Age: 82.0
Sex: F
Vaccine: COVID19-2
Symptoms: Blood glucose normal, Dizziness, Immunisation reaction, Lethargy, Nausea
Clinical narrative: Pt. received COVID booster vaccine this afternoon at 14:10.  she started  feeling dizzy and nauseas shortly afterward.  she denies chest pain or  shortness of breath.  she denies abdominal pain.  the dizziness is more like  light headedness.  she does not feel like she is going to pass out.  the room  is not spinning around her.  she sees Dr. cardiology, for palpitations.  Last Cardiac PET Stress  test in August 2022 was normal-  no e/o ischemia.  Last Echo was in 2021- no  e/o AS.  trace MR/TR.  she has never had a bad reaction to a vaccine previously.  she ate breakfast  and lunch today.  drank a small bottle of water about 1 hour ago. she states  she took all her medications this morning.   hx of diabetes.  her blood sugar today is normal. orthostatic VS were normal- no  e/o orthostasis   OBJECTIVE: Medications reviewed and reconciled with patient. Today's vitals: BP:148/79, O2:94, PA:0, PU:75, RS:20 Last Height: 60.63 in [154.00 cm] BMI: 31.54 Temp: 97.7 F [36.5 C]  (Nov 27, 2023@09:12)  Pulse: 75  (Nov 30, 2023@14:25)  Resp: 20  (Nov 30, 2023@14:25)     FSBS 159  Gen no acute distress, elderly female, sitting up on gurney bed, face is slightly  pale CV rrr  no m/r/g Lungs clear to auscultation bilaterally Abd bowel sounds present, soft, nttp, nd, no mass extr no edema skin warm and dry, no rash psych appropriate  I went back to re-examine patient 5 minutes later and the color had returned to  her face.  She stated she felt much better.  Her son was on the way to pick her  up.  At end of visit the patient was able to stand without issue and walk steadily out  of the building.    ASSESSMENT/PLAN:   1. Vasovagal response to vaccine- she was treated with PO fluids, crackers,  zofran, and benadryl.  She recovered well in the treatment room and was  discharged home in the care of her son without further concern.  This is not  evidence of a true allergic reaction.  She is eligible to receive the COVID  vaccine in the future should she desire.   Follow up with PCP as planned Follow-up prn increased symptoms. Keep all other appointments.    /es/ MD Family Medicine Signed: 11/30/2023 15:44  11/30/2023 ADDENDUM                      STATUS: COMPLETED Today, at 1424, representative of RA came to the window stating Pt  was in her office with c/o feeling lightheaded with nausea; Pt received  the Moderna Monovalent Vaccine that she received in Pharmacy today at 1410; she  was slightly pale and lethargic.  She was taken to the Triage room via WC, othostatic VS were obtained on her and a  FSBS was done:  Temp 97.1, RS:20, BP:154/84[L ARM,SITTING,CUFF,ADULT], PU 71 PA:0, O2:94[AMBIENT  AIR  l/min  %], BP:158/90[L ARM,STANDING,CUFF,ADULT], PU 75, BP:148/79[L  ARM,LYING,CUFF,ADULT], PU:73  Her FSBS was 159 at 1433.  She stated she ate breakfast and lunch today.  Dr. was notified; she ordered Zofran and Benadryl:  11/30/2023 14:54  New Order entered by MD (PHYSICIAN)      Order Text:        ondansetron 4mg OTD - give 1 tablet under the tongue once  now                         NOW                         1 DAY FROM NOW      Nature of Order:   ELECTRONICALLY ENTERED      Elec Signature:    MD (PHYSICIAN) on 11/30/2023 14:55      Ordered by:        MD (PHYSICIAN)  Nursing Medication Administration  As per Dr orders on 30-Nov-2023 for nausea Oral medication(s) administered  Oral Medication Administered: Zofran     Dose: 4 mg     Time: 1452     She tolerated the medication well; no adverse reaction noted.  11/30/2023 14:55  New Order entered by MD (PHYSICIAN)      Order Text:        Benadryl 25mg tablet PO once now                         NOW                         1 DAY FROM NOW      Nature of Order:   ELECTRONICALLY ENTERED      Elec Signature:    MD (PHYSICIAN) on 11/30/2023 14:55      Ordered by:        MD (PHYSICIAN)  Nursing Medication Administration  As per Dr orders on 30-Nov-2023 for reaction to Covid vaccine Oral medication(s) administered  Oral Medication Administered: Benadryl     Dose: 25 mg     Time: 1501     She tolerated the medication; no adverse reaction noted.  PATIENT ADVISEMENT     Patient has been advised of possible side effects     (rash/hives, nausea, difficulty breathing, redness, pain, fever)     and given the following instructions:     (a) Remain in the waiting area for 30 minutes.      (b) Notify the nurse immediately if any side effects are experienced          within that 30 minutes.      (c) After leaving the clinic area, if any side effects are experienced          notify your provider.     (d) If any urgent or emergent problems are experienced after leaving          the clinic area report to the nearest emergency room or call 911.   She was given 2 packages of graham crackers and 2 bottles of water after she was  given Zofran; she toerated the graham crackers and the water, no N/V noted.  At 1530, she ambulated to the bathroom with her cane without difficulty.  She stated "I feel much better, back to normal, thank you for taking care of me".   RETURN TO CLINIC:     Jan 22, 2024 1:00 pm (30 MINUTES) with SX PODIATRY DOYLE           3 MONTH FU   She was discharged to home with her 2 sons, in stable condition.                /es/ RN RN