Age: 11.0
Sex: F
Vaccine: COVID19
Symptoms: Angiogram, Dizziness, Drooling, Dyspnoea, Electrocardiogram
Clinical narrative: Chief Complaint  Facial droop (Complaint of)  Arrival Date/Time: 12/15/2021 13:18:00  History of Present Illness   11 yo girl presents with facial droop. Pt was in usual state of health and received second dose of covid vaccine yesterday. This morning woke up with generalized HA, 7/10, took ibuprofen before going to school and HA resolved. During PE at school, around 9:30am, after she was shuffling her feet for some time, she felt numbness on R side of her face, had difficulty speaking, she was drooling from R side of her mouth and noted to have R facial droop. Symptoms resolved after 2 minutes by the time she arrived in the nurse's office and she was noted to have normal exam by the school nurse. Pt denies any Pt denies any weakness of arms and legs, she was able to walk normally and denies any HA at the time. She also complained of feeling SOB and felt like she was going to faint. Denies CP, palpitation, fever, cough, vomiting, diarrhea.  She feels at her baseline currently.  No hx of migraine  Family History: Mom hx of migraine an von Willebrand. No fam hx of seizure Social History: Lives with family Immunizations: Up to date Review of Systems  Pertinent positives and negatives noted above in HPI. All other systems of a 10 system review are negative.    Physical Exam  Vitals & Measurements    T  HR  RR  BP  Sp02   First Set  36.4 DegC (12/15/21 13:33:11) 92 bpm (12/15/21 13:33:11) 20 br/min (12/15/21 13:33:11) 119/60 mmHg (12/15/21 13:33:11) 100 % (12/15/21 13:33:11)    General: alert, no acute distress, well-appearing, pleasant Skin: no rash, warm, dry Head: atraumatic, normocephalic Eye: normal conjunctiva, sclera clear, no discharge, pupils equal, round, reactive, extraocular movements intact ENT: RTM normal, LTM normal, pharynx: normal, normal tonsils, mouth: moist mucus membranes, no lesions Neck: supple Cardiovascular: regular rate and rhythm, no murmur, normal peripheral perfusion Respiratory: lungs CTA, respirations non labored Gastrointestinal: soft, nontender, nondistended, no organomegaly Musculoskeletal: no deformity, no tenderness, normal range of motion Neurological: appropriate LOC for age, CN II-XII intact, motor strength equal & normal bilaterally, speech normal, normal finger to nose exam, normal negative Romberg   Medical Decision Making  11 yo girl presents with transient episode of R sided facial numbness, difficulty speaking, R sided facial droop which resolved after 2 minutes. Pt had HA earlier in the day which resolved after taking ibuprofen before onset of these symptoms. Pt is back to baseline prior to coming to ED. She received second dose of covid vaccine yesterday. No fever, cough, vomiting, CP, palpitation, but reports feeling sob and felt like she was doing to faint during the episode. On exam, VSS, well-appearing, intact neuro exam with no facial droop, no motor weakness and normal speech. DDx TIA, atypical migraine, focal seizure. Consulted neurology, recommended MRI brain without contrast and MRA. 12-lead EKG also performed and normal, QTc 439  Reexamination/Reevaluation  12/15/2021 16:32 Temperature Temporal Artery: 36.4 DegC (12/15/21 13:33:00)  Systolic Blood Pressure: 119 mmHg (12/15/21 13:33:00)  Diastolic Blood Pressure: 60 mmHg (12/15/21 13:33:00)  Heart Rate: 92 bpm (12/15/21 13:33:00)  Respiratory Rate: 20 br/min (12/15/21 13:33:00)  Oxygen Saturation (SPO2): 100 % (12/15/21 13:33:00) In brief, Pt. is a 11 year old female with no significant medical history who presented with transient episode of R sided facial numbness, difficulty speaking, R sided facial droop which resolved after 2 minutes, i/s/o COVID vaccine. No fevers or infectious sxs. DDx TIA, atypical migraine, focal seizure. Consulted neurology, recommended MRI brain without contrast and MRA, which is pending. EKG w/ NSR; of note, patient complaining of feeling faint/mildly SOB when EKG was done. No CP or palpitations.   Events during my shift:  - Normal MRI, MRA and MRV of the brain; no evidence of intracranial hemorrhage or infarction or differential perfusion  - Per Neurology, patient is safe for discharge home; plan outpatient neurology follow-up   Family updated on test results and plan of care. Patient is safe for discharge home with neurology follow-up. Return precautions and anticipatory guidance provided. Written discharge instructions provided and reviewed. All questions answered.  Final Diagnosis  1. Facial droop R29.810 2. Neurological symptom R29.90 3. Headache R51.9 Assessment/Plan  Condition: stable  Disposition: discharged home  Patient and family counseled regarding diagnosis, results, and treatment plan. Questions answered. Patient and family understood.  Briefly, this is an 11-year-old female with unremarkable past medical history who presents with concern for TIA after second dose of Covid vaccine yesterday.  This morning she had acute onset headache and then around 9:30 AM in PE class, she developed right-sided numbness, drooling, difficulty speaking, and facial droop that lasted about 2 minutes.  By the time she was seen by the school nurse she had a normal exam.  No fever.  Agree with history and physical exam as above - no neurologic deficits.  MR/MRA/MRV without any acute findings.  Neurology consulted with plan for discharge home with outpatient neurology follow-up.   Patient safe for discharge home.  Discharged home in stable condition.  Patient to follow-up with neurology and PCP in 1-2 days to ensure continued improvement.  Caregiver in agreement with plan and all questions answered.  Anticipatory guidance and reasons to return to the ED discussed - new neurologic symptoms, fever, any other concerns.  12/15/21 16:22:52  IMPRESSION:  Normal MRI, MRA and MRV of the brain No evidence of intracranial hemorrhage or infarction or differential perfusion.