Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dizziness
Clinical narrative: Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/4/2021  5:11 PM Expand AllCollapse All    COVID VACCINE CLINIC 3/4/2021    Patient:   Date:  3/4/2021                                                                                             MRN:  9302775     Subjective Patient is a 65 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 left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience lightheadedness.  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 , chest pain, rapid progression of symptoms and respiratory distress.    Past Medical History: Diagnosis Date ? Anemia, unspecified   ? Excessive or frequent menstruation   ? Other and unspecified hyperlipidemia   ? Pure hypercholesterolemia   ANXIETY, claustophobia       ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, muscle aches, joint pain, dizziness and headaches    + lightheaded:     Previous Reactions: none    Objective    Vitals Vitals:   03/04/21 1200 BP: 122/74 Pulse: 87 Resp: 16 SpO2: 98%      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed. She is not diaphoretic.  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 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 is anxious.        Speech: Speech is rapid and pressured (able to calm down by time she was in the bay and observed.).        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         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)  Observed for 15 minutes in the bay.    Pt appreciated her visit today. She more likely had an anxious moment as she reports she was anxious coming in. VS and exam stable/improved. Pt to follow up with pcp as needed.      APRN Electronically Signed 3/4/2021 12:07 PM