Notes Emergency Medicine Expand All Collapse All    1/13/2021     Date:  1/13/2021                                                                                               Subjective 29 y.o. female who was seen at COVID Vaccine Clinic today for her first dose of the COVID 19 vaccination.    She denied any history of previous adverse reactions to vaccines.   She was given the Moderna vaccination in the left deltoid muscle.   During her 15 minute waiting period after the injection, the patient began to experience metallic taste and then felt lightheadedness.  She denied rash, hives, difficulty breathing, difficulty swallowing, wheezing, throat tightness, itching, facial swelling and lip swelling.   This provider was notified of patient reaction and she was then assessed in the emergency bay area.   Monitored patient for severe reaction symptoms and worsening of symptoms.   9:53 AM On arrival to treatment room, patient is pale and diaphoretic. She states she feels very lightheaded. She is able to answer questions, but is easily wanting to fall asleep. She awakes easily to verbal stimuli, states she feels very tired. Denies shortness of breath, throat swelling, difficulty breathing, rash. Reports she ate cereal for breakfast.   10:05 AM Patient is more alert and no longer diaphoretic. She is alert and states she is feeling better. Will continue to monitor.   10:12 AM Patient is alert and texting on her phone. Vital signs have improved.    10:19 AM Patient is alert and oriented and continues to do well. She states she is feeling much better. No diaphoresis noted. States she still has a little bit of a metallic taste in her mouth, but otherwise denies any other symptoms. Vital signs continue to improve.    10:36 AM Patient continues to do well. Is drinking water and ate granola bar.  Continues to feel well and reports metallic taste in improving and denies any other symptoms.    10:58 AM Patient continues to be alert and oriented. No longer pale and diaphoretic. States she is feeling well and back to baseline. Denies any complaints. Vital signs remain stable. She is able to ambulate with steady gait and denies dizziness/lightheaded with ambulation. Denies chest pain, shortness of breath, nausea, vomiting, difficulty breathing.    11:06 AM Patient's friend here to drive her home. She is ambulatory to the car and continues to feel well and denies symptoms. Discussed return precautions. Patient voiced understanding and denies any questions.      ALLERGY REVIEW OF SYSTEMS:  Patient denies facial swelling, puffy eyes, chest tightness, shortness of breath, rash, hives, itching of skin and vomiting    Metallic taste in mouth:  Diaphoresis :  lightheaded:     Previous Reactions: None    Objective    Vitals Vitals:   01/13/21 1033 01/13/21 1042 01/13/21 1057 01/13/21 1104 BP: 129/87 128/77 122/78 132/72 Pulse: 63 66 58 58 SpO2: 100% 100% 100% 100%     Blood Sugar 98 collected at 10:00 AM   Physical Exam Vitals signs and nursing note reviewed.  Constitutional:      Appearance: She is diaphoretic.  HENT:     Mouth/Throat:     Pharynx: Oropharynx is clear. Uvula midline. No pharyngeal swelling, oropharyngeal exudate, posterior oropharyngeal erythema or uvula swelling.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Bradycardia present.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal. No tachypnea, bradypnea, accessory muscle usage or respiratory distress.     Breath sounds: Normal breath sounds.  Skin:    Coloration: Skin is pale.     Comments: Diaphoretic and pale  Neurological:     Comments: Alert and able to answer questions, but wanting to fall asleep. Easily awakes to verbal stimuli.  Moving all extremities and following commands.        Assessment/Plan  Treatment included: Given water to drink and monitored. Follow up response to treatment: excellent. Patient discharge: Stable to go home and follow up with PCP. Friend is going to drive her home.       Electronically Signed 1/13/2021 11:07 AM