Age: 49.0
Sex: M
Vaccine: COVID19
Symptoms: Eye pruritus, Hypersensitivity, Migraine, Pruritus, Rash erythematous
Clinical narrative: Client (received the COVID vaccine (Pfizer dose 2, lot # EW0187, expiration 6/28/2021) at 1800. At 1829, the client reported itching on his skin and in his throat. EMT, EMT #2, PHN, and RN responded at this time. The client was sitting comfortably in his chair, alert and oriented x4. The client's vital signs were as follows: heart rate 57, O2 97, respiratory rate 14, blood pressure 150/92. The client's skin was pink, warm, and dry. The client denied any shortness of breath or chest discomfort. The client was able to speak in full sentences and had no visible swelling on his face or tongue. The client declined Benadryl at this time. The client stated he has environmental allergies and has had an anaphylactic reaction to trees in the past. The client stated he has a medical history of anxiety, acid reflux, migraines, and hay fever; he takes antacids, sumatriptan, and allegra. The client stated that he took 1 allegra at 1816, but stated he didn't know the exact dosage and did not have the medication bottle with him. The client was able to speak in full sentences. At 1835, the client identified a small, red, erethematous area approximately 1 centimeter in length on the left medial area of his elbow, which he stated itched. He also stated his eyes were itching; neither eye or eyelid appeared red. The client stated his throat was dry and was offered and accepted water. The client declined Benadryl again at this time. The client was transferred to the zero gravity chair at this time, denied any dizziness during ambulation or transfer. At 1839 the client's vital signs were as follows: blood pressure 142/84, heart rate 74, O2 97%. The client stated "I had an itchy throat this morning" and said that he had a migraine that morning but did not remember if he had taken any medication for the migraine. At 1849, the client's vital signs were as follows: blood pressure 122/84, heart rate 73, respiratory rate 16, O2 99%. At 1853, the client stated "I feel less itchy." At 1900, the client initially requested Benadryl, but then refused both the medication and vital signs when offered. The client stated that his arm "still itched" but denied that it was getting worse. The client stated "I wanted a Benadryl for the road but now I think I'm going to wait." The client denied shortness of breath, chest tightness or pain, or any difficulty breathing. The client did not appear to be in any distress and had no swelling visible on his face or tongue. The client continued to chat with staff and spoke with a pleasant demeanor. Education provided by PHN, EMT, and RN regarding primary care follow up and when to seek medical care. At 1915, the client requested Benadryl and stated "I think my rash is growing." The client's vital signs at that time were as follows: blood pressure 138/92, heart rate 88, O2 99%, respiratory rate 12. At 1922, the client was given 50mg Benadryl orally. At 1927, the client stated "my wife is here, it's time for me to go." RN  reiterated the importance of staying for a 30 minute observation time, but the client continued to leave the building. EMT accompanied the client outside, where he ambulated with a steady gait. He walked to the outdoor observation area and then sat down, requesting to be evaluated by EMS. EMS was called by RN at 1933. The client was sitting comfortably and denied any shortness of breath or chest pain. EMS arrived on scene at 1936. At 1938, the client's vital signs were as follows: blood pressure 140/90, heart rate 60, and O2 100%. The client stated at that time that he "felt better" and declined transport to the hospital. The client signed AMA paperwork at 1945 and ambulated to his car with a steady gait, accompanied by his wife, who he stated was going to drive him to an urgent care.