Age: 60.0
Sex: F
Vaccine: COVID19-2, SMALLMNK
Symptoms: Dizziness, Fatigue, Headache, Influenza like illness, Nausea
Clinical narrative: On 8/29/2023 at approximately 9:00 AM, client requested Moderna Bivalent Covid 19 vaccine and Jynneos vaccine from team. PHN, educated patient on communicable diseases, gave the patient Narcan and condoms. Team nurse, PHN, RN asked patient for demographic information and confirmed patient's immunization record and vaccine eligibility in electronic database. Upon assessment by, PHN, RN, patient denied history of cardiac issues, pericarditis, and is not immunocompromised. Patient reported history of hypertension, Migraines, COPD, diabetes, gastric bypass, and an "aortic clot" currently being treated with blood thinners. Patient reported anaphylaxis to IV heparin and penicillin. Patient reported Guillain Barre syndrome since 2008, onset 1 day after a vaccine, patient is unsure if it was hepatitis A or influenza vaccine that was given. Patient reported taking the following medications: Keppra, Gabapentin, Protonix, Eliquis, Metoprolol, Methocarbamol, Exedrine, and Tylenol. Patient denied feeling sick today and stated is receiving primary care form local Neighborhood Healthcare Clinic. PHN, sent a medical consult text to Dr at 9:20 am. Per Dr. "Mpox and Moderna approved. If possible observe for 30 min after administration." Patient left to eat breakfast and returned at 9:25 am. PHN, RN, administered Moderna Bivalent COVID 19 vaccine lot #AS7644C in the right arm intramuscularly at 9:30 am. PHN, RN, administered Jynneos MPOX vaccine lot # FDP00015 in the left arm subcutaneously at 9:31 am. PHN, educated client about 30 minute observation time, patient walked off at 9:35 am to smoke a cigarette outside and stated she would return to check in. Patient reported living at Facility and is completing the substance use treatment program, 1 week out of detox. Patient returned to the foot team table at 9:55 am stating she felt nauseous, dizzy, had a headache, and "flu like symptoms." PHN, RN, assisted client to lay down on the yoga mat and PHN, placed an ice pack on the patient's forehead. Patient alert and oriented to person, place, time, and situation. Patient's skin was dry, appropriate for Ethnicity, and had no rashes or hives upon observation by PHN. Patient reported she felt better after laying down with an ice pack. At 9:59 PHN, sat patient up and offered her some juice. Patient took two sips and stated she "felt worse" again and laid back down. Patient gave permission for PHN, to take her vital signs at 10:00 am. BP 110/68 (right arm), 98% SpO2, RR 28 (not labored upon oservation), HR 81 bpm, regular rhythm assessed by palpation. At 10:05 patient reported radiating pain up the right ride of her neck and into her head, reported head pain at 9/10. Patient denied numbness and tingling. Patient reported she has migraines and was having one start before vaccines were given. PHN, covered client's eyes with a mask per patient's request. Patient gave permission for PHN, to take her vital signs at 10:05 am. BP 108/65 (right arm), 98% SpO2, RR 24 (not labored upon observation), HR 88 bpm. Patient gave permission for PHN, to take her vital signs at 10:10 am. BP 112/70 (right arm), 99% SpO2, RR 20 (not labored upon observation), HR 77 bpm. At this time patient reported headache was "getting better" and pain was 7/10. Patient reported feeling relaxed and "tired." Patient gave permission for PHN, to take her vital signs at 10:15 am. BP 98/63 (right arm), 98% SpO2, RR 16, HR 75 bpm. At this time patient reported neck pain has resolved and headache pain was now 4/10. Patient reported dizziness was gone, but continued to feel slightly nauseous. At 10:19 am PHN, offered more juice. Patient drank one sip of juice, it was well tolerated as patient lied back down. Patient gave permission for PHN, to take her vital signs at 10:20 am. BP 105/70 (left arm), 98% SpO2, RR 16, HR 73 bpm. At 10:24 PHN assisted client to sit back up and offered her the rest of the juice. Patient denied any nausea, dizziness, headache continued at 4/10. Patient's skin was dry, appropriate to Ethinicty, and no rashes were observed. Patient denied chest pain or other discomforts at this time. Patient gave permission for PHN, to take her vital signs at 10:25 am. BP 110/80 (left arm), 99% SpO2, RR 16, HR 81 bpm. PHN, assisted patient to stand up at 10:38 am. Patient gave permission for PHN, to take her vital signs at this time. BP 120/78 (left arm), 98% SpO2, RR 16, HR 86 bpm. Patient stated was feeling better, denied nausea, dizziness, and neck pain never returned. Patient reported it feels like "my migraines." At 10:37 am PHN, walked with patient back to her program next door and alerted the program manager together. Plan in place for patient to follow up with Neighborhood healthcare primary care provider in 24 hours. Patient walked off at 10:45 am with steady gait and balance.