Progress Notes (Nurse Practitioner) Family Medicine Cosigned by: MD at 3/18/2021  2:57 PM Expand AllCollapse All       Subjective male who was seen at 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, the patient began to experience lightheadedness.  He denied rash, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, itching, 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 blood pressure abnormality , chest pain, collapse, hypotension and rapid progression of symptoms.   Pmh: htn, hld and sleep apnea.      ALLERGY REVIEW OF SYSTEMS:  Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, eyes watering, eyes itching, cough, chest tightness, shortness of breath, wheezing, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches (negative for headaches)    Denies vision changes.:  +lightheaded, lips tingling:     Previous Reactions: none    Objective    Vitals Vitals:   03/16/21 1429 03/16/21 1432 BP: (!) 182/96 (!) 173/105 Pulse: 86   SpO2: 99%        Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is obese. He is not ill-appearing.  HENT:     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds and air entry.  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.    Tingling resolved. Still feeling lightheaded. Pt rested and had snacks and water. Slowly lightheadedness was reducing in severity.    After 15 minutes of observation, he was able to stand w/o increased lightheadedness.  He ambulates the bay w/o difficulty.     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: Vaccine-Related Anxiety (include misc mental health) and Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   Lightheadedness/elevated bp. Anxiety as well.   Review of his prior bp numbers in epic records show fluctuation of his bp ranging from 180's to 140's.  Recommended that he monitor bp at home. He doesn't have red flag symptoms related to elevated bp.  He's to follow up with pcp accordingly.    Electronically Signed 3/16/2021 2:29 PM