Age: 28.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Feeling hot
Clinical narrative: Progress Notes Expand AllCollapse All      Patient:                                                                                     DOB:  9/4/1992  Date:  3/12/2021                                                                                           MRN:      Subjective Patient is a 28 y.o. female who was seen at COVID Vaccine Clinic today for her second  dose of the COVID 19 vaccination.    She was given the Pfizer vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience lightheadedness and feeling faint and hot.  She denied difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, 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 , collapse, hypotension, rapid progression of symptoms and skin changes.    Past Medical History: Diagnosis Date ? Acne   ? Acute gastritis   ? ADD (attention deficit disorder)   ? Allergy   ? Anxiety   ? Depression   ? Migraines   ? Shingles 2017 ? Wears glasses     in the past         ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, vomiting, abdominal pain, dizziness and headaches       Previous Reactions: She reports hx of fainting with vaccines in the past. She didn't have problem with 1st dose of Pfizer. Today she is here for 2nd dose.     Objective    Vitals Vitals:   03/12/21 1437 03/12/21 1450 BP: 115/70 124/64 Pulse: 70 76 SpO2: 98% 100%      Physical Exam Constitutional:      Appearance: She is obese. She is diaphoretic.     Comments: flushed  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 moist.  Neurological:     General: No focal deficit present.     Mental Status: She is alert, oriented to person, place, and time and easily aroused.     Gait: Gait normal.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal. Behavior is cooperative.        Thought Content: Thought content normal.        Judgment: Judgment normal.      Pt wheel chaired to the medical bay. Pt given ice packs x 2 and brought to the bed and placed in trendelenburg position. Pt vs taken and is stable. Pt feels better in this position. Slowly inclined to sitting position. Tolerating well. Skin dry.    Assessment/Plan  Treatment included: water, snacks and ice packs 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)   She reports having improvement of symptoms after observation in medical bay for 40 mins.  She is to be taken home by dad who was able to come in to pick her up. Pt wheeled to front by this provider and able to stand and walk w/o assistance to car.  Monitor symptoms at home and follow up with pcp as needed.