Progress Notes APRN (Nurse Practitioner)  Cosigned by: MD at 2/28/2021  7:27 AM Expand All Collapse All   COVID VACCINE CLINIC  2/24/2021                                               Date:  2/24/2021                                                                                            Subjective: is a 50 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 15 minute waiting period after the injection, the patient began to experience throat tightness.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing,  hoarseness, stridor, itching, lightheadedness, 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 , chest pain, collapse, hypotension, increased swelling, rapid progression of symptoms, respiratory distress, skin changes and tongue swelling.   PMH: DM, hypothyroidism, asthma     ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, abdominal pain, muscle aches, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/24/21 1350 02/24/21 1352 BP: (!) 152/93 (!) 142/80 Pulse:   85 SpO2:   100%      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is obese. She is not diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.     Comments: Clear/patent oral airway Eyes:     Conjunctiva/sclera: Conjunctivae normal.  Neck:     Thyroid: No thyromegaly.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No wheezing.  Musculoskeletal:     Cervical back: Neck supple.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.  Neurological:     General: No focal deficit present.     Mental Status: She 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: antihistamines 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)   VS stable. Improving symptoms/resolved. Monitored for 1 hour.  Low suspicion for anaphylaxis. More likely generalized allergies and/or anxiety.  Doing well. Pt going home with husband.        APRN Electronically Signed 2/24/2021 1:56 PM