Age: 79.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dizziness
Clinical narrative: Progress Notes  APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/8/2021  3:04 PM COVID VACCINE CLINIC   3/8/2021    Patient                                                                                Date:  3/8/2021                                                                                             MRN:      Subjective Pt  is a 79 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 30 minute waiting period after the injection, the patient began to experience lightheadedness.  She denied rash, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, 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 , rapid progression of symptoms and respiratory distress.    Past Medical History: Diagnosis Date ? Allergic rhinitis, cause unspecified   ? Allergy   ? Asymptomatic postmenopausal status (age-related) (natural)   ? Atrial fibrillation (HCC)     PAF ? Breast cancer (HCC)   ? Calculus of kidney   ? Depressive disorder, not elsewhere classified     seasonal ? Egg allergy     ;No flu vaccine due to egg allergy ? Measles without mention of complication   ? Mixed hyperlipidemia   ? Obstructive sleep apnea (adult) (pediatric)   ? Osteoarthrosis, unspecified whether generalized or localized, unspecified site   ? Other complications of anesthesia, initial encounter     hard to wake up ? Outcome of delivery, single liveborn   ? Rubella without mention of complication   ? Tinnitus   ? Unspecified essential hypertension   ? Unspecified hypothyroidism   ? Varicella without mention of complication       ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, sore throat, frequent throat clearing, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, dizziness and headaches    Negative for vision changes:  + lightheaded:     Previous Reactions: vaccines d/t hx of egg allergy.     Objective    Vitals Vitals:   03/08/21 1313 BP: 126/64 Pulse: 61 SpO2: 99%        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 is anxious (slightly, improved after removal of mask for a few minutes. Pt placed mask back on. Feels better).        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: see physical exam 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) Anxiety   Pt observed in bay area for 15 minutes. Improved and is doing well. Pt assisted out via wheelchair by husband. Pt declined help out. She felt well in standing position in the medical bay prior to discharge. Pt declined water and snacks.    F/up with pcp as needed.   APRN Electronically Signed 3/8/2021 1:33 PM