Progress Notes Expand AllCollapse All    COVID VACCINE CLINIC 3/3/2021    Subjective Pt. is a 65 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 30 minute waiting period after the injection, the patient began to experience throat tightness.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, 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 , hypotension, rapid progression of symptoms, respiratory distress and tongue swelling.    Past Medical History: Diagnosis Date ? Belching   ? Bloating   ? Chicken pox   ? Cold sensation of skin   ? Diarrhea   ? Ear pain   ? Generalized headaches   ? German measles   ? Graves disease   ? Measles   ? Mumps   ? PVC (premature ventricular contraction)   ? Sinusitis   ? Thyrotoxicosis without mention of goiter or other cause, without mention of thyrotoxic crisis or storm     Hyperthyroidism; ? Type II or unspecified type diabetes mellitus with unspecified complication, not stated as uncontrolled (HCC)     DM Type II with comp;  ? Unspecified essential hypertension     Hypertension;  ? Varicella without mention of complication     Chicken Pox;          ALLERGY REVIEW OF SYSTEMS:  Patient complains of sore throat, frequent throat clearing and headaches (states she was outside yesterday and developed a headache/sinus headache. She has not taken anything for it.)   Patient denies chills, fever and malaise/fatigue       Previous Reactions: hx of reaction to tetanus. Reaction was arm swelling and throat swelling per pt.    She did not take any medications I.e. anti-histamines prior to coming.  She has throat clearing, states this is chronic, unchanged.    She reports that she isn't sure if this is allergic or anxiety.     Objective    Vitals Vitals:   03/03/21 0940 03/03/21 0945 BP: (!) 190/71 (!) 167/76 Pulse: 86   SpO2: 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.     Comments: Clear airway Eyes:     General:        Right eye: No discharge.        Left eye: No discharge.     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 is anxious (slightly anxious).        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.         Assessment/Plan  Treatment included: antihistamines and water pepcid and zyrtec 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 Systemic reaction (hypoglycemia, hypotension, generalized rash). HTN   More likely anxiety related in her reaction today. No progression of her symptoms of throat tightness. She reports it is resolving. Time of observation was 30 minutes. She feels comfortable going home. She is aware of what to monitor for.  IN regards to her elevated bp, pt states she was off her medications for a while and working on diet.  She is stable w/o cp, sob, jaw pain, neuro deficits, lightheadedness, dizziness. Recommend she monitor her bp at home and if continues to be elevated >140/90 that she follow up with her pcp.  She also is aware of hypertensive emergency and to go to ED if needed.  She is stable and looks well on discharge. Pt is comfortable going home. She ambulated w/o difficulty and complaints.     Pt also was offered tylenol here in the bay for her sinus headache that she developed yesterday after being outside. She declined. She reports she will take at home and resume her nasacort as usual.     Electronically Signed 3/3/2021 9:50 AM     3 of 3