Your Health. Your Family. Your Choice.
Life Threatening? No
Write-up: Patient is a 14 yo male c/o intermittent upper left chest pain for $g20 min after Pfzier vaccine. Reported pain 3/10, described as sharp and non-radiating. Denied previous episode w/ similar symptoms. Reported feeling some anxiety but denied being diagnosed or treated with anxiety. Upon assessment no acute distress noted. Alert and orientedx4, verbal and able to make needs known. Respiration even and unlabored. Skin pink, warm, dry and intact. No sx of allergic reaction. Chest non-tender, heart rate WNL, noted irregular rhythm, no murmur or extra sounds noted. No loss or altered level of consciousness noted. Mother present with patient and reports having HX of elevated BP which physician recommended increased activity and weight loss, denied medication treatment. No HX of allergies per mother. Past medical HX obtained from patient and physical assessment completed simultaneously. Pt assessed while sitting in chair. VS 160/81, HR 62, O2 97% RR 20, sponataneous resolution on symptoms after 2-3 minutes, patient observed additional 30 minutes, no acute distress noted, pt denied pain or symptoms. Advised mother to have patient evaluated by PCP for irregular heart rhythm ASAP. Advised mother to take patient immediately to ER if symptoms return or develop new symptoms. Advised mother to call 911 if patient develops chest pain, SOB, altered or loss of consciousness. Mother verbalized understanding of all advice and education. Patient went home with mother
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