Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dizziness
Clinical narrative: Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: Dr at 3/1/2021 10:50 AM Expand AllCollapse All    COVID VACCINE CLINIC 3/1/2021    Subjective 74 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 lightheadedness.  She denied difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, itching, dizziness, 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 and respiratory distress.   PMH: currently on ciprofloxacin for an UTI.    Past Medical History: Diagnosis Date ? Allergic rhinitis, cause unspecified     Allergic Rhinitis; NG PMH ? Allergy   ? Awareness under anesthesia     Pt was hard to wake when had anes in 1970's ? Carpal tunnel syndrome   ? Colon polyps   ? Coronary artery disease   ? H/O heart artery stent 2005 ? Hearing loss     bilateral hearing aids ? Iritis   ? Iron deficiency anemia   ? Lumbosacral spondylosis without myelopathy   ? Osteoarthrosis, unspecified whether generalized or localized, unspecified site     Osteoarthritis; NG PMH ? Osteopenia     osteopenia, MVA with whiplash injury that caused servical spondylosis 60's,  s/p laminectomy 75, 88 ? Other and unspecified hyperlipidemia     Hyperlipidemia, Pure; NG PMH ? Pain, chronic   ? Peripheral vascular disease, unspecified (HCC)   ? Tinnitus   ? Unspecified essential hypertension     Hypertension; NG PMH ? UTI (urinary tract infection)   ? Wears hearing aid in both ears 2017         ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, abdominal pain, muscle aches, joint pain, dizziness and headaches    + lightheaded:     Previous Reactions: none      Objective    Vitals Vitals:   03/01/21 1025 03/01/21 1040 BP: (!) 144/56 132/61 Pulse: 93 70 Resp: 20 14 SpO2: 99%          Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is obese. She is not ill-appearing or diaphoretic.  Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Skin:    General: Skin is warm and dry.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline.     Gait: Gait abnormal (walks with a cane. ).  Psychiatric:        Mood and Affect: Mood is anxious.        Behavior: Behavior 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: Vaccine-Related Anxiety (include misc mental health)   Observed in the medical bay for approx 15 minutes. Pt responded well with water and rest. She was able to demonstrate ambulation in the bay w/o reoccurence of lightheaded. Pt reports she feels a lot better. Pt encouraged to monitor bp at home and follow up with pcp if noted to be 140/90 consistently. Pt walked out by RN accompanied by pt's husband.    Pt voiced appreciation for today's care/visit.    APRN Electronically Signed 3/1/2021 10:32 AM