Age: 50.0
Sex: F
Vaccine: COVID19
Symptoms: Dizziness, Dizziness postural, Erythema, Headache, Hyperhidrosis
Clinical narrative: The client reported dizziness to EMT and requested for her blood pressure to be obtained. RN responded. The client reported dizziness and sweating in her hands. Vitals obtained at 12:20PM were as follows BP 156/92, HR 69, O2 99%. The client reported a history of hypertension and stated that she has a medication prescribed. The client reported to RN that she did not take the prescribed medication this morning. The client subsequently stated to RN that she takes the medication as needed or when she experiences symptoms of high blood pressure. The client stated her current symptoms are normal for her when she experiences an episode of high blood pressure. The client reported feeling something on her cheek and removed her mask. RN noted an area of increased pink color that was approximately one inch in diameter. The client's family member reported the client has a history of rosacea and flushing when she is stressed. The client denied any other s/s of anaphylaxis. Client reported a history of anaphylaxis after taking penicillin and sulfa medications as a child. The client is not prescribed an Epi-Pen currently. The client stated her dizziness had resolved. Vitals obtained at 12:26 PM were as follows BP 165/96, HR 67, O2 99%. The client denied any current dizziness. The client stated when she experiences an episode of high blood pressure that drinking water and taking her medication help improve her symptoms. The client was provided water and began drinking it. RN noted mild diffuse redness across the client's chest. The client's family member stated this was normal for the client. The client denied any other signs or symptoms of anaphylaxis. The client denied any symptoms following her first or second doses of Moderna COVID vaccine. Vitals obtained at 12:32 PM were as follows BP 148/92, HR 69, O2 99%. The client denied any current dizziness or sweating of her palms. The client reported a slight headache and rated the pain at a 2 out of 10 on a 10 point scale. The client stated she commonly experiences headaches with stress and high blood pressure. The client stated her hands felt cold. The client stated she did eat a small sandwich and drank coffee today. The client stated she had not consumed any water today. The diffuse redness was still present on the client's chest and the spot on her right cheek. Repeat vitals obtained at 12:42PM were as follows: BP 156/92, HR 67, O2 99%. The client reported new onset of dry mouth, sweating and coldness of her hands, and headache still present. The client stated the pain of the headache was a 2 on a 10 point scale. RN provided education to the client on possible adverse reactions and when to seek medical care. RN recommended the client follow up with a medical provider regarding her blood pressure. The client voiced understanding of this education. The client stood up unassisted from the anti-gravity chair. The client reported slight dizziness upon standing but stated that she felt "okay to leave." RN offered continued observation. The client declined and stated that she would like to leave the vaccination site. The client's family member confirmed he was driving the client home. The client ambulated unassisted with a steady gait out of the observation area at 12:48 PM.