Progress Notes APRN (Nurse Practitioner) Family Medicine Cosigned by: MD at 3/4/2021, 8:45 AM Expand All Collapse All  COVID VACCINE CLINIC  3/3/2021  Patient Date: 3/3/2021  Subjective Patient is a 74 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 right deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience diaphoresis.  She denied rash, hives, 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 , collapse, drooling, hypotension, rapid progression of symptoms, respiratory distress, skin changes and tongue swelling.   Past Medical History:  Diagnosis Date ? Allergy   all year ? Anxiety ? Arthritis ? Asthma   exercise induced ? Calculus of gallbladder without mention of cholecystitis or obstruction   Cholelithiasis; ? Diabetes mellitus ? Diabetes mellitus, type 2;  ? Diverticulosis of colon (without mention of hemorrhage)    Diverticulosis without Hemorrhage ? Esophageal reflux    GERD; ? Hearing loss ? Hypertension ? Irritable bowel syndrome    Irritable Bowel Syndrome ? Past Hospitalization    Diagnosis: Chest Pain, atypical; at: Health Center; Approximate Date: 18000101;  ? Nextgen Comments    Palpitations/SVT; Anxiety disorder; HRT; Microscopic hematuria ? Osteoarthrosis, unspecified whether generalized or localized, unspecified site    Osteoarthritis;  ? Other and unspecified hyperlipidemia    Hyperlipidemia, Pure;  ? Pancreatitis ? PONV (postoperative nausea and vomiting) ? Type II or unspecified type diabetes mellitus without mention of complication, not stated as uncontrolled;     DM type II w/o comp;  ? Unspecified essential hypertension    Hypertension ? Unspecified hemorrhoids without mention of complication    Hemorrhoids;  ? Unspecified tinnitus  ALLERGY REVIEW OF SYSTEMS:  Patient complains of headaches (frontal, reports from using her hearing aids and is loud in the expo center. Present prior to vaccine today.  ). Patient denies chills, fever and malaise/fatigue;    Previous Reactions: none  Pt reports she last ate around 10 am.  She declines any food/snacks from bay today.    Objective   Vitals Vitals:  03/03/21 1355 BP: (!) 115/99 Pulse: 73 Resp: 16 SpO2: 97%  Blood Sugar 134 collected at 1354  Physical Exam  Constitutional:  General: She is not in acute distress.  Appearance: Normal appearance. She is well-developed. She is not diaphoretic (no visual diaphoresis. ) 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.  Pulses: Normal pulses.  Heart sounds: Normal heart sounds.  Pulmonary:  Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. No wheezing.  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 normal.  Psychiatric:  Mood and Affect: Mood normal. Behavior: Behavior normal.  Thought Content: Thought content normal.  Judgment: Judgment normal.     Assessment/Plan Treatment included: water  Follow up response to treatment: excellent.  Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)  Flushed sensation  Pt observed for 15 minutes. t  Symptoms resolved. BG good and pt able to ambulate w/o dizziness, lightheaded, sob, cp.   Follow up with pcp if not improving or worsening. Continue to monitor BG and BP at home.   Pt and pt's husband voices appreciation of care today.   APRN Electronically Signed  3/3/2021 1:57 PM  Division of Health.