Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Blood pressure abnormal, Dyspnoea, Injection site pain, Muscle spasms
Clinical narrative: Progress Notes PA-C (Physician Assistant) ? ? Physician Assistant Cosigned by: MD at 1/8/2021  9:47 AM Expand All Collapse All    COVID VACCINE CLINIC      Date:  1/7/2021                                                                                             MRN:  5234562     Subjective Patient is a 46 y.o. female who was seen at COVID Vaccine Clinic today for her first dose of the COVID 19 vaccination.    She denied any history of previous adverse reactions to vaccines.   She was given the Moderna vaccination in the right deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience increased  breathing rate following right shoulder/clavicle pain.  She denied rash, hives, welts, 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  and respiratory distress with increased work of breathing.         ALLERGY REVIEW OF SYSTEMS:  Patient complains of shortness of breath ( most likely from mild anxiety) and muscle aches       Previous Reactions: none    Objective    Vitals Vitals:   01/07/21 1136 01/07/21 1146 BP: (!) 140/92 129/70 BP Location: Right arm Right arm Patient Position: Sitting Sitting Cuff Size: Regular Adult Regular Adult Pulse: 88 76 Resp: 14 12 SpO2: 100% 100%     Physical Exam Vitals signs reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Right Ear: Hearing and external ear normal.     Left Ear: Hearing and external ear normal.     Nose: Nose normal.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Musculoskeletal: Normal range of motion and neck supple. No neck rigidity or muscular tenderness.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds. No murmur. No friction rub. No gallop.   Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing or rales.  Chest:     Chest wall: Tenderness ( right mid clavicle) present.  Musculoskeletal: Normal range of motion.  Skin:    General: Skin is warm and dry.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.     Sensory: No sensory deficit.     Gait: Gait normal.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: avoidance measures and talking with the patient.. Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.   Patient was thought to have a mild muscle spasm from the injection that may have cause a mild anxiety attack.  Patient was fully cooperative the whole time and appreciative for SV team of medical staff.  Patient's symptoms quickly resolved and she was able to leave without assistance.  Patient declined assistance to her car.       PA-C Electronically Signed 1/7/2021 2:05 PM