Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Asthenia, Balance disorder, Dizziness, Dyspnoea, Fatigue
Clinical narrative: Patient assessed and monitored by EMS on 2/4/2021 post vaccination: Chief Complaint: Difficulty breathing; tremors  Secondary Complaint: Dizziness; full body weakness  History of Present Illness: Patient was receiving COVID 19 vaccine. After injection, patient began experiencing labored breathing, full body tremors, and became extremely weak. Patient requested to be checked out.  Medical History: Obtained From: Not Recorded  Current Medications: None - Reported By Patient Allergies: Albuterol Lidocaine Sulfur  Neurological Exam Level of Consciousness: Alert  Loss of Consciousness: No  Chemically Paralyzed: No  Stroke Scale: Cincinnati Negative Mental Present: Oriented-Time, Oriented-Event, Oriented-Place, Oriented-Person, Normal Baseline for Patient Pupils Left, Right  Size: Normal, Normal  React: Reactive, Reactive           Motor, Sensory  LA: Normal, Normal  RA: Normal, Normal  LL: Normal, Normal  RL: Normal, Normal   Airway Status: Patent Performed By: Patient Outcome: Unchanged  Respiratory  Effort: Normal Sounds: L: Clear R: Clear  Sounds: breath sounds clear all fields   Cardiovascular  JVD: Not Appreciated  Cap. Refill: Less than 2 Seconds  Edema: Not Appreciated  Pulses  Left, Right  Carotid: Not Checked, Not Checked  Radial: Strong, Strong  Femoral: Not Checked, Not Checked   Injury Details Reason for Encounter: Injury/Trauma  Drugs/Alcohol?: None   Initial Physical Findings  Assessment Skin: Capillary Nail Bed Refill less than 2 seconds, Dry, Normal, Warm  Skin Findings: Skin CTC normal, warm, dry, pink  Left Shoulder Findings: Injection site of vaccine; no swelling noted  Mental Status: Normal Baseline for Patient, Oriented-Event, Oriented-Person, Oriented-Place, Oriented-Time   Impression / Diagnosis  Symptoms: Breathing Problem, Tremor, unspecified, Weakness, Tachypnea, not elsewhere classified  Impression: Dizziness, Weakness  Initial Patient Acuity: Emergent (Yellow)   Activity 15:40:  HR=98, BP= 106/70, Alert, RA SpO2=99, Resp.= 22 Labored Crew was requested over to RN vaccine station to assess female patient presenting with labored breathing, slight tachypnea, full body tremors, and general body weakness. Patient had just received first dose of Moderna COVID-19 vaccine. Patient is AAOx4, (-)LOC, (-) signs of anaphylaxis. Patient is assisted onto stretcher, secured with straps x3 and side rails raised and brought over to ems triage area. Patient denies any pain, complains of uncontrolled full body tremors.   15:47:  HR=78, BP=134/90, Alert, RA SpO2=98, Resp.=20 Labored, Cincinnati Negative Crew assesses, patient shows no signs of anaphylaxis, lung sounds clear in all fields. Patient feels light headed and is lowered to supine position. Patient states she has had an episode similar to present in doctors office a few years ago when administered albuterol, and event had subsided approx. 30 minutes later.   16:01:  HR=78, BP=136/p, Alert, Resp.= 18 Labored, Cincinnati Negative Vitals reassessed. Still above normal baseline for patient.   16:10:  HR=80, BP=120/p, Alert, RA SpO2=98, Resp.=18 Labored, Cincinnati Negative Vitals reassessed, patient now showing full body involuntary tremors and complains of extreme weakness when moved to fowlers. Patient Cincinnati negative, no signs of anaphylaxis. Patient moved back to supine position.   16:18: HR=76, BP=122/68, Alert, RA SpO2=97, Resp.=18 Normal Vitals reassessed, breathing no longer labored, patient states she feels better and wishes to go to bathroom. Patient is assisted to bathroom with assistance from RN.   16:35: HR=74, BP=126/68, Alert, RA SpO2=97, Resp.=18 Normal Vitals reassessed, patient wishes to walk around and see how they feel, crew monitors. No tremors are noted for several minutes, patient now sitting fowlers on stretcher. Patient is advised that at any time they can call 911 if they feel they don't feel right or are unsure of condition. Patient is always made aware that ems crew does not diagnose and does not have the ability to see and diagnose underlying conditions that a hospital would have the capabilities to do so. After several more minutes of walking and discussion of patient condition, patient wishes to sign RMA , and go home with husband, daughter was waiting at residence. patient signs RMS, AMA, RN signs as witness. Patient care diminished.  2/5/2021 at 11:08am: Public health nurse called patient at  for follow-up. Patient stated she was ?not steady on feet for a while? on prior night. Patient stated she started to feel ?back to normal? today. The only symptom patient is reporting today is feeling tired. Received verbal consent from patient to update her HCP, Dr. , about her reaction post vaccine. , RN