VAERS ID: 906871

AGE: 60| SEX: F|STATE: (United States)

Description

Progress Notes; Nurse Practitioner Cosign Needed Expand All Collapse All COVID VACCINE CLINIC 12/22/2020 Date: 12/22/2020 Subjective Patient is a 60 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 Pfizer vaccination in the left deltoid muscle. During her 15 minute waiting period after the injection, the patient began to experience Headache over the front of the head. 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 respiratory distress with stridor, wheezing, dyspnea, increased work of breathing, persistent cough and cyanosis. Finger stick BS 101 12:15 pm granola bar and water given Review of Systems Neurological: Positive for headaches. All other systems reviewed and are negative. Objective Vitals Vitals: 12/22/20 1203 12/22/20 1226 BP: (!) 158/81 (!) 153/75 BP Location: Left arm Left arm Patient Position: Sitting Sitting Pulse: 76 72 SpO2: 98% 98% Physical Exam Vitals signs and nursing note reviewed. HENT: Head: Normocephalic. Nose: Nose normal. Mouth/Throat: Mouth: Mucous membranes are moist. Eyes: Pupils: Pupils are equal, round, and reactive to light. Neck: Musculoskeletal: Normal range of motion. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. Musculoskeletal: Normal range of motion. Skin: General: Skin is warm. Capillary Refill: Capillary refill takes less than 2 seconds. Neurological: General: No focal deficit present. Mental Status: She is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Assessment/Plan Treatment included: no therapy. Follow up response to treatment: no side effects. Patient discharge: Stable to go home and follow up with PCP. Pt reports headache went away after she ate. No new symptoms manifested. Pt released at 12:30 pm Electronically Signed 12/22/2020 12:29 PM

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Symptoms

Headache, Blood glucose normal

Vaccines

VAX DATE: 12-22-2020| ONSET DATE: 12-22-2020| DAYS TO ONSET: 0
NameDose #TypeManufacturerLotRouteSite
COVID19 (COVID19 (PFIZER-BIONTECH)) 1 COVID19 PFIZER\BIONTECH EH9899 IM RA

RECVDATE:12-22-2020
RPT_DATE:
CAGE_YR:60
CAGE_MO:
DIED:U
DATEDIED:
L_THREAT:U
ER_VISIT:
HOSPITAL:U
HOSPDAYS:
X_STAY:U
DISABLE:U
RECOVD:U
LAB_DATA:
V_ADMINBY:
OTHER_MEDS:
CUR_ILL:
HISTORY:
PRIOR_VAX:
SPLTTYPE:
FORM_VERS:
TODAYS_DATE:12-22-2020
BIRTH_DEFECT:U
OFC_VISIT:U
ER_ED_VISIT:U
ALLERGIES:
V_FUNDBY:

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