Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Nausea, Palpitations
Clinical narrative: Progress Notes Expand AllCollapse All      Patient:                                                             DOB:  1/5/1954  Date:  3/15/2021                                                                                           MRN:      Subjective Patient is a 67 y.o. male who was seen at COVID Vaccine Clinic today for his first  dose of the COVID 19 vaccination.    He was given the Pfizer vaccination in the right deltoid muscle.   During his 15 minute waiting period after the injection, the patient began to experience slight nausea and heart racing sensation.  He 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 he was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , chest pain, collapse, rapid progression of symptoms, respiratory distress and skin changes.    Past Medical History: Diagnosis Date ? Cancer (HCC) 2004   surgery ? Malignant neoplasm of colon, unspecified site (HCC)   ? Peripheral neuropathy due to chemotherapy (HCC) 2004 ? Rheumatoid arthritis(714.0)     Rheumatoid Arthritis; NG PMH     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, itching of skin, vomiting, abdominal pain, muscle aches, dizziness and headaches       Previous Reactions: none to vaccines.     Objective    Vitals Vitals:   03/15/21 1433 03/15/21 1437 BP: (!) 168/62 (!) 152/68 Pulse: 62   SpO2: 98%          Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is not ill-appearing or 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.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds and air entry.  Skin:    General: Skin is warm.     Coloration: Skin is not pale.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood is anxious (slightly anxious affect.).        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: no therapy 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)   Pt improved after monitoring in bay for 15 minutes. He denies any concerns and states symptoms have resolved. Pt able to ambulate out of the facility w/o assistance. He expresses appreciation of his care today.