Age: 69.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dizziness
Clinical narrative: Progress Notes Cosign Needed Expand AllCollapse All    3/12/2021    Patient:                                                                                                           DOB:  6/7/1951  Date:  3/12/2021                                                                                           MRN:      Subjective Patient is a 69 y.o. female who was seen at COVID Vaccine Clinic today for her second  dose of the COVID 19 vaccination.    She was given the Pfizer vaccination in the right deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience lightheadedness.  She denied rash, hives, welts, 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 ? Acquired hypothyroidism 12/7/2017 ? Nextgen PMH Comments     TAH - benign fibroids;Endometriosis;I-131 therapy for thyroid nodule ? Thyrotoxicosis without mention of goiter or other cause, without mention of thyrotoxic crisis or storm     Hyperthyroidism; NG PMH ? Unspecified essential hypertension     Hypertension; NG PMH       ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, muscle aches, joint pain, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   03/12/21 1431 BP: (!) 148/72 Pulse: 73 SpO2: 100%        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.  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 normal.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: no therapy and other than removal of double mask for a brief moment 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)   Bp checked and pt evaluated. Pt doing well. She feels better knowing her bp is okay and not high.  She is pleased with care and denies any concerns today. Pt able to ambulate out of the facility w/o assistance.