Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Chest discomfort, Dizziness, Dyspnoea, Electrocardiogram, Headache
Clinical narrative: Nurse notified by client At Approximately 9:25 or 9:30 Client taken to private area for further evaluation by EMT  EMT present  Client?s husband present Client reports light-headedness, tightness and pressure in her chest, and Shortness of breath At 9:33 Vitals taken : O Sat 97, manual BP 170/120, Pulse 95 At 9:36 Vitals taken: Pulse 104, O Sat 96 Client reports pressure in her chest and tightness Client?s husband reports that this happens at home when she is excited and he states she was nervous today about receiving the vaccine. Client was advised to be transported or to at least have the ambulance paramedics perform a EKG to monitor her heart Client did not want to be transported or assessed by the ambulance paramedics EMT informed client of the risk of heart attack and stroke  Client continued to decline transport or ambulance arrival At 9:40 Vitals taken: Manual BP 160/110 Client offered water  At 9:43 EMT administered one Nitroglycerin 0.4mg tablet sublingually  Client felt an immediate headache which subsided afterwards  Vitals taken: Pulse 91, O Sat 97  EMT discussed selfcare regarding the Nitroglycerin she keeps at home and when and how to use it more effectively At 9:48 Vitals taken: Manuel BP 150/110  Client reports the tightness and pressure is lessening No longer light-headed or dizziness Client reports past history of light-headedness with hypertension and using Nitroglycerin as needed sometimes quite frequently  Client states she took one Nitroglycerin 2 to 3 weeks ago At 9:54 Vitals taken: Right arm Manuel BP 170/110 , Left arm Manual BP 170/110, Pulse 90, O Sat 97 At 10:05 EMT called and arranged to a firetruck crew on Special duty detail come to assess Client with a EKG/heart monitor since the client voiced concerns about being unable to pay for an ambulance or possible transport At 10:07 Manual BP 170/100, Pulse 88, O Sat 97 Client reports feeling lighter in her chest with no pressure in her chest  She knows this because she states that she now no longer has difficulty breathing like before when she was first assessed At 10:16 Client reports that her blood pressure medication dosages were changed yesterday She recently had a doctor?s visit EMT educate client on the need to check her BP and keep records for her physician  Client reports she was worked up about coming today to receive  the vaccine and did not sleep well last night  At 10:23 Firearm arrive on site At 10:26 Vitals taken via monitor by firemen BP 176/122,  Pulse 90 Client reports to firemen that she was not nervous about the vaccine today. EKG / Heart monitor applied At 10:34 Normal Sinus rhythm reported  Firemen states heart monitor reading looks good however Firemen and EMT advised that she follow up with her physician if she decided not to be transported.  Firemen and EMT advised that she go to the hospital but that it was her choice to refuse  At 10:37 Client refused to be transported  Client signed and agreed to the statement : Client informed of the risks of Heart attack and stroke. Client refused to be transported after EKG/heart monitor reading Client feels well enough to leave  Client assisted to the car using a wheelchair and her husband will drive her home