Notes (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/19/2021  9:22 AM Expand AllCollapse All    Clinic 3/18/2021    Patient:  Date:  3/18/2021                                                                                               Subjective Patient is a 30 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 paresthesia down R arm.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, lightheadedness, dizziness, facial swelling, lip swelling, tongue swelling and weakness in arm.   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 rapid progression of symptoms.   PMH insignificant     ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches    + paresthesia in R arm:     Previous Reactions: none    Objective    Vitals Vitals:   03/18/21 1430 BP: 108/62 Pulse: 72 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.     Cranial Nerves: No facial asymmetry.     Sensory: Sensation is intact.     Motor: No weakness.     Coordination: Coordination is intact.     Gait: Gait normal.     Comments: + 5/5 strength against resistance to bilateral upper extremities. Pt able to put on her own sweater without difficulty or assistance.   Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.       Assessment/Plan  Treatment included: ice pack Follow up response to treatment: fair. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Local reaction (arm pain, bleeding/bruising, mechanical irritation, localized rash)   Suspect superficial nerve secondary to injection. Discussed ice/warm cloth, movement of R arm. Follow up with pcp as needed. We will check in with her tomorrow via phone. Pt voiced appreciation of evaluation today.    Nurse Practitioner Electronically Signed 3/18/2021 8:58 AM