Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by: MD at 3/18/2021  2:52 PM Expand AllCollapse All    COVID VACCINE CLINIC 3/17/2021     Date:  3/17/2021                                                                                               Subjective Patient is a 34 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 left deltoid muscle.   During her 30 minute waiting period after the injection, the patient began to experience itching.  She denied rash, hives, welts, difficulty breathing, difficulty swallowing, wheezing, throat tightness, hoarseness, 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 , rapid progression of symptoms, respiratory distress, skin changes and tongue swelling.   Medical hx insignificant     ALLERGY REVIEW OF SYSTEMS:  Patient complains of itching of skin   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, vomiting, abdominal pain, muscle aches, joint pain, dizziness and headaches       Previous Reactions: same itching with 1st vaccine of Pfizer.     Objective    Vitals Vitals:   03/17/21 1625 03/17/21 1640 BP: 128/74 124/79 Pulse: 71   SpO2: 100%            Physical Exam 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.  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: antihistamines benadryl and pepcid Follow up response to treatment: fair. Patient discharge: Stable to go home and follow up with PCP.  Differential Diagnosis: Systemic reaction (hypoglycemia, hypotension, generalized rash)   All over itching. Similar to last time. Pt given benadryl 50 mg and pepcid 20 mg. Pt not drowsy at time of discharge. States she does fine with benadryl. She feels comfortable going home and managing it on her own.  States she will seek emergent care if new symptoms arise.  Pt wishes to be discharged.  Discussed symptoms to monitor for. No progression of symptoms while observed in the bay.        APRN Electronically Signed 3/17/2021 5:00 PM