Age: 65.0
Sex: M
Vaccine: COVID19
Symptoms: Blood pressure abnormal, Chest pain, Dyspnoea, Headache, Hypoglycaemia
Clinical narrative: Immunization 3/29/2021 COVID Vaccine Clinic Need for vaccination +1 more Dx Referred by MD Reason for Visit Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/30/2021  8:12 AM Expand AllCollapse All   COVID VACCINE CLINIC 3/29/2021    Patient: (name)                                                                              DOB: (date) Date:  3/29/2021                                                                                           MRN:  (number)    Subjective Patient is a 65 y.o. male who was seen at the COVID Vaccine Clinic today for his second  dose of the COVID 19 vaccination.    He was given the Pfizer vaccination in the left deltoid muscle.   During his 15 minute waiting period after the injection, the patient began to experience shortness of breath as he was walking out to the front.  He reports no issues with the vaccine as he was waiting.   He denied rash, hives, welts, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, dizziness, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and he was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , chest pain, rapid progression of symptoms and respiratory distress.   Pmh: hx of iron deficient anemia. He just stopped taking his iron supplements on Saturday after being on it for 10 days. He also was taking Diflucan and had some "adverse reaction" of nausea and sleeping issues.    Denies hx of heart or lung disease, not on any inhalers or medications for these.     Past Medical History: Diagnosis Date ? Fatigue, unspecified type 2/7/2017 ? Impotence of organic origin     Impotence, Organic; NG PMH ? Obstructive sleep apnea   ? Osteoarthritis   ? Unspecified essential hypertension     Hypertension; NG PMH     ALLERGY REVIEW OF SYSTEMS:  Patient complains of shortness of breath   Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, cough, chest tightness, wheezing, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   03/29/21 1035 BP: 138/58 Pulse: (!) 102 SpO2: 92%      Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is not ill-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Heart sounds: Normal heart sounds.     Comments: HR improved with rest down to 90 Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds and air entry.     Comments: Speaking full sentences.  Skin:    General: Skin is warm.     Coloration: Skin is not pale.     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: no therapy Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Systemic reaction (headache, itching, tachycardia, hypoglycemia, hypotension, generalized rash)   Pt with improvement/resolution of sob with rest.  I suspect sob related to iron deficiency. Recommend that he monitor breathing at home . If symptoms return or  Worsen, seek care in ED. Certainly to follow up with pcp accordingly for management of his iron levels.     Pt voiced appreciation and denies any other questions or concerns.  (name), APRN Electronically Signed 3/29/2021 10:42 AM