Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Erythema, Feeling hot, Flushing, Heart rate increased
Clinical narrative: Covid19 clinic site.  Nov 9, 2021, 10:50   Patient is at clinic, and is here for her 3rd moderna booster vaccine. Patient approx 13min 45 sec, after her vaccine admin was seated in observation area, when she drew the attention of the nurse on duty.  RN was the staff nurse on duty.   Patient was found seated, alert and responsive. Patient appeared flush, with mild facial redness, patient was able to speak, and answer the nurses questions. Patient stated that she felt hot, and that her heart felt fast. Patients radial pulse was noted above 100bpm at the right wrist, 3+, and Resp at 23, no facial edema was noted. Patient was escorted by the nurse to an area further away for patient privacy and treatment. Nurse instructed patient to remove her mask at this time.  Time was noted as 1055,  Assessment> AxO4, Perral, EOMS. No facial edema, Patient able to maintain own airway, and speak clearly, and answer nurses questions. No strider was noted, no wheezes noted, Facial flushing, and mild redness was noted. Eyes remained clear and not watering, no edema, no puffiness, Patient was able to hear the nurse and responded clearly, no s/s of stroke noted. Patients neck was free of edema, and no JVD, Patients breathing remained at a rate of >20, with a radial pulse of over >100, with a cap refill <3sec, no LE edema, was noted, LE pulse was equal to radial pulse, and was noted at 2+ on assessment. Patient second finger on her right had was used to gain a pulse ox reading, and it was >98% with a pulse noted >100, at this time 2 cooling packs where applied to the patients back area, calming methods where used to reduce patient anxiety, and provide for patient comfort. Patient remained calm and affect was pleasant. Patient stated that she had been a science teacher for 20+ years, and started in her late 30's and is currently retired. Patient was able to clearly give a good hx and was up to date on current events, time, place, and person, dob, and age. Patient was able to use abstract thought process during assessment. Patients vital signs where constantly monitored during patient assessment, and patient vital signs remained stable and trended down to within mid normal ranges.   Vitals: 1055 Pulse 96, R21, 99% RA, 112/82, radial pulse noted at 2+, LE pulse noted 2+ and equal to radial. 1110 Pulse 86, R16, 98%RA, radial pulse matched pulse ox, and 2+ 1115 Pulse 76, R15, 97%RA 1118 Pulse 61, R15, 97%RA, 112/82 same B/P noted twice.  1122 Pulse 84, R14, 99%RA   Second assessment  AxO4, affect pleasant, EOMs, Perral, facial redness appears less, and patient is no longer flush. Radial pulse 2+, Apical pulse matched vitals charted, and no extra heart sounds noted, airway clear, airway patent, breathing equal rise and fall of chest, and no reported c/o SOA/SOB, lung sounds are clear all fields, and no noted wheezing, or strider noted with airway. Patient has no edema noted.   Patient reports she is feeling better. Patient is given opportunity to walk approx 100 yard, and is monitored by the nurse with no gait issues, no c/o of soa/sob. Patient states she feels ok and can go home. Patient is advised to contact 911 if she has any s/s of shortness of breath, difficultly breathing, or feels like she having any serious reaction. Patient education on serious reactions is given. Additional patient teaching is performed on patient safety, and is advised to have a friend or family member if possible to contact/stay with. Patient leaves site.