Age: 34.0
Sex: F
Vaccine: COVID19
Symptoms: Blood glucose normal, Confusional state, Dizziness
Clinical narrative: Progress Notes APRN (Nurse Practitioner) ? ? Nurse Practitioner Cosign Needed Expand All Collapse All    COVID VACCINE CLINIC 12/22/2020      Date:  12/22/2020                                                                                            Subjective Patient is a 34 y.o. female who was seen at COVID Vaccine Clinic today for her first dose of the COVID 19 vaccination.  She denied any history of previous adverse reactions to vaccines.   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 and confussion.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, 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 respiratory distress with stridor, wheezing, dyspnea, increased work of breathing, persistent cough and cyanosis.   Pt  Presents with lightlessness and confusion.  Blood sugar on presenting was 74.  She has a history of fibromyalgia and Migraines.  She had a gastric bypass in 2010. She was given a protein bar to eat.  Fingerstick BS done 20 minutes later was 96.  Pt was feeling better after eating.    Review of Systems  Neurological: Positive for light-headedness.  Psychiatric/Behavioral: Positive for confusion.  All other systems reviewed and are negative.        Objective    Vitals Vitals:   12/22/20 1612 12/22/20 1628 12/22/20 1639 BP: (!) 135/92 127/79 128/84 BP Location: Right arm Right arm   Patient Position: Sitting Sitting   Pulse: 98 74 88 SpO2: 98% 98% 98%     Physical Exam Vitals signs and nursing note reviewed.  Constitutional:      Appearance: Normal appearance.  HENT:     Head: Normocephalic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal.     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Musculoskeletal: Normal range of motion.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds.  Abdominal:     General: Abdomen is flat.  Musculoskeletal: Normal range of motion.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     Mental Status: She is alert.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.         Assessment/Plan  Treatment included: no therapy. Follow up response to treatment: no side effects. Patient discharge: Stable to go home and follow up with PCP.   Pt was released at 4:39 with no symptoms at that time.       APRN Electronically Signed 12/22/2020 4:40 PM       Division of Health       3 of 3