Age: 58.0
Sex: M
Vaccine: COVID19
Symptoms: Somnolence
Clinical narrative: Patient received the 2nd COVID vaccine (Pfizer, lot #EW0182, use by date 05/17/21 at 1515) at 1438. The patient reported feeling dizzy to EMT, who immediately moved him to the anti-gravity chair. RN assisted in positioning him in a Fowler's position and ice packs were placed on his back and behind his neck. Patient's face mask was removed and his vital signs were taken at 1459, the patient was wearing a thick jacket, so the palpable radial pulse on the left forearm was 145, HR 83, RR 16, oxygen saturation was 97%., and pupils were equal. The patient denied any shortness of breath, difficulty breathing, difficulty swallowing, chest pain, or loss of consciousness. The patient was alert and oriented to person, place, time, and situation. The patient was speaking in full sentences and immediately responsive to questions. The patient was given a bottle of water and reported last eating around 1300. The patients color slowly reappeared when he was placed in Fowler's position. Reported being allergic to penicillin and taking Seroquil, 400mg, daily and Hydroxyzine, 25 mg for anxiety. Denied any chronic medical disorders other than general anxiety. Vitals were retaken at 1459, BP: palpable radial pulse, 140, RR 16, HR 79, and oxygen saturation at 98%. The patient stated that he felt flushed in his face, and the patient was immediately offered Benadryl but he stated, " Let's wait a few minutes, I don't like taking anything if I don't have to."The patient denied any shortness of breath, difficulty breathing or swallowing, lip tingling, or facial swelling. The patient decided to take the oral Benadryl at 1503 and was given Benadryl, 50mg oral suspension, PO. At 1505 we attempted to position him to a sitting upright position in the gravity chair and he stated, " I feel lightheaded, can we place me back how I was?" EMT and RN repositioned the patient in the anti-gravity chair to a Fowler's position and assisted the patient with removing two layers of shirts, as he was wearing multiple layers. Vitals were retaken at 1506: 120 palpable radial pulse, RR 16, HR 78, and oxygen saturation at 97%. The patient was alert and oriented to person, place, time, and situation. The patient was able to follow commands, had strength equal bilaterally in the upper extremities, and had a symmetrical smile. Vitals were retaken at 1515, BP: 120/82 (R arm), HR 81, RR 16, oxygen saturation at 97%. The patient was given juice and repositioned to a semi-Fowler's position. Denied dizziness or lightheadedness. The patient stated, " I'm usually pretty sensitive to medication, now I just feel like I could go to sleep." Denied experiencing shortness of breathing, difficulty swallowing, or difficulty breathing. Vitals were retaken at 1528, BP 120/85, HR 66, RR 16, oxygen saturation at 98%.  The patient was able to follow commands, and stated, " I feel a pressure in my head." RN was going to call 911 to have EMS transport the patient to a hospital, but the patient denied EMS services and did not want 911 to be called when it  was offered at 1528. The patient was repositioned to a Fowler's position. Patient reported no longer feeling flushed on the left side of his face at 1535. At 1540, vitals were retaken, BP 120/85 ( R arm, sitting upright), HR 79, RR 16, and oxygen saturation at 97%. The patient's color returned and he denied feeling lightheaded or dizzy. RN instructed the patient about emergency precautions and to follow up with his primary care provider.  RN educated the patient about not operating machinery as the patient was given Benadryl and this may cause him to be drowsy. The patient contacted a friend to pick him up from the site. RN  gave the patient reporting information. Vitals were retaken at 1550, BP: 120/82, HR 76, RR 16, and oxygen saturation at 98%. The patient's mouth was moving with regular movements and the patient was rapidly responding to questions. Patient called friend to coordinate his ride home. RN educated him about ER precautions again. The patient was alert and oriented to person, place, time, and situation, and his facial color had returned to baseline. EMT was instructed to stay with the patient until patient's friend arrived on site. At 1610  EMT reported to  RN that patient reported feeling flushed and lightheaded again. EMT immediately placed him in a Fowler's position and RN called 911, EMS. The patient stated, " It's hard for me to recall things, like my head is really foggy." Patient's speech was slower than baseline, no facial swelling was observed and patient denied any difficulty breathing, shortness of breath, chest pain, or loss of consciousness. Patient was alert and oriented to person, place, time, and situation. Fire Department  assumed care at 1615, RN gave report to the responders. The responders completed an EKG on site and completed a set of vitals. Patient denied transportation by EMS to hospitaland signed AMA paperwork given to him by the responders. Patient's friend arrived on site at 1618. RN educated patient's friend about transporting patient to hospital, as patient stated, " I'm going to have my friend take me to the hospital." RN quickly educated patient's friend  that if while transporting patient to hospital, he began to experience shortness of breath, loss of consciousness, or difficulty breathing, to immediately pull over and call 911. Patient's friend verbalized understanding and patient was pushed in a wheelchair to the friend's vehicle, as he was very lightheaded. EMT,  EMT, and RN assisted patient into the vehicle. Patient and friend stated that they were going to pick up a few items from patient's car and then go to the hospital immediately. Patient left the site at 1621.