Reporte zur Charge 022C21A-HRSA

Symptomtext

Patient presents to clinic as Walk-In. Pt was scheduled on 5/12/21 to receive her 2nd COVID vaccine Per Immunization note, patient received vaccine 5/12/2021 at 9:47:19 AM. Patient reports symptoms began about 5 minutes after receiving dose. Patient reporting initially feeling dizzy and then beginning to feel short of breath with an onset of chest pain. RN went to check on pt in observation area and decided to Triage her in the RM. Pt was alert and oriented x4 and speaking clearly, though having difficulty catching her breath. Pt pink in color, warm to touch, lips pink. Pt?s color appropriate for race. Pt was then escorted to Triage RM 1 via wheel-chair by I. RN who assisted her into the wheelchair. At 9:50am we checked the patient?s Vital signs: Blood Pressure: 160/104 , Heart Rate : 89 beats per minute. Pulse oximeter : 99%. No signs of edema or face or tongue swelling. EKG performed per Dr. and Report given to another Dr. who decided against giving any medications to pt at this time. -Pt reporting that she is feeling Short of breath and feeling palpitations in her chest. -Pt is reporting having Chest Pain 10/10. -Pt reporting feeling dizzy and lightheaded. -Pt reporting having ?starry vision? and having difficulty focusing her vision. -Pt reporting feeling pulsating pain in her right knee that radiates up her body to her neck. Pt reports rating pain an 8/10. Pain worsens when pt?s right knee is touched. Pt reports that her veins in her right knee feel ?full? and like ?blood isn?t passing through?. -No signs of edema or face or tongue swelling Patient?s breath sounds are clear, bilaterally, auscultated anterior and posteriorly, upper and lower lobes. Time: 10am ; Blood Pressure: 166/115 Heart Rate: 90 Pulse oximeter: 99 Point of Care completed. Blood Sugar checked and was 121 mg/dL. Time: 10:01am: Complete Neurological exam check performed. -Patient alert and oriented x4. - Patient able to breathe on their own but feeling short of breath still. Pt on room air. - Patient able to smile and frown equally bilaterally. - Patient?s speech is purposeful and clear. No slurring. - Patient able to lift upper bilateral extremities for 10 seconds at heart level. No arm drift. - Patient able to grasp and squeeze Nurse?s hands with equal strength bilaterally. - Patient able to push back and forth against Nurse?s arms with bilateral lower extremities. Strength equal bilaterally. -Bilateral upper and lower extremity pulses examined. All Pulses equal and rated +3 (Normal). -No signs of edema or face or tongue swelling Time: 10:10am Blood pressure: 159/105 ;Heart rate : 91 beats per minute ; Pulse oximeter : 99% Paramedics entered the RM at 10:11am. Report given to Paramedics including a cover sheet, list of medications and copy of EKG. 10:20am: Pt at this time is complaining of painful headache that feels like something is squeezing her head. Pt also reporting feeling pulsations in her neck. Pt declines feeling chest pain anymore. Pt reports that feeling short of breath and the new onset headache are her most prominent symptoms, besides still feeling dizzy and having ?starry? blurry vision. Paramedics leave with Pt to hospital at 10:25am. Pt awake and alert and speaking clearly and purposefully. No signs of edema or face or tongue swelling at any point.