Age: 51.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Cardiac flutter, Cold sweat, Feeling cold, Headache
Clinical narrative: Patient received the 1st COVID vaccine ( Pfizer, lot # EW0185, use by 06/24/21 at 0845) at 1313. Client reported to EMT that she felt a headache coming on, and was a little nauseous. The client was given a bottle of water and RN was notified immediately. RN assisted the client to the anti-gravity chair, was placed in a semi-fowler's position, while RN assessed the client.  The client was alert and oriented x 4. Vital signs were taken simultaneously at 1400, HR- 84, RR-16, BP-158/90, oxygen saturation at 98%. At 1402 the client stated, " My headache is a little better and my nausea is gone." Denied shortness of breath, chest pain, difficulty swallowing, lightheadedness, or feeling flushed. Denied drinking much water prior to coming to the site. Vital signs taken at 1405, HR- 86, RR-16, BP- 160/88, oxygen saturation at 99%. Client reported having an allergic reaction to codeine (anaphylaxis) and having type II diabetes mellitus, asthma, and a heart murmur. The client reported currently taking singulair, victoza, trulicity, lantus, metformin, and fenofibrate. Vital signs taken at 1410, BP- 160/88,HR-87, RR-16, oxygen saturation at 98%. The client was speaking in full sentences and was in no apparent distress. The client continued to drink water. The client reported not seeing a primary care provider for over a year. Denies any vision changes, headache, or lightheadedness. Vital signs taken at 1415, BP- 160/ 88, HR- 86, RR-16, oxygen saturation-98%. RN educated the client about V-safe, Emergency Room precautions, and to follow up with her primary care provider. RN advised the client to stay on site until 1430. The client stated, " I might be a little anxious, I'm sorry, I'm not trying to be a bother." The client was reassured to always tell the medical personnel on site if she felt unwell in anyway. EMT and PM remained in the observation area. At 1431, the client stated, " I feel a flutter in my chest that feels bounding." The client was cold and clammy, RN called 911 immediately at 1431. Vital signs taken at 1431, BP- 156/84, HR-83, RR-18, oxygen saturation- 99%. The client remained in the semi-fowler position, was alert and oriented x4, and was speaking in full sentences. Denied difficulty breathing, vision changes, shortness of breath. No rash or hives were present. Vital signs taken at 1436, BP- 140/88, HR- 80, RR-16, oxygen saturation- 99%. Client stated, " The heart fluttering is feeling better." The client was no longer cold or clammy. Vital signs taken at 1441, BP- 142/88, HR- 82, RR-16, oxygen saturation- 99%. EMS arrived on site at 1443. The firefighter/paramedic assessed the client, had the client stand up from the anti-gravity chair, asked her how she felt, and she stated, " I feel a lot better." The firefighter/ paramedic asked the client if she still had the fluttering sensation in her chest, the client stated, " No." The EMS team did not complete a set of vitals or complete an EKG on the client. The firefighters left the site at 1447.  RN re-educated the client about following up with her primary care provider and educated the client about emergency room precautions. Client ambulated to her car where her family members were waiting for her, she had an even and steady gait.