Age: 80.0
Sex: F
Vaccine: COVID19
Symptoms: Blood pressure increased, Extraocular muscle paresis
Clinical narrative: ALLERGY REVIEW OF SYSTEMS:  Patient denies fever, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, shortness of breath, rash, hives, itching of skin, abdominal pain, muscle aches, dizziness and headaches    Pt sent a picture of herself to her son after getting her vaccine. Noted her R eye drooping. :     Previous Reactions: none    Objective    Vitals Vitals:   02/16/21 1535 02/16/21 1545 02/16/21 1555 BP: (!) 185/77 (!) 162/80 (!) 160/63 Pulse: 68     Resp: 16     SpO2: 98%            Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General: Lids are normal.     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.     Comments: Pt showed this provider picture she took of her R eye drooping. Picture demonstrates slight decrease in eye opening in comparison to L eye. Currently no eye drooping is noted.   Cardiovascular:     Rate and Rhythm: Normal rate.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Musculoskeletal:     Right lower leg: No edema.     Left lower leg: No edema.  Skin:    General: Skin is warm.     Coloration: Skin is not pale.     Findings: No erythema.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit or facial asymmetry.     Sensory: Sensation is intact. No sensory deficit.     Motor: No weakness, tremor, abnormal muscle tone or pronator drift.     Coordination: Coordination is intact. Coordination normal.     Gait: Gait (steady gait with walker) normal.     Comments: Equal movement and strength +5/5 to upper and lower extremities.   Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.     Comments: Slightly anxious affect.          Assessment/Plan  Treatment included: no therapy and reassurance 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)   Pt to follow up with pcp/new pcp if her bp at home continues to be elevated >140/90.  We discussed reasons to go to ED. She is stable today and is feeling good. She declined a wheelchair out to the front. She was wanting to walk with her walker. This provider walked out with her and her husband out to the front where they were met by their son. Pt did well on her ambulation without stopping. Pt and husband both voiced appreciation.    APRN Electronically Signed 2/16/2021 3:54 PM