Age: 14.0
Sex: F
Vaccine: COVID19
Symptoms: Hypersensitivity, Injection site urticaria, Throat irritation, Throat tightness, Tremor
Clinical narrative: Patient received her second dose Pfizer COVID vaccine (Lot#FL3209 exp: 06/30/2022) on 1/23/22. Patient alerted RNs and stated she felt tightness in her throat and was shaking a lot. Patient was accompanied by her Grandma. Grandma stated that patient had finished her 15 minute observation and as soon as they got in the car patient stated that her throat "felt weird." Grandma then decided to bring patient back to vaccination site from their car. RN took patients vital signs at 1222. BP: 146/84, HR: 84, O2: 98%. Patient stated her "throat felt weird." RN retook patients vital signs and reassessed patient at 1227. BP: 137/82, HR: 105, 02: 99%, RR: 16. Patient was shaking and there was noticeable hives around the injection site on left arm and on the left side of her neck. Patient stated that she felt her "throat was tight." RN assessed patients respiration rate at 1231 RR: 16. RN called EMS at 1227. RN called Vaccine Operation Lead asked if it was okay to give minor Benadryl without parent present. RN asked RN to get parent verbal consent for approval of Benadryl IM administration. Verbal consent to give Benadryl IM was given by Father for patient over facetime to RN at 1233. Patient stated she weighed 48 kilograms (105 lbs). With client's assent, RN gave patient IM Benadryl (LOT#: 041020 exp: 04/23) in the right deltoid at 1233 (1mL (50mg) as directed in emergency protocol for patients >45 kilograms). RN retook patients vital signs at 1234. BP: 135/93, HR: 98, O2: 98%, RR:16. EMS arrived at 1235 and assumed care. EMS assessed patient and recommended that patient go to hospital since parent guardian wasn't on site. Grandma called patients father via facetime and he stated he did not want his daughter going to the ED. EMS had to receive Physician approval for AMA. Paramedics educated father on worsening signs and symptoms of allergic reaction and recommended that patient go to ED as soon as possible. Father of patient verbalized understanding and stated he would take daughter to ED. Physician from local hospital gave consent to release patient to grandmas care. EMS left vaccination site at 1246. RN retook patients vital signs at 1302. BP: 134/83, HR: 123, O2: 99%, RR:16. Patient stated she had not eaten anything all day. Patient was given a juice, water and crackers. Patient finished her snack. Patient stated that she was feeling a lot better and that symptoms had subsided. Patient completed 30 minutes of extra observation at 1303. Patient stated that she was feeling "a lot better" and symptoms had completely subsided. RN educated patient and her Grandma on worsening sign and symptoms of COVID vaccine and when to seek EMS. RN educated patient and her Grandma on worsening signs and symptoms of an allergic reaction and recommended patient go to ED as soon as possible. Patient and Grandma verbalized understanding. Grandma stated that she "was going to take her granddaughter to her Dad's and then he was going to take patient to the ED." Patient left vaccination site with a steady gait and unassisted with her Grandma at 1305.