Age: 73.0
Sex: F
Vaccine: COVID19-2
Symptoms: Injection site irritation, Paraesthesia, Pruritus
Clinical narrative: Client presented to Covid Vaccination Site on 10/05/2022 requesting a Pfizer Bivalent booster upon receiving her primary series of Pfizer along with two monovalent boosters of Pfizer. At 1638 client received a Pfizer Bivalent booster Lot# GJ3277 on left arm by nurse. At 1641, client was sitting down in the observation area when she reported to nurse that she was feeling ?sweaty.? Lead nurse and nurse proceeded to sitting client in the gravity chair. Client was able to walk from regular chair to the gravity chair. Client reported to Lead Nurse, feeling tingling sensation on left arm. Client is alert and oriented to name, DOB, and situation. Nurse observed no redness or inflammation by the injection site. Client denies any itchiness, dizziness, difficulty breathing, and pain at this time. Client reports no adverse reactions to previous four Pfizer vaccines other than feeling tired after vaccinations. Client also reports not having anything to eat throughout the day other than breakfast around 10:30 am. Client was offered water and was able to swallow. Per client she does not take any medications, has a history of high blood pressure but no longer takes medications for it. Client reports a history of allergic reaction to Dilaudid when she was in the hospital, and that all she remembers was that she ?couldn?t breathe?. Client also reported having ?spasms? when taking Morphine, and ?swelling of tongue, purple spots all over the body? when taking Penicillin. Vital signs were taken by nurse at 1642; BP: 156/91 mmHg, HR: 73, RR:18, O2 Sat: 98. Per client her blood pressure was reading high. She reports her blood pressure is usually below baseline. At 1646 client reported, ?I have a headache from side to side.? Client denies any itchiness, difficulty breathing, and dizziness at this time. At 1646 vital signs were taken by nurse; BP: 139/92 mmHg, HR:78, RR:18, O2 sat: 98. At 1713 vital signs were retaken by nurse; BP 148/104, HR:75, RR: 18. At 1658 client reported to Lead Nurse, ?I feel spasms on left arm.? Lead nurse called emergency at 1659. At approximately 1708 fire department arrived to the facility and care was transferred over to paramedics. Client refused to go to the hospital after given the option by paramedics. At approximately 1711 paramedics left the facility. Client was asked by Lead Nurse if someone can pick her up, and client states she lives alone and no one can pick her up. Client reports, ?I still have a tingling sensation on tip of my thumb but it has decreased.? Lead nurse educated client that tingling sensation on thumb is not a common symptom and that if it does not go away or if it progresses to call emergency and go to the hospital. Lead Nurse also advised client on what to look for as far as adverse effects and to immediately go to the hospital either by calling emergency or having someone else take her. Lead Nurse educated client on possible side effects from the vaccine. Client verbalizes understanding on instructions given by Lead Nurse.  At approximately 1716 client left the facility with a steady gait. At 1717 Lead Nurse called Clinical Supervisor to make her aware of the situation. Clinical supervisor advised Lead Nurse to call client to make sure she arrived home safely. At 1800, Lead Nurse called client via county phone. Client answered and reported she arrived home safely but that her left arm at the site of the injection was ?irritated? and stated ?I feel itchy all over body.? Client denies any rash, swelling of face, and difficulty breathing. Lead Nurse educated client that itchiness all over body might be a possible allergic reaction and that it could progress to something more severe like an anaphylactic reaction. Lead Nurse instructed client to call emergency. Client verbalized understanding and stated she was going to have dinner first and if she felt anything worsening should call emergency.