Age: 6.0
Sex: M
Vaccine: COVID19
Symptoms: Asthenia, Chest pain, Full blood count, Metabolic function test, Syncope
Clinical narrative: Patient 6 year old male. DOS: 03/23/2022.   Subjective:      Chief Complaints:       1. Passing out & having chest pains.       HPI:     Asthma:         6 year 5 month old male presents with c/o Chest pain.         Pt presents with mother s/p fainting at school during P.E. Mother states pt was running in PE while wearing his mask and fainted and afterwards had chest pain. Pt rec'd his 2nd covid vaccine yesterday and mother states he had no reaction to the first covid vaccine.          Translator given/used  No. Admission to hospital or ER  N/A . Discharge summary received  N/A,  Follow up appointment has been scheduled  Yes .       ROS:      Had 2nd dose of Pfizer covid vaciine at about 6pm yesterday. Was normal, slept OK, went on bus OK. Had breakfast at school. While walking to PE passed out - details not known. When mom went to collect him at about 10 am he was weak and needed to be on wheel chair to come to the car. complains of mid chest pain.  Has asthma but on no meds now and had no breathing problems in the recent past.      Medical History: Pneumonia.       Surgical History: Denies Past Surgical History.       Hospitalization/Major Diagnostic Procedure: strep pneumonia admitted for 1 month TCH May 2019.       Family History: Father: alive, healthy, hyperlipidemia. Mother: alive, healthy. 2 brother(s) . .        Social History: Academic problems: Not applicable. no Drug. Preventive Dental care: Yes  Preventive Dental Care Routine . Environmental hazards: Not applicable. Use OTC Meds or Herbal supplements: Yes . No Self referral to specialists. NO Barriers to care . Pneumonia vaccine  pneumococcal  Record in chart . no DNUtobacco use . no Alcohol. Caffeine: yes, Soda. no Domestic Violence . Education: yes. no Exercise. Home smoke detector use: yes . no Legal problems. Housing: Lives with Family. Occupation: Not applicable. Pets: Dog. No Sexually active. no Tobacco Use  Are you a: never smoker. no Travel,      Medications: Not-Taking Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol Solution 1 puff as needed Inhalation every 4 hrs, Notes: prn, Not-Taking Albuterol Sulfate (2.5 MG/3ML) 0.083% Nebulization Solution 3 ml as needed Inhalation every 4 hrs, Notes: prn, Not-Taking Nebulizer/Pediatric Mask - Kit as directed NEEDS MASK AND TUBING ONLY , Discontinued Albuterol Sulfate (2.5 MG/3ML) 0.083% Nebulization Solution 3 ml Inhalation every 6 hrs as needed, Notes: duplicate, Medication List reviewed and reconciled with the patient      Allergies: N.K.D.A.     Objective:      Vitals: Ht 49, Wt 52, BMI 15.23, BMI % 44.35, Temp 98.1, Pulse sitting 111, RR 20, BP sitting 88/62, Oxygen sat % 99, Pain scale 0.      Examination:     Pediatric Exam:       GENERAL APPEARANCE: alert, active.        EYES: normal.        NOSE: nares patent and clear, mucosa normal.        ORAL CAVITY: moist mucus membranes, tonsils normal.        LUNGS: clear, equal breath sounds bilaterally.        ABDOMEN: soft,nontender, no masses, no organomegaly.        SKIN: no rashes, no skin lesions.        NEUROLOGIC EXAM: normal tone and motor development, normal sensory system and reflexes, normal cranial nerves II-XII.         able to walk well on heels and toes..            Assessment:      Assessment:   1. Syncope, unspecified syncope type - R55 (Primary)   2. Fainting spell - R55     ? adverse event after covid vaccine.   Plan:          Labs:         Lab: COMPREHENSIVE METABOLIC PANEL W/EGFR                             Lab: CBC (H/H, RBC, INDICES, WBC, PLT)                             Procedure Codes: Z5025 cbc, Z0053 COMPRE METAB PANEL.     Preventive Medicine:     Screening / Special Tests: Preventive Dental Care Date Completed Routine .  Flu shot Date Given Record in Chart.  Pneumonia shot Date Given Record In Chart.  Eye Exam Date Completed Never had eye exam done.    Counseling: BMI Counseling  Counseling for Nutrition Provided Yes, counseling for Physical Activity Provided Yes.    HCOSET: Patient care plan Visit summary given, details explained Verbal understanding Expressed by patient,Follow up visit plan discussed,Visit Summary Given,Medication side effects discussed.       Follow Up: 1 - 2 days (Reason: F/U if symptoms persist or worsen)