Age: 25.0
Sex: F
Vaccine: COVID19
Symptoms: Lip dry, Lip swelling, Musculoskeletal stiffness, Paraesthesia, Rash
Clinical narrative: Patient presented to the vaccination site on 01/30/22 accompanied by her husband. The client reported that they received a 1st dose of Janssen COVID vaccine on 04/06/21. Client reported onset of "tingling in my body, dizziness, weakness, heart racing, feeling disoriented, and vision changes" a few minutes after receiving the Janssen COVID vaccine. The client stated she was given oral Benadryl at the vaccination site and took Tylenol at home. The client stated the symptoms lasted about one day. The client denied any chronic conditions, current medications, or known allergies. The client reported a history of syncope after donating blood in 2018. RN 1 submitted a medical consult via text message to Clinical Project Coordinators requesting to proceed with the COVID vaccine Moderna booster. The client stated she had not eaten today, was provided a snack, and began eating it while waiting a response from the medical consult. Per Dr., approval to proceed with COVID vaccine Moderna was obtained from medical consult team via text message from Clinical Project Coordinator. RN 1 educated client on possible adverse reactions, when to seek medical care and to register with V-Safe. Client received COVID vaccine Moderna booster Lot# 084J21A on 01/30/22 at 1148 while seated in a high fowler's position in the anti-gravity chair. The client reported pressure in her head and stated "it's not like anything I've felt before" to EMT. RN 1 and RN 2 responded. The following was obtained with RN 2 translating intermittently. The client reported that she felt "high" to RN 1 and reported pressure in her head. The client was alert and oriented to person, place, time, and situation. RN 1 noted the client resting her head on the anti-gravity chair with her eyes closed while responding to questions. Vitals obtained at 11:58AM were as follows: HR 78, O2 100%, automatic BP 120/87. The client stated she was unable to move her head because it would make her dizzy and stated she felt tight in her body. The client reported pressure in her chest. Respirations were 18 at 12:05PM. RN 3 responded for additional assistance. The client reported feeling "warm." The client reported "something" in her throat. The client was provided a cool pack placed on her chest.  The client reported after her first dose of Janssen COVID vaccine that she also had swelling of her body. She first noticed the swelling on her hands and said her rings were tight. Vitals obtained at 12:10 PM were as follows: HR 78, O2 100%, automatic BP 121/88. The anti-gravity chair was reclined to a semi-fowler's position. The client reported persistent feeling "light" in her head. Reported the feeling of "something" still in her throat that comes and goes. RN 1 evaluated the client's skin on her arms and chest. No redness or discoloration was noted. RN 1 noted the client rubbing her lips together and touching them with her hands. RN 3 inquired about symptoms on the client's lips. The client stated her lips felt, "like when given an anesthetic." Vitals obtained at 12:21 PM were as follows: HR 76, O2 100%, automatic BP 126/86. RN 1 showed the client her reflection in a phone camera. The client stated her lips looked slightly swollen. RN 1 and RN 3 recommended administration of oral Benadryl. The client stated she was able to swallow without difficulty. RN 3 provided education regarding possible adverse reactions regarding the Benadryl. The client voiced understanding of this education and consented to receiving oral Benadryl. The client consumed 50mg Benadryl Oral Solution without difficulty at 12:22 PM. The client began drinking water after taking the Benadryl. The client stated her lips felt "dry." The client denied any tightness in her throat and drank some more water.  Vitals obtained at 12:29 PM were as follows: HR 78, O2 99%, automatic BP 119/90. The client stated she felt "cold." The icepack was removed from her chest. At 12:31PM the client stated her lips felt better, her head felt "light," and denied any dizziness. The client reported pressure in her chest and described it as "tingling." The client denied any pain on inspiration, palpation, or shortness of breath.  Vitals obtained at 12:31 PM were as follows: HR 75, O2 99%, automatic BP 121/95. RN 1 noted normal lung sounds upon auscultation and no murmurs, gallups, or rubs with auscultation of the heart. The client stated she felt "normal but cold." At 12:45PM the client reported little red bumps on her arms and chest that were not present previously. RN 1 noted small red spots on her left forearm. RN 1 noted an area of redness on the client's chest about 1 inch in diameter that was not previously present. The client denied any symptoms including itchiness. The anti-gravity chair was adjusted to a high fowler's position per request of the client. The client denied any dizziness. Vitals obtained at 12:48 PM were as follows: HR 71, O2 100%, automatic BP 132/95. RN 1 and RN 3 provided education regarding possible adverse symptoms and when to seek care. The client voiced understanding of this education. The client stood up unassisted, ambulated unassisted with a steady gait, and left the vaccination site 12:55 PM. The client stated her husband was going to drive her home. VAERS completed for adverse symptoms after second dose.