Age: 46.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Dizziness, Dysphagia, Dysphonia, Feeling abnormal
Clinical narrative: 16:03: Vaccine Administered 16:13 Patient received there 2nd COVID vaccine and was monitored. After 10 minutes the patient demonstrated that she started the" I feel different, I am having tingling in my throat and it feels very different then it did before." She reported feeling dizzy and nauseous. She declined lying down. Pts vital signs were obtained HR 104, 99% O2, BP 138/88. Pt was given a sip of water and advised that she would remain in the clinic for additional monitoring. I advised the I could administer an Epi-pen and call the paramedics which she stated she didn't want at this time as she has never needed something like that before.   1633 - Patient was reassessed for vitals 132/88 BP, 99% O2 and 87 HR. Pt stated that she feels like her tongue is weird maybe swollen and it still feels weird to swallow, she isn't anxious but has a bit of a groggy mental haze. She stated that she feels weaker then usual and has a pressure in her head. I called Dr. and got permission to administer 25mg of Diphenhydramine orally. Pt stated that she has taken this medication before and that she will be safe to drive after taking this medication. Pt was advised that she would be monitored for another 20 minutes to ensure that the medication kicks in and symptoms start to resolve.   16:52pm 132/92 BP, 99% O2, 88HR. Hoarse voice, scratchy throat tongue is improving doesn't feel as swollen. Pt was evaluated by Dr.  17:26 Patient was discharged and advise to closely monitor her symptoms for the next 3 hours.   I received a call saying that patient was having some tingling in her lips and tongue and slight nausea. She was given 25 mg oral Benadryl by the RN. The patient was monitored for approximately an hour with serial vital signs. I briefly assessed this patient. She reports feeling some tingling in her lips with improvements in tingling in her tongue. She also reports feeling warm. Patient states that her throat feels scratchy and she feels like she has to clear her throat. Her heart sounds were normal and she has a normal respiratory effort and lungs clear to auscultation. No tongue swelling or posterior oropharynx swelling. Posterior oropharynx is pink and moist. Patient was advised that she is most likely having a reaction to the COVID vaccine. Patient should continue to monitor her symptoms at home. Patient states there will be someone at home with her. Patient was advised if she has any worsening symptoms such as tongue swelling, shortness of breath, chest pain, palpitations, body wide rash or throat swelling that she should report to the emergency department or call 911. Patient is advised that she can take another Benadryl. She was given 25 mg of Benadryl around 4:00 PM. Patient is advised that if her symptoms do worsen she can take another 25 mg of oral Benadryl in the next four hours. If she is on her way to the hospital or waiting for an ambulance she should take another Benadryl. Patient was also advised to take over-the-counter allergy medicine such as Claritin or Zyrtec for a couple of days. She is to call the clinic with any questions. Patient verbalizes understanding and has no further questions.