Age: 41.0
Sex: F
Vaccine: COVID19
Symptoms: Hypotonia, Malaise, Miosis, Mydriasis, Pallor
Clinical narrative: Patient came with husband to receive first dose Moderna at vaccine clinic. Patient was foreign speaking, LVN translated on her behalf. Patient stated that she was hot and thirsty prior to vaccine administration and was given water by Lead, RN. RN informed Team that was going to a nearby store to get more water to team and patients.   Upon registering patient into vax system, patient stated she had blood drawn (not Covid related) in March where they took 8 tubes of blood in which afterwards she felt sick. Patient was given the 1st dose of Moderna and was seated in observation area for 15 minutes. While patient's husband was receiving his shot of Moderna, patient stated that she was not feeling  well. Nurse, RN stood beside her in the observation area to continue to monitor her. Patient began to place both hands on her head and stated, "I no feel good." She then turned to RN with a blank stare. RN then held patient by her shoulders and asked if she was okay, while LVN translated. Patient began to close her eyes and dropped her head back. RN began to hold onto patient while LVN got water and attempted to arouse patient. Upon pouring cold water patient opened her eyes and said she was okay but then went limp against RN. RN instructed EMT to call 911 and proceeded to arouse patient again, while LVN performed a sternal chest rub on patient.   RN was reported back to clinic site and was informed by team that patient is currently undergoing a reaction. RN witnessed patient's face which was ashen in color and began preforming vital signs on patient. BP: 228/106; HR: 108; O2: 73. RN continue to ask patient to state name and where patient was located, patient was able to verbalize understanding and state name and location. RN proceeded to ask patient (while LVN translated) if she had taken any medications, in which patient's husband stated yes: to Cymbalta and Hydralazine.    Patient began to have minor shakes to the body while her head and eyes rolled back. RN held patient's head as we continued to pour water on her. Patient stated to LVN that she wanted to lie down and go to sleep. LVN informed patient that she will remain in current position that she is in. Patient would become unresponsive for about 5 to 10 seconds, and when she became responsive stated that she would like more water poured on her. Patient's husband informed us that patient battles with depression and anxiety.   While still waiting on EMS who was now on site, but at the front of clinic gate, patient stated that she felt her throat was "closing up." While observing patient RN held patients hands and asked patient to squeeze both hands. Patient was capable of squeezing left hand, but could not fully squeeze her right. RN began to assess and observed patients right eye was drooped and right side of patient's body became flaccid. Areas of patient's body that were dry, were cool to touch, and pupils began to constrict then dilate . RNs continued to have patient talk while awaiting for EMS. RN performed another set of vitals on patient: BP: 206/137; HR: 155; O2: 76.   Upon EMS arrival patient was coherent enough to ask Nurses if we could accompany her to the hospital. Team informed patient that  EMS would be taking her to the nearest hospital. EMS took down patients information and placed patient on Oxygen. RN updated EMS on patients reaction and performed one last set of vitals before transporting patient to hospital. BP: 93/75; HR: 76; O2: 97. Patient remained still weak but able to get from chair to stretcher.   Patient left clinic site and was transported by EMS in stable condition.