Age: 66.0
Sex: F
Vaccine: COVID19
Symptoms: Blood pressure abnormal, Dizziness, Hypoglycaemia, Hypotension, Rash
Clinical narrative: Progress Notes   Family Medicine     COVID VACCINE CLINIC, 3/3/2021    Patient:     Patient a 66 y.o. female who was seen at a 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 rash, hives, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, 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  and rapid progression of symptoms.    Past Medical History: Diagnosis Date ? Depression   ? GERD (gastroesophageal reflux disease)   ? Hyperlipidemia   ? Hypertension   ? Obstructive sleep apnea (adult) (pediatric)   ? Osteoarthritis     She does have a way to monitor her blood pressure. She last ate around 9:30 am    ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, cysts, itching of skin, abdominal pain, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   03/03/21 1315 03/03/21 1326 03/03/21 1340 BP: (!) 167/81 (!) 167/81 (!) 163/63 Pulse: (!) 103 (!) 103 80 Resp: 18 18 16 SpO2: 100% 100% 100%        Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not ill-appearing, toxic-appearing or diaphoretic.  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.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Gait: Gait abnormal (has her own wheelchair that she uses for long distances. ).  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: water and snacks Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Systemic reaction (hypoglycemia, hypotension, generalized rash) HTN   Overall well appearing, not in distress. Pt observed in the bay for approx 25 minutes.  Bp slowly improving. She is here with husband who will take her home. She feels better after water and snacks. Pt encouraged to monitor her bp at home. Follow up with pcp if continues to be elevated.  Pt and husband voices understanding and denies any other questions or concerns.       Electronically Signed 3/3/2021 1:27 PM