Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Dry eye
Clinical narrative: Progress Notes  APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by:  MD at 3/4/2021  8:28 AM Expand AllCollapse All    COVID VACCINE CLINIC  3/2/2021    Patient:                                                                            Date:  3/2/2021   MRN:  10238282     Subjective patient is a 69 y.o. female who was seen at a 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 and dry eyes.  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  and rapid progression of symptoms.   PMH includes diabetes (metformin), hyponatremia (chronic) and htn (metoprolol and losartan.) She last ate this am around 9:30.  1/2 granola bar. BG was 122 at home before coming in.      ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, malaise/fatigue, sore throat, frequent throat clearing, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, shortness of breath, wheezing, hives, eczema, cysts, itching of skin, abdominal pain, muscle aches, joint pain, dizziness and headaches    + dry eyes:  + lightheaded:     Previous Reactions: none    Objective    Vitals Vitals:   03/02/21 1110 03/02/21 1117 03/02/21 1130 BP: (!) 175/93 (!) 154/98 (!) 159/75 Pulse: 65 68 79 Resp: 18 16 14 SpO2: 100% 99% 100%      Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Mouth/Throat:     Pharynx: Oropharynx is clear.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     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 and snacks Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Vaccine-Related Anxiety (include misc mental health) and Systemic reaction (hypoglycemia, hypotension, generalized rash)   Monitored/observed for 25 minutes.  Pt reports improvement in overall symptoms. She feels good to go home. Pt has husband with her today and he will be driving. Pt encouraged to monitor her blood pressure. Follow up with pcp if noted to be persistently elevated.  Anxiety/stress response suspected causing elevation of bp.