| Days after vaccination:||0
|Vaccination / Manufacturer
||Lot / Dose
||Site / Route|
|COVID19: COVID19 (COVID19 (JANSSEN)) / JANSSEN
||1805020 / 1
||RA / IM
Administered by: Pharmacy Purchased by: ?
SMQs:, Anaphylactic reaction (broad), Acute pancreatitis (broad), Neuroleptic malignant syndrome (broad), Parkinson-like events (broad), Noninfectious encephalopathy/delirium (broad), Gastrointestinal nonspecific symptoms and therapeutic procedures (narrow), Hypoglycaemia (broad), Dehydration (broad), Hypokalaemia (broad)
Life Threatening? No
Birth Defect? No
Permanent Disability? No
Office Visit? No
ER Visit? No
ER or Doctor Visit? Yes
Other Medications: Not known. Patient was not a customer of pharmacy at the time of admin.
Current Illness: Pt stated a cut on finger which he was taking antibiotics for; however, no other issues within last month.
Preexisting Conditions: Pharmacy unaware of health conditions. Pt has omitted that from intake form. No previous care given to pt at time of incident.
Diagnostic Lab Data: ER evaluation 3/6/2021. Follow-up from medical assistant at ER with pharmacist concluded pt was anxious and nervous of side effects of vaccine. This caused somewhat of a "panic attack" causing multitude of symptoms. Vaccine believed to cause nausea.
CDC Split Type:
Write-up: Pt was held for 15 minutes. Past 15 minutes, patient was ready to leave but complained of nausea. Asked pt to stick around. Took blood pressure. It was low ~90/55. Asked again how he was doing, stated okay but feeling chills/cold. Started to shake uncontrollably. Ask pt if he thought a hospital visit was necessary; he stated no at that time. Decision was made to call squad; BP was elevated now and still shaking. Transported at that time.