Age: 26.0
Sex: M
Vaccine: COVID19
Symptoms: Headache, Loss of consciousness, Neck pain, Syncope
Clinical narrative: Written by Doctor: April 7, 2021 2:09 p.m. DOB 2/07/1995, male, received his second dose of Moderna Vaccine (Lot 019B21A) at 1:13 p.m.  He stood up and walked to the usher?s table to have his vaccine card completed.  Approximately one minute after receiving his vaccine, he had a syncopal episode falling directly backwards striking his head on the floor.  I, MD did not directly witness the fall, but everyone who witnessed the fall said that he fell completely unimpeded to the floor.  I was notified and immediately assisted the patient who was with his girlfriend.  Patient initially appeared ?out?, but almost immediately opened his eyes and asked what happened.  His skin was cool and clammy.  A pulse oximeter was placed on his finger registering 98% o2 and a pulse of 53.  I kept him lying on the floor until he was completely awake and aware of his surroundings.  At the time he said his neck was not sore, but his head was sore.  Approximately 2-3 minutes later, we were able to assist him in standing to immediately sit down in a wheelchair.  He was taken to the cot in the hallway just outside the Medical Observation where I was able to help him to stand and then lie down.  An icepack was provided to put on the back of his head, he was provided water, Gatorade, and two cookies.  Patient said that he hadn?t eaten all day and had been feeling slightly hungry prior to his vaccination.  I had patient move all extremities and asked his questions to verify that he was full awake and oriented to person, place, and time.  Patient girlfriend  stayed with patient while he ate his cookies.  I addressed my concerns about patient striking his head on the floor and the possibility of a closed head injury.  Girlfriend felt that patient was now completely back to his normal state of mind.  I had patient remain lying down for 20 minutes.  When I returned to check on him, he was sitting up and wanted to leave.  I told him that he needed to be able to walk up and down the hallway before I would feel comfortable letting him leave.  He stood up and walked halfway down the hallway before saying he was lightheaded.  I immediately went to him to lead him back to the cot, but he insisted that he needed to use the bathroom to urinate.  Both girlfriend and I stood in the doorway to assist patient if he needed, but he was able to finish urinating, then returned and sat in the wheelchair.  I spoke to both Doctors via a phone call and had spoken to someone earlier.  After letting them know that patient did not want an ambulance called, but I was going to strongly recommend he go to the nearest ER before returning home, I returned to the patient.  Vital signs at 1:53 were Pulse Ox of 98%, pulse 78, and blood pressure sitting of 140/75.  Again, I strongly recommended that girlfriend drive him to an ED for an evaluation and possible cat scan.  Patient also now had some paracervical neck pain which I also said should be evaluated.  Patient and girlfriend both insisted they didn?t want an ambulance called and girlfriend felt comfortable taking patient out of the clinic.  Patient said he was hungry, and they were going to get food first.  Girlfriend gave me her phone number (xxx)xxx-xxxx and I gave her my phone number (xxx-xxx-xxxx).  I told her I was going to call her every hour to check on patient and told her to call me at any time.  I recommended acetaminophen for the headache and other vaccine symptoms but no ibuprofen because of the possible head injury.  I recommended to immediately call an ambulance or go to an ED for nausea, worsening headache, confusion, or drowsiness.  Girlfriend is not to let patient sleep longer than 30 minutes at a time.  Patient was able to walk out of the clinic easily under his own power without any assistance.  He stated he was feeling much better.