Age: 26.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Nausea
Clinical narrative: 26 y.o. female who was seen at SVH 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 headache and nausea.  She denied rash, hives, welts, 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 , rapid progression of symptoms and vomiting.    Past Medical History: Diagnosis Date ? Abnormal Papanicolaou smear of cervix with positive human papilloma virus (HPV) test 5/3/2017 ? Allergy     seasonal ? Anxiety   ? Asthma     allergy induced ? Carpal tunnel syndrome   ? Depression   ? Head ache   ? Herpes simplex     vaginal ? Iron deficiency anemia     in pg only ? PCOS (polycystic ovarian syndrome)   ? Postpartum hemorrhage of vagina 12/29/2017   Hymenal laceration with small vaginal extension, heavy bleeding, resolved with repair. Uterine tone maintained.     ALLERGY REVIEW OF SYSTEMS:  Patient complains of headaches   Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, vomiting, abdominal pain, muscle aches and joint pain    + nausea:     Previous Reactions: none    Objective    Vitals Vitals:   03/08/21 1054 03/08/21 1114 BP: 121/71 114/73 BP Location: Right arm   Patient Position: Sitting   Pulse: 74 69 SpO2: 100% 100%            Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal 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 normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: water and tylenol (500 mg), ibuprofen (200 mg) and pepcid (20 mg). she had already taken 600 mg of ibuprofen and 500 mg of tylenol this am for her dental work.  Ice pack as well on neck Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns) Headache and nausea.   Symptoms improving with medication treatments as listed above. Nausea resolved. She feels comfortable going home. She was monitored in the bay for 25 minutes. She denies any concerns. Follow up with pcp as needed.