Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Diarrhoea, Dry mouth, Dyspnoea, Nausea
Clinical narrative: Progress Notes by Family Medicine Nurse Practitioner  COVID VACCINE CLINIC  2/19/2021    Patient is a 54 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 mouth dryness.  She denied rash, hives, 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 , drooling, hypotension, increased swelling, rapid progression of symptoms, respiratory distress, skin changes and tongue swelling.   PMH includes seasonal allergies (took zyrtec this am as routinely scheduled), htn, hld.      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, cysts, itching of skin, abdominal pain, muscle aches, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/19/21 1533 02/19/21 1536 02/19/21 1541 02/19/21 1600 BP: (!) 157/91 (!) 164/91 (!) 158/92 (!) 149/87 BP Location:   Right arm     Pulse:       88 SpO2:       99%      Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: Clear oral airway/intact.  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.     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.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: antihistamines and water Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Vaccine-Related Anxiety (include misc mental health) and Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   Pt stable and doing well. Pt agreeable to monitor symptoms. Aware of when to seek emergent care. Follow up with pcp otherwise. Pt given ride with one of her co-workers. Pt ambulatory out of the facility.    Electronically Signed 2/19/2021 3:41 PM