Age: 67.0
Sex: F
Vaccine: COVID19
Symptoms: Injection site pruritus, Pruritus, Tremor
Clinical narrative: Progress Notes: (Nurse Practitioner) ? ? Family Medicine Cosign Needed    3rd Attempt to call patient for follow up via phone. No answer.    Progress Notes  (Nurse Practitioner) ? ? Family Medicine    2nd Attempt to call patient for follow up via phone. No answer.    Progress Notes (Nurse Practitioner) ? ? Family Medicine    Attempt to call patient for follow up via phone. No answer.    Progress Notes: (Nurse Practitioner) ? ? Family Medicine Cosign Needed Expand All Collapse All     2/24/2021    Patient                                                                   Date:  2/24/2021    Subjective is a 67 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 itchy, shaky, hot, chest tightness.  She denied rash, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, 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, drooling, hypotension, rapid progression of symptoms, respiratory distress, skin changes and tongue swelling.   PMH includes none.  She does not take any medications but is on Vyvanse.none. She denies any medial hx. Not on any medications. She did drink a protein shake this am.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of chills, chest tightness and itching of skin (to R shoulder/injection site area)   Patient denies fever, malaise/fatigue, nasal sores, sneezing, sore throat, frequent throat clearing, cough, shortness of breath, wheezing, rash, hives, eczema, abdominal pain, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/24/21 1024 02/24/21 1029 BP: (!) 180/73 (!) 150/90 Pulse: 71   SpO2: 97%        Blood Sugar 108 collected at 1050     Physical Exam 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:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: Clear oral airway Eyes:     Conjunctiva/sclera: Conjunctivae normal.  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.     Findings: No rash.     Comments: Injection site and R arm without erythema or swelling.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood is anxious.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: antihistamines, 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), Local reaction (arm pain, bleeding/bruising, mechanical irritation, localized rash) and Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   PT monitored and improving. Pt ambulates well without dizziness. Chest tightness resolved and itchiness improving. Precautions discussed with patient. Pt aware of what to monitor and when to go to ED.  Pt voiced understanding and appreciated. Pt able to ambulate out of the facility with ease.    APRN Electronically Signed 2/24/2021 12:27 PM