Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/16/2021  9:52 AM Expand AllCollapse All    VACCINE CLINIC  3/15/2021    Patient:                                                                                   DOB:   Date:  3/15/2021                                                                                           MRN:    Subjective Patient is a 40 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 right deltoid muscle.   During her 30 minute waiting period after the injection, the patient began to experience chills.  She denied rash, hives, welts, 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, hypotension, rapid progression of symptoms and respiratory distress.   Hx of htn, currently changing out medication to new one as she is 9 weeks pregnant. She is experiencing vaginal spotting in the last 2 weeks. Her obgyn is aware and monitoring. Recent u/s done and is okay.        ALLERGY REVIEW OF SYSTEMS:  Patient complains of chills   Patient denies fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, cough, chest tightness, shortness of breath, wheezing, rash, hives, itching of skin, vomiting, abdominal pain, muscle aches, dizziness and headaches       Previous Reactions: none     Objective Vitals There were no vitals filed for this visit.        Physical Exam Constitutional:      General: She is not in acute distress.    Appearance: Normal appearance. She is well-developed. She is morbidly obese. She is not 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 laying down and covered with blanket.  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) Chills.    She reports improvement of feeling chilled here in medical bay.  She was able to sit up in bed w/o dizziness/lightheaded. Ambulates w/o assistance. She feels ready to go home.  Continue care with obgyn and follow up with pcp as needed. Pt voiced appreciation of her care today.    APRN Electronically Signed 3/15/2021 4:15 PM