Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 2/28/2021  7:38 AM Expand AllCollapse All    COVID VACCINE CLINIC  2/26/2021    Patient:                                                                                 Date:  2/26/2021                                                                                           MRN:  10046638     Subjective Patient is a 74 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 left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience difficulty breathing and heart racing.  She denied rash, hives, welts, 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 , chest pain, collapse, hypotension, rapid progression of symptoms and respiratory distress.   PMH includes parkinson and items below. No hx of DM.     Past Medical History: Diagnosis Date ? Depression   ? GERD (gastroesophageal reflux disease)   ? Hyperlipidemia   ? Hypothyroidism   ? Osteoarthritis   ? Pain, chronic   ? Unspecified cataract           ALLERGY REVIEW OF SYSTEMS:  Patient complains of shortness of breath (and feeling palpitations. )   Patient denies chills, fever, malaise/fatigue, sore throat, frequent throat clearing, eyes watering, eyes itching, puffy eyes, eye redness, cough, chest tightness, wheezing, muscle aches, dizziness and headaches       Previous Reactions: none    Objective    Vitals Vitals:   02/26/21 0304 02/26/21 1457 BP: 123/72 123/62 Pulse: 76 73 Resp: 16   SpO2: 97% 97%      Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is not ill-appearing, toxic-appearing or diaphoretic.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.  Eyes:     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.     Pulses: Normal pulses.     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.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Gait: Gait abnormal (walks with cane and uses seated walker).  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.      0305 pm: pt walked around in bay with her cane. She was able to ambulate w/o difficulty. Reports slight lightheadedness but states this occurs with her intermittently /chronically. Nothing worse.  Pt given snack after return to bed for further observation. She had water given to her earlier prior to ambulation.     Assessment/Plan  Treatment included: water and snacks 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)   Monitored in bay for approx 40 minutes. She reports great improvement after snack. She feels well. Suspect stress response to vaccine. No dizziness, lightheaded or palpitations/sob with ambulation. She would like to go home. Husband is with her today and is able to be with her. She left in her seated walker, pushed by husband. Accompanied out by staff member.  Follow up with pcp if not improving. Discussed reasons for ED visit.    APRN Electronically Signed 2/26/2021 3:11 PM