Age: 39.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Dizziness, Throat tightness
Clinical narrative: A (L.V.N.), L.V.N.    Start Time 7/19/2021 11:36 AM      Filed at 7/19/2021 11:37 AM  Status: Signed    Patient is a 39 year old female presents requesting vaccination for COVID-19. Patient's identity was verified utilizing two patient identifiers. Allergies reviewed and pt. has no history of severe allergic reactions.    Patient received EUA fact sheet and was given opportunity to ask questions: Yes Pfizer-BioNTech COVID-19 vaccine # 1 in series administered, see Immunizations activity for vaccine details. Injection site: left deltoid. Administered by, LVN  . See Immunizations activity for vaccine details. Patient tolerated well and agrees to remain for observation period to monitor.    Patient 39 year old is female will be observed for 15-minute period for signs and symptoms of adverse reaction.  Follow up information provided:  verified second dose date is on vaccine administration card and reminded patient to keep card with them, appropriate home care per vaccine EUA fact sheet for any possible side effects and second dose appt date   Future Appointments Date Time Provider Department Center 7/19/2021  2:20 PM E48 COVID VACCINE PFIZER ELCOV E48U 7/20/2021 10:00 AM (M.D.), M.D. ELFM04 E48U 7/21/2021  2:00 PM   (P.A.), P.A. L3ORP1 LA3U 7/28/2021 11:15 AM (P.A.), P.A. L3ORP1 LA3U 8/9/2021 10:40 AM E48 COVID VACCINE PFIZER ELCOV E48U 8/16/2021  8:10 AM (L.V.N.), L.V.N. ELFAMA E48U     LVN 11:36 AM 7/19/2021      (R.N.), R.N.    Start Time 7/19/2021 12:01 PM      Filed at 7/19/2021 12:02 PM  Status: Signed    Benadryl 50mg Rd 1147am  Epi 03.mg  right thigh   R.N.), R.N.    Start Time 7/19/2021 12:27 PM      Filed at 7/19/2021 12:27 PM  Status: Signed    1147 VO Dr. Benadryl 50 mg IM, given RD.   Electronically signed by: RN 7/19/2021 12:27 PM    (R.N.), R.N.    Start Time 7/19/2021 12:11 PM      Filed at 7/19/2021 12:56 PM  Status: Addendum      Patient is a 39 year old female who was completing - 15minute observation period with the following signs and symptoms of an adverse reaction: Pfizer #1  in series  Was administered administered at 1137 am today .  10 minutes after the vaccine patient reported feeling slightly dizzy to nurse and then started feeling tightness in throat. Patient alert and oriented but was very anxious and also was feeling anxious that her son had a HX of epilepsy and wanted us to make sure to keep an eye on him, son 13 yr old and daughter 16 yr old accompanied patient today    o Action(s) taken: vital signs done and at 1138 am, RN STAT called @1140 , MD STAT called Dr. @ 1143 o Allergy to COVID-19 vaccine documented in Allergies activity:  o Patient advised to discuss second dose considerations with a clinician   RN     o The patient had the following:  § sensation of throat swelling or throat closing in conjunction with other symptoms(s) as above, patient felt lightheaded and was shaky, no visible swelling noted around face, or LIPS.    ? Administered epinephrine and Benadryl 50mg per Verbal order MD and  Given at 1147 am  Patient was placed on Oxygen 3 liters via mask at 1205 pm Patient reported that she had a reaction in past to Solumedrol at an outside facility around 09/2020, Solumedrol not given .  ?   ? Activated local emergency response plan. YES at 1150 am § Transferred to external Emergency Department (ED) arrived at 1202 pm , LAFD TEAM 3  Paramedics .  Patient left with paramedics and belongings at 1209 pm.  Pts husband was notified, patient also called her mother and pts daughter took patient car keys.    §   DONE: Order DR ADVICE ALLERGY [241092].  § Associate order with diagnosis code, VACCINATION FOR SARS-COV-2 [659210].  o Patient was observed for 45 minutes total time at clinic ? Order DONE  DR ADVICE ALLERGY  § Included "COVID-19 vaccine allergy" in order comments.     Encounter Blood Pressures and Pulses from 07/17/21 1246 to 07/19/21 1246    Date and Time BP Pulse BP Patient Position BP Location Cuff Size 07/19/21 1234 171/89(Abnormal)  105 SITTING RA-RIGHT ARM Large Adult 07/19/21 1159 182/88(Abnormal)  112 SITTING RA-RIGHT ARM Large Adult 07/19/21 1150 179/92(Abnormal)  100 SITTING RA-RIGHT ARM Large Adult 07/19/21 1145 211/101(Abnormal)  138 SITTING RA-RIGHT ARM Standard Adult          Orders Placed This Encounter ? Dose #1 - VACC COVID-19, MRNA, LNP-S, PF (PFIZER-BIONTECH) ? Dose #2 - VACC COVID-19, MRNA, LNP-S, PF (PFIZER-BIONTECH) ? DR ADVICE ALLERGY ? MEASURE PULSE OXIMETRY ? ADMINISTER O2 BY NASAL CANNULA ? EPINEPHrine Inj Syg 0.3 mg (ADRENACLICK/EPIPEN) ? diphenhydrAMINE Inj 50 mg (BENADRYL)