Age: 47.0
Sex: M
Vaccine: COVID19
Symptoms: Chest discomfort, Dizziness, Dyspnoea, Eye swelling, Hyperhidrosis
Clinical narrative: 1145: Per pt, he was vaccinated in August 2021 with J&J and "2 hours later I woke up with swelling to my face, my eyes were swollen shut and stridor" in which pt took "3 benadryls" and his symptoms resolved thereafter. Pt denies any previous history of any anaphylaxis or reactions to any vaccines. Pt stated he was a "baby" when it was indicated that he had allergies to PCN. There is no history of pt's 1st Covid Vaccine- J&J noted in his chart despite pt indicating that he had it done at (Privacy). Pt denies any discomfort or distress and was vaccinated on gurney in AR due to reported above history. Pt tolerated vaccine well, will monitor in AR for recommended time.   1150: Comfort measures provided- rest and po water, crackers, tolerating very well. Pt smiling and very conversive with RN, appears in no acute distress. Continue to monitor.   1155: Pt appearing diaphoretic with c/o midsternal "chest pressure" that is non-radiating, 3/10. Pt with noted occasional episodes of tachycardia where HR will go from 97 to 142 bpm x 20 seconds and during this time pt will experience dizziness. Placed on monitors and VS as charted below. Pt stated he ran out of his BP medications 3 days ago and has not taken any since then. His baseline reported SBP is 130mmHg per pt. Pt remains speaking in full and clear sentences, RR even and unlabored, -wheezing/stridor. Currently, warm, pink and dry while sitting semi-fowlers. Call out to Dr. and report given, awaiting orders.   219/111 97 18 97 on Room Air  1205: Verbal orders obtained for Benadryl po if pt is able to obtain a ride home. Pt calling his wife who confirms she can come pick pt up but coming from (Privacy) so ETA is 1 hour. Pt remains as charted above with "waves" of palpitations, diaphoresis but "constant" chest pressure that is not worsening.   223/1631 89 20 98 on Room Air  1210: Pt medicated with Benadryl 25mg po and tolerated it very well. Remains with intermittent palpitations, dizziness and diaphoresis and ongoing 3/10 midsternal chest pressure. LSCTA, -wheezing and no stridor noted on auscultation. Also, RN auscultation of heart sounds did not indicate any rubs, gallops or murmurs. Pt remains speaking full and clear sentences. Will continue to monitor closely.   1220: Pt states "I feel a little better all around" but confirms that he still does have 3/10 midsternal chest pressure from earlier. Pt also remains diaphoretic but warm to touch and skin color remains pink. Pt with new c/o of difficulty breathing but remains with LSCTA, -wheezing or stridor. Pt continues to speak in full and clear sentences. VS as charted below, call out to Dr. for further instructions. Will continue to monitor very closely.   196/116 85 20 98 on Room Air  1225: Verbal order for 2 puffs of Albuterol now for difficulty breathing and emergency number initiated per Dr. Pt remains as charted above with 3/10 midsternal chest pressure that has not gotten worse. Albuterol per pt "did not help". VS as charted below 223/134 93 20 99 on Room Air  1235: Report given to Medic 7. Pt transported via ambulance to ER.