropharyngeal erythema.     Comments: No swelling or lips or tongue.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  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.        Assessment/Plan  Treatment included: water and Tylenol 1000mg Follow up response to treatment: good. Patients symptoms all resolved prior to discharge. Her O2 remained 99-100% and she denied difficulties breathing. Her respirations decreased while she was in the bay.  Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Vaccine-Related Anxiety (include misc mental health)      Electronically Signed 2/24/2021 12:31 PM