Progress Notes APRN (Nurse Practitioner) ? ? Family Medicine Cosigned by:, MD at 3/16/2021  9:55 AM Expand AllCollapse All     VACCINE CLINIXC 3/15/2021   Subjective Pateint  is a 30 y.o. male who was seen at  Vaccine Clinic today for his first  dose of the COVID 19 vaccination.    He was given the Pfizer vaccination in the left deltoid muscle.   During his 15 minute waiting period after the injection, the patient began to experience lightheadedness and nausea, hot, dry mouth.  He 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 he 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 and vomiting.    Past Medical History: Diagnosis Date ? Hernia   ?  Past Hospitalization      Admit on: 20130219; Diagnosis: Aseptic meningitis, dehydration; at: HealthCare;  MD;    Hx of + covid infection in November 2020.    ALLERGY REVIEW OF SYSTEMS:  Patient complains of chills and vomiting (scantly, x 3 times)   Patient denies fever, malaise/fatigue, facial swelling, sore throat, frequent throat clearing, rash, hives, itching of skin, abdominal pain, dizziness and headaches    + nausea:  + lightheaded:     Previous Reactions: none with vaccines.     Objective    Vitals Vitals:   03/15/21 0956 03/15/21 1009 03/15/21 1032 BP: (!) 142/95 127/79 129/83 Pulse: 84     SpO2: 99%          Blood Sugar 112 collected at 1045     Physical Exam Vitals reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is ill-appearing. He is not diaphoretic.     Comments: Slightly flushed  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.     Heart sounds: Normal heart sounds.  Pulmonary:     Effort: Pulmonary effort is normal.     Breath sounds: Normal breath sounds and air entry.  Abdominal:     Tenderness: There is no abdominal tenderness.  Skin:    General: Skin is warm.     Coloration: Skin is pale (improved with rest).     Findings: No rash.  Neurological:     General: No focal deficit present.     Mental Status: He is alert and oriented to person, place, and time.  Psychiatric:        Mood and Affect: Mood normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.        Patient with several brief episodes of dry heaving/burping throughout his observation here.  He's managed to have scant amount of emesis. Pepcid 20 mg given, then zofran odt 4mg given,  He was feeling better with ice pack and laying down. Upon sitting up he started to feel lightheaded and dizzy again. Restarted to burp with scant periods of nausea with dry heaves. Pepcid 20 mg given again. Pt able to sit up but still feeling nauseated. New ice pack given to neck. Pt asked to call for a ride. Security had to go out to his car to get his phone. Pt called his mom. Mom will come to pick pt up.  Pt reports dizziness/lightheaded with position changes with increased nausea upon transfer to wheelchair.    Assessment/Plan  Treatment included: water, snacks and pecid and zofran. Follow up response to treatment: no change. Patient discharge: Transported to ED . Differential Diagnosis: Red flag symptoms (CP, SOB, NVD, Visual/Neuro concerns)   Nausea and lightheaded/dizziness primarily.    Pt monitored in bay for over an hour. Stable vs.  Mom here to pick up patient and will transport to ED at  for further evaluation/treatment due to failing PO challenge. Pt wheeled out in wheel chair. ED notified of patient coming.     , APRN Electronically Signed 3/15/2021 10:12 AM