Age: 30.0
Sex: F
Vaccine: COVID19
Symptoms: Crying, Dizziness, Headache, Hypoaesthesia, Malaise
Clinical narrative: April 6th, 2021     Today at about 2:43pm, one of our technicians came to me and stated that a customer (employee too) had just got her second COVID-19 shot (Moderna), and she was at her car and not feeling well. The patient's co-worker had told us that her finger tips were numb and that she had a headache. The technician asked the customer to come back in, which she did and sat down in a chair immediately in front of me. I went directly to talk to her, as another technician was helping in the clinical services room, drawing up more shots.       I asked the patient how she was feeling, and what she was feeling.  She said she did not feel well, that her finger tips were numb, and she had this incredible pounding in the back of her head, and she ran her hand over the lower back part of her head and neck.  She looked down and I asked her again how she was doing, she said not well, that she was beginning to get light headed and was looking a little pale.  I called to the pharmacy team for help, to clear out the clinical services room and asked the technician to help me slowly walk her to the room.  As we got her in the room I asked her if she would be ok to lay down on the floor and put her feet up in a chair, briefly explaining that this would help with the dizziness and keep her safe should she faint, because she would already be on the floor. another technician popped in and asked her if she could get her a cold cloth for her forehead, Patient said yes and the technician did so. an employee was working at the computer and just quietly stayed working (for another store).  I moved around him and got the Blood Pressure Machine.  I asked the patient if it would be ok it I monitored her blood pressure, she said yes. Patient was always 100% coherent and helped move her arm for me. I asked the employee for a piece of paper to document the reading, but the technician ran and got me one.  Her first set of vitals were high.  I marked them down and the employee told me the time.  I just sat on my knees next to the patient for a while and tried to comfort her. I asked her a couple of times if she felt any change, and she said yes,     Shot given 2:40pm     2:45pm BP 149/99 Pulse 71   SX:  fingers numb, pounding in the back of her head  cool cloth placed on forehead  calmed area down & quietly talked to the patient to determine how she was doing  ************************************************  (Patient volunteered that she had just gotten tested for COVID-19 and that she tested negative.) I asked patient how she was feeling and she said that she was feeling a little worse.  She said she was starting to get the shakes.  I asked her if she had gotten anything to eat on her lunch and she said no. I asked her if she felt like it and if her BP was good, how would she like a sip of juice.      ********************************************     I asked the patient how she was feeling and she stated that her tight felt ever so slightly tight, but she said "I am asthmatic, and it did not feel any different than what she had experienced before.   I took her BP/P again...  2:55pm BP 157/105 Pulse 68  I looked at the employee and he looked at me, and I told the patient that I would be right back.  I quickly went and consulted with the technician and we decided that we should call 911 due to the increased in BP, pulse lower and the change in symptoms.  The technician called 611 and talked to an employee and I called 911 and explained what was going on and what our need was.  (The technician and I quickly discussed that neither of us felt that she was having an allergic reaction, just an adverse reaction, Epi was not called for. ) Employee stated that the clinic recommended we give her Benadryl.  I did a fast check w/ the technician, it was not on our standing order/ protocol. Antihistamines can exacerbate asthma.) Then I went back to the patient.  By the time I had gotten off the phone with 911, 2 more employees were in the room, and the patient was just getting off the phone with her father.  Once I got positioned in the room, one employee left,  I asked one employee sit down in a chair and the other employee was by the door leading to the pharmacy.  I told the patient that we had called for an ambulance.  I briefly explained due to her BP/P and her symptoms changing.  I asked her if she wanted another cool cloth and she said yes.  I asked an employee to get one for her from the sink in the pharmacy.  I was again kneeling at her side.  I saw her eyes well up with tears and a few tears were running down her face.  I asked another employee to get me a paper towel, which he did, and I handed it to the patient.  I tried to reassure her that things would be ok and this was just to ensure that she was safe.  She stated that she felt a little nauseated.  I then took her BP/P again.  3:05PM  BP 146/99 P 66 2 employees and I remained with the patient, all calm and I made sure she knew we were there for her.  I am not sure the time the EMTs arrived, but another employee let us know and we opened the door to let them in.  They asked the patient a lot of questions and I gave them my sheet of what I had recorded for her blood pressure and pulse (BP/P).  They asked the patient if they would help her into a sitting position, she said yes, but it was an awkward position, so I asked the patient if it would be ok if I helped support her back, she said yes, and I did just that.  I stayed with the patient until they got her situated on the gurney and I helped cover up her legs.  I went back to work when the EMT's wheeled the patient away.     The BP/P is the best of my recollection, as the EMT's took my sheet of paper.     At no time did the patient ever exhibit difficulty breathing, labored breathing or any change in her breathing.  She was calm and her chief complaint was the numbness in her fingers and the pounding headache at the back of her head.