Age: 39.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Head discomfort, Palpitations, Rash
Clinical narrative: S:The pt walked in, is a 39 year female C/O dizzy after Janssen J&J Covid-19 Vaccine    O: Appearance: alert, well appearing, and in mild distress and oriented to person, place, and time.    A: Pt received Janssen J&J Covid-19 Vaccine at 1424, pt observed for 30 minutes, 1453 pt reported she had been feeling dizzy for about 10 minutes, stated she only had breakfast additional 15 minutes of observation given, 1505 stated her head felt heavy and palpitations, rash on face The patient is in need of an appointment for medical evaluation.    P: 1506 Notified Doctor.     1507 Transferred via wheel chair from vaccine clinic to triage nurse clinic, accompanied by MD   1512 VO Benadryl 50mg IM, administered   1521 VO Atenolol 25mg PO, given   1605 VO Atenolol 25mg PO, 1607 given   1618 Follow up appointment with pcp per MD   Future Appointments Date Time Provider Department Center 3/29/2021 10:30 AM, M.D.     1640 Pt discharged home by MD in stable condition.  Pt's husband waiting for pt outside.   Electronically signed   3/27/2021 4:41 PM   3:16 pm   patient taken back to nurse triage due to facial rash and pressure in head > 20 minutes after receiving J&J vaccine, she then advises has palpitations, no difficulty breathing, no oral symptoms, no lip swelling,    History:  patient with history of systemic mastocytosis diagnosed last year and history of frequent recurrent macular erythematous rashes frequently triggered by anxiety, last more significant reaction was 1 year ago after a facial, in which she had some lip swelling without oral swelling or difficulty breathing, patient on cetirizine 10 mg by mouth once daily which she took this am, (per allergy can take up to three times daily if needed ) in past she has been given prednisone tapers,  Although she states she has not had history of anaphylaxis, recent allergy referral for second opinion states "history of anaphylaxis"  Patient denies reactive airways disease, or history of oral swelling or difficulty breathing with her reactions.    Vitals:   03/27/21 1505 03/27/21 1514 03/27/21 1547 03/27/21 1602 BP: (!) 160/102 (!) 189/106 (!) 167/90 (!) 167/100 BP Patient Position: SITTING SITTING LYING LYING BP Location: LA-LEFT ARM LA-LEFT ARM LA-LEFT ARM LA-LEFT ARM Cuff Size: Standard Adult Standard Adult Standard Adult Standard Adult Pulse: 111 110 82 82 SpO2: 99% 99% 100% 100%    Exam blood pressure 183/104  Pulse 100 , O2 sat:  100% on room air resp rate regular at 16-12 / min Gen:  In NAD  Heent:  Erythematous rash macular face confluent extending to neck, cheeks, no lip swelling  Oropharynx, without swelling,  Lung:  Clear to auscultation bilaterally, no wheezing,  Cor:  Regular rate at 100 beats/minute  Abdomen: soft      4:36 pm - rash less prominent on face, still with erythematous macular lesions, but less dark  Patient denies palpitations, headache, chest pain, dizzyness, or shortness of breath      VACCINATION FOR SARS-COV-2 Note: given  Plan: VACC COVID-19 , RECOMBINANT SPIKE PROTEIN-AD26, PF (JANSSEN/J&J), 0.5 ML   SYSTEMIC MASTOCYTOSIS Note: has follow up with allergy    URTICARIA Note: suspect triggered by anxiety, given diphenhydramine 50 mg im x 1, patient instructed to increase cetirizine as per allergy suggestion to 10 mg three times daily, continúe benadryl 25-50 mg q8 h as needed hives,  Plan: DIPHENHYDRAMINE HCL 50 MG/ML INJ SOLN   ELEVATED BP READING WO HTN DIAGNOSIS Note: atenolol 25 mg by mouth given at 3:23 pm, with blood pressure drop to 167/90 from 189/106, in 40 minutes, second dose of 25 mg by mouth given at 4:06 pm , will give atenolol 25 mg by mouth once daily to take at home for elevated blood pressure until follow up this week by primary care provider by telephone visit   Plan: ATENOLOL  25 MG ORAL TAB     Patient and any caregivers present are advised if there is no improvement in Her symptoms, She is to follow-up with me in the above stated time.    Orders Placed This Encounter ? VACC COVID-19 , RECOMBINANT SPIKE PROTEIN-AD26, PF (JANSSEN/J&J), 0.5 ML ? Atenolol Tab 25 mg (TENORMIN) ? diphenhydrAMINE Inj 50 mg (BENADRYL)     3/27/2021 3:32 PM