Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosign Needed Expand AllCollapse All    COVID VACCINE CLINIC 3/24/2021    Patient:                                                                        DOB:    Date:  3/24/2021                                                                                           MRN:   Subjective Patient is a 60 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 he did fine.  However, pt noted to be sitting on side after pushing his sister in wheelchair to take a "break."  He was noted to be wheezy and sob along with diaphoresis.  Pt states he has hx of asthma and forgot to bring his inhalers.  He normally doesn't walk much anyway and today was a long walk.  He was offered a wheelchair and brought to the bay for inhaler treatment. .  He denied rash, hives, welts, difficulty swallowing, 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 rapid progression of symptoms.    Active Problem List   Diagnosis ? Essential hypertension [I10] ? Long term (current) use of anticoagulants [Z79.01] ? New onset atrial fibrillation (HCC) [I48.91] ? Neuropathy (HCC) [G62.9] ? Hypotonic bladder [N31.2] ? Diverticulosis [K57.90]     Per previous hx report, colonscopy 2004   ? Diabetes mellitus type 2 in obese diagnosed 2014 [E11.69, E66.9] ? Class 3 severe obesity due to excess calories with serious comorbidity and body mass index (BMI) of 45.0 to 49.9 in adult (HCC) [E66.01, Z68.42] ? Unspecified hemorrhoids without mention of complication [K64.9] ? Open wound of other and unspecified parts of trunk, without mention of complication [IMO0002] ? Obstructive sleep apnea (adult) (pediatric) [G47.33] ? Hypertrophy of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS) [N40.1] ? Degeneration of lumbar or lumbosacral intervertebral disc [M51.37]     ALLERGY REVIEW OF SYSTEMS:  Patient complains of shortness of breath and wheezing   Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, cough, chest tightness, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   03/24/21 0825 Pulse: 89 Resp: (!) 24 SpO2: 100%            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:     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.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. Tachypnea present.     Breath sounds: Decreased breath sounds and wheezing present.     Comments: Albuterol inhaler used. Improved with use. O2 maintains at 100%.   Skin:    General: Skin is warm.     Coloration: Skin is not pale.     Findings: No rash.  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.      Pt with reported improved symptoms and breathing after 2 puffs of albuterol. Pt declined blood pressure check.  Heart sounds RRR. Improvement of wheezing and air movement.  Eupneic. Skin dry.     Assessment/Plan  Treatment included: albuterol Follow up response to treatment: good. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   Asthma exacerbation due to exercise. Recommend keeping albuterol on him at all times if he is out of the home. Continue maintenance. Follow up with pcp accordingly.    APRN Electronically Signed 3/24/2021 8:31 AM