Age: 19.0
Sex: F
Vaccine: COVID19
Symptoms: Headache, Malaise, Nausea, Somnolence, Speech disorder
Clinical narrative: Client received the 1st COVID vaccine (Pfizer Lot #EW0187 and 06/28/2021) at 1848. At 1859, Office Assistant was walking past the client when she noticed that the client appeared unwell. Assistant asked the client if she was feeling ok, the client responded, ?I feel dizzy.? Assistant alerted PHN that the client was feeling dizzy. PHN responded. The client appeared drowsy but was oriented to person and place. The client?s eyelids were open halfway, and the client was mumbling answers to the questions. The client stated, ?I feel dizzy and hot under my skin.? Vital signs were taken by EMT at 1901 (Heart rate 92, Oxygen 99%, blood pressure 112/P?client was wearing a long-sleeved shirt). Client?s skin was warm and dry. At 1902 client appeared more alert, and PHN gave the client juice to drink, which she accepted and drank. Client stated that she has a history of vasal vagal reactions to needles and was anxious about receiving today?s vaccine. EMT and PHN transitioned client to zero gravity chair at 1904 and gave client chips and a granola bar to eat. The client accepted the snacks and started to eat them. At 1905 client stated, ?my head feels weird like I want to lay back.? PHN advised client to lay her head back onto the gravity chair head rest. Client laid her head back for less than 30 seconds than continued to eat. PHN offered the client Benadryl and she refused. Client stated that the last time that she ate was around 1100 or 1200. Client was wearing a beanie and long sleeves, we asked the client if she can remove her hat and outer layer, however, she refused. The client had a flat affect and was soft spoken. Vital signs taken at 1915 (oxygen 98%, heart rate 94, blood pressure 138/84). Client denied any shortness of breath. At 1919, client stated, ?I feel like I?m going to throw up.? The zero-gravity chair was positioned into a seating position and the client was given an emesis bag. Client did not vomit, and she sat with the emesis bag until 1923 and then stated that the feeling was gone. Client has a history of sickle cell anemia and stated that she receives blood transfusions every 2-3 weeks but had not received a transfusion in 8 weeks. Client is currently prescribed Metformin but has not taken the medication because ?she does not trust it.? Client stated that she was prescribed Lexapro 1 month ago and took her first dose the day before the vaccine but did not take it the day of the vaccine. She stated that she has anxiety but denied any other medical conditions. She is allergic to Toradol. Vital signs taken at 1924 (oxygen 98%, heart rate 91, blood pressure 146/102). At 1925 she sated ?my head hurts, it?s a sharp pain.? PHN called EMS at 1926. EMS arrived at 1928 and assumed care. EMS medic stated that her blood glucose levels were at 82 and advised her that they wanted to take her to the emergency room to be examined. The client refused transport to the hospital and stated, ?I don?t want to go to the hospital, it?s so expensive.? Client continued to refuse transport and stated that she will have her boyfriend take her to the hospital. Client?s boyfriend entered the building and client signed an AMA at 1953. PHN provided education to client and boyfriend on life threatening symptoms and to call EMS if any symptoms appear on their way to the hospital. PHN also advised client to follow up with her primary care provider and to follow up with an allergist before receiving her second vaccine. Client left the facility AMA at 1954 with her boyfriend, unassisted and with a steady gait. Client and her boyfriend stated that they would go to the hospital.