Age: 88.0
Sex: F
Vaccine: COVID19
Symptoms: Body temperature increased, Chills, Fatigue, Headache
Clinical narrative: Progress Notes  APRN (Nurse Practitioner) ? ? Family Medicine    Pt called to follow up on covid-19 vaccine done on 02/26/21.  She states she did develop chills, fatigue and blood pressure was up and down (from baseline, "not of any concern"). Slight elevation of temp, under 100 F.  This was on Friday. Then over the weekend, she slept a lot.  Today she feels well and "ready to get dose #2".  Denies any further questions or concerns.   Pt is appreciative of phone call.     APRN      Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by:  MD at 2/28/2021  7:37 AM Expand AllCollapse All    COVID VACCINE CLINIC 2/26/2021    Patient:                                                                             DOB:    Date:  2/26/2021                                                                                           MRN:       Subjective Patient is a 88 y.o. female who was seen at 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.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, dizziness, facial swelling, lip swelling, tongue swelling and weakness face, arms/legs.   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 , chest pain and rapid progression of symptoms.   PMH:   Past Medical History: Diagnosis Date ? Allergy     year round ? Cardiac pacemaker in situ 10/26/2017 ? Chronic kidney disease, stage III (moderate) (HCC) 7/17/2020 ? Coronary artery disease   ? Diverticulosis   ? Esophageal reflux   ? Esophageal stricture   ? Hearing loss   ? Hiatal hernia   ? Hypothyroid   ? Osteoarthritis   ? Palpitations   ? Perennial allergic rhinitis 5/22/2017 ? Postablative ovarian failure   ? Proteinuria     Hypertensive ? Rheumatic fever   ? Rotator cuff tear, left     Nonsurgical treatment ? Sciatica   ? Skin cancer     nose X2 ? Unspecified cataract     removed ? Unspecified essential hypertension           ALLERGY REVIEW OF SYSTEMS:  Patient complains of headaches   Patient denies chills, fever, malaise/fatigue, facial swelling, ear pain, sinus pain, sinus pressure, frequent throat clearing, eyes itching, puffy eyes, eye redness, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, abdominal pain, muscle aches and dizziness    Denies vision changes.  L eyelid with droop. Chronic. Unchanged. :     Previous Reactions: none    Objective    Vitals Vitals:   02/26/21 1408 02/26/21 1414 BP: (!) 156/66 (!) 145/56 Patient Position:   Sitting Pulse: 60   SpO2: 99%        Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not ill-appearing, toxic-appearing or diaphoretic.  Eyes:     Comments: Slight drooping of L eyelid, chronic, unchanged per pt and pt's granddaughter, Otherwise no facial drooping or asymmetry.   Neck:     Thyroid: No thyromegaly.  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.  Musculoskeletal:     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Gait: Gait (walks with steady gait. ) normal.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: water Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   Pt monitored for approx 30 minutes. She has improvement of bp on observation along with headache has subsided.  She is encouraged to monitor her bp at home and follow up with pcp if bp stays above 140/90.  Granddaughter had requested pt to be evaluated. She is appreciative of this evaluation.     APRN Electronically Signed 2/26/2021 2:47 PM