Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/4/2021  8:45 AM Expand AllCollapse All    COVID VACCINE CLINIC 3/3/2021    Date:  3/3/2021      Subjective Patient is a 66 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 L arm tingling.   She 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 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.   PMH includes htn, takes 2.5 mg daily. She denies having issues with bp this am before coming. She ate breakfast earlier this am. No hx of diabetes.   Hx of covid-19 infection in December. Not hospitalized. Still struggles with stamina since her illness. Evaluated in ED on 02/20/21 for chest pressure. Negative cardiac work up per pt. She is followed by her pcp.      ALLERGY REVIEW OF SYSTEMS:  Patient complains of malaise/fatigue (feels tired today.) and shortness of breath (chronic, not with exertion, tires easily. not changed from baseline.)   Patient denies chills, fever, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, wheezing, vomiting, abdominal pain and diarrhea    L arm numbness/tingling down arm. Negative focal neuro deficits. :     Previous Reactions: none    Objective    Vitals Vitals:   03/03/21 1023 03/03/21 1045 03/03/21 1115 BP: (!) 156/84 (!) 152/89 (!) 147/80 Pulse: 61   76 Resp: 16   14 SpO2: 99%   100%        Physical Exam Vitals and nursing note reviewed.  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:     General: No visual field deficit.    Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  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: Normal range of motion. No muscular tenderness.  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 cranial nerve deficit or facial asymmetry.     Sensory: Sensation is intact.     Motor: Motor function is intact.     Coordination: Coordination is intact.     Gait: Gait is intact. Gait normal.     Comments: +5/5 strength against resistance to upper and lower extremities.   Psychiatric:        Attention and Perception: Attention normal.        Mood and Affect: Mood is anxious (slight anxious affect).        Speech: Speech normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Cognition and Memory: Cognition normal.        Judgment: Judgment normal.      Pt was taken to bathroom by LPN via wheelchair during her stay. She still felt weak upon her return. No dizziness/lightheadedness.  She was given snacks and water x 2.   Assessment/Plan  Treatment included: water, snacks and reassurance/observation for about 40 minutes 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 Local reaction (arm pain, bleeding/bruising, mechanical irritation, localized rash)   Pt improved with snacks and water. Discussed what to monitor and potential anxiety underlying as well. Pt to continue to monitor her bp at home and f/up with pcp if it continues to be elevated >140/90. Pt was able to ambulate out with ease and w/o dizziness/lightheadedness.  Pt voiced appreciation of care today.    APRN Electronically Signed 3/3/2021 11:21 AM