Progress Notes (Nurse Practitioner) Family Medicine Cosigned by: MD at 3/16/2021  9:55 AM Expand AllCollapse All    COVID VACCINE CLINIC 3/15/2021    Subjective Patient is a 35 y.o. male who was seen at COVID Vaccine Clinic today for his first  dose of the COVID 19 vaccination.    He was given the Pfizer vaccination in the left deltoid muscle.   During his 15 minute waiting period after the injection, the patient began to experience hot sensation in L side of chest.  He denied rash, hives, welts, 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 he was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , chest pain, collapse, rapid progression of symptoms and respiratory distress.   No medical hx.  Not on any medications     ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, ear pain, 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, abdominal pain, muscle aches, joint pain and dizziness    Denies cp:  No injection site pain:     Previous Reactions: none to vaccines    Objective    Vitals Vitals:   03/15/21 1520 03/15/21 1533 BP: (!) 147/82 134/77 Pulse: 69 76 SpO2: 98% 98%        Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is not ill-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds and air entry.     Comments: Speaking full sentences.  Skin:    General: Skin is warm.     Coloration: Skin is not pale.     Findings: No rash.     Comments: No tenderness on chest wall or L deltoid with palpation.   Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: no therapy 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) and Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   Pt observed in medical bay for approx 15 mins. Chest hotness resolved in medical bay after 5 minutes of being in bay.  He denies any other concerns. Possible anxiety/ stress response. VS and exam stable. Reassuring. Pt to follow up with pcp as needed. Discussed reasons to go to ED if needed. Pt voices understanding and is appreciative of his care today.   Pt is predominantly Spanish-speaking. Translator used: Myself.   Electronically Signed 3/15/2021 3:58 PM