Age: 65.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Feeling abnormal, Pruritus
Clinical narrative: Progress Notes  Date:  3/26/2021                                                                                             Subjective Patient is a 65 y.o. female who was seen at COVID Vaccine Clinic today for her second  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 itching and head fog.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, 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 , hypotension, rapid progression of symptoms, respiratory distress, skin changes, tongue swelling and vomiting.   Had mild reaction to her fist COVID vaccine - has some head itching on right side Resolved without medications   Initially with complaints of "feeling foggy" to frontal head Also feeling itching - more to right side of body.     ALLERGY REVIEW OF SYSTEMS:  Patient complains of itching of skin and dizziness (when up to bathroom)   Patient denies fever, malaise/fatigue, sinus pressure, runny nose, cough, shortness of breath, wheezing, rash, vomiting, abdominal pain and diarrhea       Previous Reactions: See above    Objective    Vitals Vitals:   03/26/21 1326 03/26/21 1346 03/26/21 1413 BP: (!) 156/83 (!) 161/80 (!) 152/75 Pulse: 59 68   SpO2: 99% 100%            Physical Exam HENT:     Head: Normocephalic.  Cardiovascular:     Rate and Rhythm: Normal rate.     Pulses: Normal pulses.  Pulmonary:     Effort: Pulmonary effort is normal.  Musculoskeletal:        General: Normal range of motion.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No erythema or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood 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: Systemic reaction (hypoglycemia, hypotension, generalized rash)   Benadryl given for itching - significant improvement in this noted Continues to complain of having "funny feeling" and fog.  Denies headache and does not wish to have tylenol Blood pressure in the ED bay are slightly higher than her baseline Hx of migraine headaches, but this is not similar to that With medical history, pt does not feel comfortable with going home and would like to be evaluated in the ED They will go by private vehicle - husband here with her Report called to ED charge nurse.      Electronically Signed by APRN 3/26/2021 2:38 PM    Progress Notes  Cosigned by: MD at 3/30/2021  8:03 AM    Date:  3/26/2021                                                                                               Subjective Pt is a 65 y.o. female who was seen at COVID Vaccine Clinic today for her second  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 itching and head fog.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, 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 , hypotension, rapid progression of symptoms, respiratory distress, skin changes, tongue swelling and vomiting.   Had mild reaction to her fist COVID vaccine - has some head itching on right side Resolved without medications   Initially with complaints of "feeling foggy" to frontal head Also feeling itching - more to right side of body.     ALLERGY REVIEW OF SYSTEMS:  Patient complains of itching of skin and dizziness (when up to bathroom)   Patient denies fever, malaise/fatigue, sinus pressure, runny nose, cough, shortness of breath, wheezing, rash, vomiting, abdominal pain and diarrhea       Previous Reactions: See above    Objective    Vitals Vitals:   03/26/21 1326 03/26/21 1346 03/26/21 1413 BP: (!) 156/83 (!) 161/80 (!) 152/75 Pulse: 59 68   SpO2: 99% 100%            Physical Exam HENT:     Head: Normocephalic.  Cardiovascular:     Rate and Rhythm: Normal rate.     Pulses: Normal pulses.  Pulmonary:     Effort: Pulmonary effort is normal.  Musculoskeletal:        General: Normal range of motion.  Skin:    General: Skin is warm.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No erythema or rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood 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: Systemic reaction (hypoglycemia, hypotension, generalized rash)   Benadryl given for itching - significant improvement in this noted Continues to complain of having "funny feeling" and fog.  Denies headache and does not wish to have tylenol Blood pressure in the ED bay are slightly higher than her baseline Hx of migraine headaches, but this is not similar to that With medical history, pt does not feel comfortable with going home and would like to be evaluated in the ED They will go by private vehicle - husband here with her Report called to ED charge nurse.      APRN Electronically Signed 3/26/2021 2:38 PM