Age: 58.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Eye discharge, Feeling cold, Headache, Stress
Clinical narrative: Progress Notes PA-C (Physician Assistant) ? ? Orthopedics Cosigned by: MD at 12/22/2020  9:46 AM Expand All Collapse All        12/21/2020    Patient:                                                                                           Date:  12/21/2020                                                                                             Subjective Patient is a 58 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 dizziness/shakiness. This provider was notified of patient reaction and she was then transferred to the emergency bay via wheelchair where she was assessed. Monitored patient for severe reaction symptoms, including rapid progression of symptoms, respiratory distress with dyspnea, increased work of breathing, persistent cough and cyanosis, vomiting, hypotension, dysrhythmia, chest pain and collapse.    She denied difficulty breathing, throat tightness and tongue swelling, nausea.    She reports a history of atrial fibrillation and states that she had a procedure in the past and the anesthesia provider questioned her about this diagnosis. She reports taking metoprolol and methimazole on a daily basis. She took all of her am medications today, including an 81 mg aspirin. Reports history of watery eyes and blurred vision, takes Zyrtec daily. Denies any worsening of these symptoms outside of her baseline. Denies use of anticoagulant use or diabetes.  Last ate and drank about 1130 or noon.    Review of Systems  Constitutional: Negative for diaphoresis.  HENT: Negative for congestion, drooling, facial swelling, rhinorrhea, sneezing and trouble swallowing.   Eyes: Positive for discharge. Negative for redness.  Respiratory: Negative for chest tightness and shortness of breath.   Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Negative for nausea and vomiting.  Skin: Negative for color change, pallor and rash.  Neurological: Positive for dizziness and headaches. Negative for syncope.  Psychiatric/Behavioral: Negative for agitation and confusion. The patient is not nervous/anxious.          Objective Vitals There were no vitals filed for this visit.      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is obese. She is not toxic-appearing or diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Nose: No rhinorrhea.  Eyes:     Comments: Watering of both eyes   Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Comments: At right radial pulse Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.  Skin:    General: Skin is warm and dry.     Coloration: Skin is not pale.     Findings: No rash.  Neurological:     Mental Status: She is alert and oriented to person, place, and time.        Assessment/Plan  Stress reaction following vaccine administration.   Patient was transported to the emergency bay via wheelchair.   Treatment included no therapy, but did continue with vital checks at approximately 5 minute intervals.    1603-blood pressure using the large adult cuff was 154/60 with large adult cuff, heart rate 69 with regular rate and rhythm at right radial pulse, 96% O2 sat on room air.  Patient continues to feel slightly dizzy and shaky though denies any chest pain, shortness of breath, swelling of the lips or tongue.    1611 vital signs reassessed with blood pressure of 150/63, heart rate 64, 97 percent on room air, continues to feel slightly dizzy/shaky, though, reports not nearly as bad.  Patient continues to answer questions appropriately and is talking without any signs of further decompensation.   1618-reports feeling better. Vital signs rechecked with BP of 121/55, 59 hearty rate and 96% RA. No new complaints.   1624- patient reports a slight headache, but denies chest pain, shortness of breath, chest tightness, lip or tongue swelling.    Discharge vitals obtained at 1626-with blood pressure of 135/55, heart rate of 58, 95% on RA. No new complaints, except feeling a bit cold.  Patient reports feeling better and feels that she can safely discharge.  Discussed need for urgent evaluation at the emergency department or to call 911 if symptoms of chest pain, shortness of breath, angioedema present.  Patient expresses understanding and all questions were answered to her satisfaction today.   Follow up response to treatment:excellent.   Patient discharge:  Stable to go home and follow up with PCP.    Orders Placed This Encounter Procedures ? COVID-19 MRNA      PA-C Electronically Signed 12/21/2020 4:05 PM