Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by MD at 3/16/2021  9:55 AM Expand AllCollapse All    COVID VACCINE CLINIC 3/15/2021    Patient:                                                                            Date:  3/15/2021                                                                                           MRN:  10187641     Subjective Patient is a 54 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 lightheadedness, dizziness and nausea.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, stridor, itching, facial swelling, lip swelling and tongue swelling.   This provider was notified of patient reaction and she was then assessed in the emergency room.   Monitored patient for severe reaction symptoms, including but not limited to blood pressure abnormality , rapid progression of symptoms and vomiting.   Diabetic on metformin and levemir.  Ate about 2 hours ago. Did not check her sugars today.        ALLERGY REVIEW OF SYSTEMS:  Patient complains of dizziness (lightheaded)   Patient denies chills, fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, hives, eczema, itching of skin, vomiting, abdominal pain, muscle aches, joint pain and headaches    + nausea:     Previous Reactions: none    Objective    Vitals Vitals:   03/15/21 1003 03/15/21 1022 BP: (!) 149/86 123/67 Pulse: 85   SpO2: 99%        Blood Sugar 171 collected at 1007     Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She 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.     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, snacks and pepcid for nausea 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) Nausea/lightheaded.   Symptoms resolved. VS stable. Exam reassuring. Pt reports feels comfortable going home. She is ambulatory and is appreciative of today's care.    Pt is predominantly Spanish-speaking. Translator used: Myself.   APRN Electronically Signed 3/15/2021 10:18 AM