Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Dry skin, Hypoaesthesia, Skin warm
Clinical narrative: Progress Notes (Nurse Practitioner) ? ? Family Medicine Cosign Needed Expand AllCollapse All     2/25/2021      Date:  2/25/2021                                                                                               Subjective a 77 y.o. female who was seen at Clinic today for her first  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 L hand numbness.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, 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, rapid progression of symptoms and respiratory distress.   PMH includes DM, HTN, asthma.  Takes metformin and losartan around noon every day. She has not taken her bp medication yet today as she takes it with lunch.       ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, cysts, itching of skin, muscle aches, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/25/21 1145 02/25/21 1201 BP: (!) 160/97 124/83 Pulse: 72   SpO2: 99%              Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not diaphoretic.  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:     Cervical back: Neck supple.  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.     Cranial Nerves: No cranial nerve deficit or facial asymmetry.     Sensory: Sensation is intact. No sensory deficit.     Coordination: Coordination is intact.     Gait: Gait abnormal (walks with walker, steady gait).     Comments: +5/5 strength against resistance to both upper and lower extremities.        Assessment/Plan  Treatment included: water Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Vaccine-Related Anxiety (include misc mental health) and Local reaction (arm pain, bleeding/bruising, mechanical irritation, localized rash)   Exam is stable/unremarkable. VS improved. Pt monitored for 20 minutes. She feels well. Possible more likely anxiety related than a local reaction. Pt aware to monitor and follow up with pcp if needed. Pt here with husband whom walked out with her. She declined wheelchair. She feels well.    APRN Electronically Signed 2/25/2021 11:59 AM