Age: 73.0
Sex: F
Vaccine: COVID19
Symptoms: Pain in extremity, Rash
Clinical narrative: Progress Notes  Family Medicine Cosign Needed Expand AllCollapse All     2/25/2021                                                                                Date:  2/25/2021                                                                                               Subjective  is a 73 y.o. female who was seen at 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 L arm/hand numbness .  She denied rash, difficulty breathing, 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 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, rapid progression of symptoms and respiratory distress.   PMH: none per pt. Not on any medication. She has not been back to her pcp for "several years".  No known hx of htn. She does have a bp cuff at home.      ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, itching in ears, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, muscle aches, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/25/21 1118 02/25/21 1136 BP: (!) 172/84 124/82 Pulse: 96   SpO2: 99%        Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not 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.  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.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Findings: No rash.  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: Motor function is intact. No weakness.     Coordination: Coordination is intact. Coordination normal.     Gait: Gait normal.     Comments: +5/5 strength to upper and lower extremities. Equal facial movement.   Psychiatric:        Mood and Affect: Mood is anxious (slightly).        Behavior: Behavior 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: Vaccine-Related Anxiety (include misc mental health) and Local reaction (arm pain, bleeding/bruising, mechanical irritation, localized rash)   Exam is stable/unremarkable. VS improved after monitoring. Pt monitored for 20 minutes. She feels well. More like anxiety than local reaction. Pt aware of what to watch for. Education on monitoring bp at home and recommended that she follow up with pcp sometime next week to get up to date on her physical and follow up on bp records she will have done at home.     Electronically Signed 2/25/2021 11:33 AM