Age: 56.0
Sex: F
Vaccine: FLU4, MMR
Symptoms: Vomiting
Clinical narrative: Pt presented to the clinic today for MMR and influenza immunization. Immunizations were administered by RN. "Pretty quick" after the immunizations were given, the patient walked to the reception desk. States while talking with the receptionist she started to develop: -sweat -feeling warm -foggy hearing -not feeling right -felt like she was going to pass out. Sat down in waiting room chair. Was taking deep breaths, but symptoms worsened. RN obtained wheelchair to bring patient back to exam room. Pt appeared pale, was responding to commands, but her eyes were closed, stated she was nauseous. RN and I transferred pt to exam table and during transfer pt was unable to assist us. She had a syncopal episode that lasted a few seconds.    Within a few seconds of being laid in the L lateral decubitus position the pt was fully alert and proceeded to have small amount of brown emesis.    Exam: Initial BP after episode of emesis was 88/62.  Afebrile. HR normal. Normal respiratory rate. When laying supine the patient's color returned to normal.  She had normal speech. She was alert and oriented.  Heart was RRR without murmur. Lungs were CTA bilaterally.  No oral or intraoral swelling. Normal phonation.  CN 2-12 grossly intact.  She was provided with a cool cloth, remained supine or laying on her side on exam table, was given emesis basin. She has been laying on exam table for approx 25 mintues. Still feels chilled and slight nausea.  Pt drank some water. After another 20 min  she was provided with juice. Within approx 40 min she had another episode of emesis.  She continued to feel chilled. Symptoms of orthostasis resolved.  Third BP reading prior to discharge was 110/72. Pt was ambulatory.  Gait was normal.  Nausea was improved but still present. I recommended she be evaluated in the ER.  I offered to call paramount for transport but pt and her sister declined. They preferred that the sister drive her. Because she was ambulatory and no longer hypotensive, I agreed.   She denied chest pain, DIB, wheezing,    PMhx: has h/o R hip "goes out" treated with chiropracitc care; is asymptomatic the large majority of the time but approx 4 times a year she goes to chiropractor "if it starts to feel like it's going to go out again". Has h/o bilateral knee soreness. Syncope in a hot shower once remotely.   States she does not like to look when getting her blood drawn but has never syncopized or had near syncope following blood draw or when receiving immunizations. Has never had influenza vaccine. Is uncertain if she has had MMR immunization in the past. States she was hesitant and nervous to receive immunizations today. PShx: cholecystectomy Meds: none Nonsmoker Denies etoh use   Pt was discharged in the care of her sister. Plan is to have them drive her to the ER for further evaluation and fluids.  *I called the patient to check in with her, approximately 2 hours after she left our clinic and she reported she had mild nausea, but was otherwise doing better.  I called her again, the following day around 11am and she reported that she was feeling much better. She stated "I feel about 95% better."  She ate breakfast as she normally would and tolerated it without issue.  She was at work when I spoke to her.