Age: 43.0
Sex: F
Vaccine: COVID19
Symptoms: Blood pressure increased, Chest discomfort
Clinical narrative: Patient presents for evaluation of encounter for immunization.  Here for moderna COVID-19 vaccine #1.  See scanned vaccination screening form and post vaccine questionnaire.@1713 Patient reports that her lungs "felt tight". She denies mouth swelling, facial swelling, tongue swelling, throat tightness, difficulty breathing or speaking. Denies GI distress, nausea. Denies rashes, itching or other symptoms. She denies allergies. Denies chronic conditions. Denies daily medications. She reports her only medical history is "childhood asthma" and does not take any medication currently. (1715) Patient escorted to exam room for privacy and monitoring. Patient able to ambulate without difficulty or distress. She reports her "chest tightness" is a 6 (0-10 scale). And denies other symptoms including chest pain, itching, mouth swelling, SOB. Patient reports she prefers to sit in chair, vs lying on exam table, VS monitored by RN.   ROS:  CONSTITUTIONAL:  Negative for chills, fatigue, fever, and weight change.   EYES:  Negative for blurred vision, eye pain, and photophobia.   E/N/T:  Positive for Denies mouth, tongue swelling. Denies throat tightness..   CARDIOVASCULAR:  Negative for chest pain, palpitations, tachycardia, orthopnea, and edema.   RESPIRATORY:  Positive for Denies cough, distress, endorses "tight chest".   GASTROINTESTINAL:  Positive for Denies nausea, vomiting, GI distress, diarrhea.   INTEGUMENTARY/BREAST:  Positive for Denies rashes, lesions, changes to skin..    Vitals:   Current: 2/19/2021 4:48:38 PM T: 97.9 F (temporal);  BP: 174/104 mm Hg (right arm, sitting);  P: 81 bpm (finger clip, sitting)O2 Sat: 100 % (room air)  Repeat:  5:38:26 PM  BP:   182/108mm Hg (left arm, sitting, 5:17pm) 5:38:59 PM  BP:   158/97mm Hg (right arm, sitting, 5:26PM) 5:40:22 PM  O2 Sat:   100% (room air, 5:26PM) 5:39:56 PM  P:   73bpm (finger clip, sitting, 5:26PM)   Exams: Initial Exam completed by NP at 1713, 1720, 1730, 1740 and 1746. No changes from baseline  GENERAL: well developed, well nourished, in no apparent distress;; well developed; well nourished; well groomed; no apparent distress  EYES: lids and conjunctiva are normal; pupils and irises are normal;  E/N/T: normal external ears and nose;;  Hearing: grossly normal Lips, Teeth and Gums:  normal; Oropharynx: normal mucosa;  NECK: Neck is supple with full range of motion;  RESPIRATORY: normal respiratory rate and pattern with no distress; even and unlabored, no wheezing;  CARDIOVASCULAR: normal PMI placement; no thrills, heaves, or lifts; normal rate and rhythm without murmurs; normal S1 and S2 heart sounds with no S3, S4, rubs, or clicks;; normal rate; regular rhythm; irregular rhythm; Radial pulses +2 CR< 3 seconds BUE;  GASTROINTESTINAL: no masses or tenderness;  SKIN: no ulcerations, lesions or rashes no skin thickening, induration, or subcutaneous nodules;  NEUROLOGIC: AOx3, awake, alert, calm  PSYCHIATRIC: mental status: alert and oriented x 3; appropriate affect and demeanor; recent and remote memory are intact; good insight and judgement;   Procedures:  Encounter for immunizationBenadryl 50 mg tab given PO per, NP at 5:14pm  1. Epinephrine given IM, in the right thigh; administered by: employee; ( lot #0GM147; exp. 11/2021 ) 5:37pmVS were monitored closely by RN and NP during reaction, see chart for RN's VS  **Requested RN to chart her VS: see "Post COVID-19 Vaccination Questionnare for VS completed by employees  1714 Benadryl given PO  1726: VS: Ox 100% on RA RR 16 HR 73 BP 158/97  1731  VS: Ox 98% RA  RR 16 HR 84 - patient reports chest tightness is worsening: Ordered IM epi, given by RN  1738 VS:Ox  99% RA RR 16 HR 83 BP 167/114  1742 VS: Ox 100% RA RR 16 HR 89  1746 VS: Ox 100% RA RR 16 HR 80 167/98  Plan:   Encounter for immunizationvaccine given per protocol.30  minutes after vaccine, patient c/o chest tightness.  PO benadryl and IM epi given per protocol, VS monitored per protocol and documented by RN and NP   1) Protocol followed for anaphylaxis 2) Patient remained stable under care. Patient AOx3, awake, no respiratory distress, talking and smiling.  3) (1537) Informed patient we are calling 911 due to administration of Epi and patient's reported symptoms. Patient refused. Re-educated to the importance of calling 911. Patient refused x 3.  4) Husband presented to drive patient to the emergency room. Re-educated to the importance of calling 911 for anaphylaxis. Patient and husband refused. Husband committed to taking patient straight to Emergency Room, and to call 911 on the way if she gets worse in any way. Patient and husband both agreed to this.  5) Educated patient that she must seem emergent medical attention for anaphylaxis. Educated patient to NOT get second vaccine.  6) (1746) Patient reports her chest tightness has gone from a 6 to a 2 (0-10 scale) 7) Patient and husband v/o and agrees to POC.  8) (1746) Patient left in stable condition, under the care and supervision of husband with plan to go straight to the Emergency Room and to call 911 immediately if anything changes or worsens. 9) Case and chart reported to Medical Director.