Age: 19.0
Sex: F
Vaccine: COVID19, COVID19, COVID19
Symptoms: Gaze palsy, Headache, IIIrd nerve paralysis, Magnetic resonance imaging head normal, Malaise
Clinical narrative: 3rd Moderna dose recorded in system on 6/6/21 (no lot number documented)  ER note by Dr: History of Present Illness: The patient is a 19 y.o. female who presents to the ED with Double Vision Yesterday onset with diplopia with lateral vision to each side but normal when looking forward. No previous episodes. Mild headache with some tingling to the neck fingers and both arms. Vision otherwise not impaired. Also with back pain over the past 2 days. No recent neck injury or head injury in the last week. Also with speech issues with difficulty saying certain words. Also with recent cold symptoms with cough, runny nose and muscle. No exposure to covid and had negative COVID test. Positive BCP. No fever documented. Feels she has forgotten how to walk and knees are giving out. BP- 108/87, 99/55, 99/62  SpO2- 97%, 97%, 97%, 97% Constitutional: Appears well-developed in no acute distress. Hair is significantly impaired where she needs assistance from her mother to walk to the examination room. Eyes: Pupils are equal, round, and reactive to light. With extraocular movements she does demonstrate some significant abnormalities with each eye demonstrating some impairment with medial gaze causing strabismus with lateral gaze that is much more severe to both sides. Neurological: The patient is alert, she has no focal sensory or motor deficits to the extremities, she does have cranial nerve deficits as described previously there is no facial droop. She does have a gait disturbance.  Given aspirin, but will start on heparin if thrombus noted.  ER note by  RN: Reporting double vision since waking up this morning, dizziness since yesterday, and pain to the back of the head that has been going on for about a week. States that she has been feeling ill for a few days but tested negative for COVID. Unsteady gait, requires someone to help balance to help her stay upright.  H&P note by Dr: Information obtained from: patient, mother and history review via medical record. Chief Complaint: Double vision. History of Present Illness: Patient is a 19 y.o., White female right-handed student who presents with sudden onset of diplopia, disequilibrium, tingling of extremities, posterior neck and lower back discomfort, and distorted speech. She states that last evening she began with diffuse odd feeling of dizziness and tingling in her hands and throughout her extremities but was otherwise normal. She and her mother felt that this was likely due to vertigo from recent URI. However, upon arising this morning she noticed considerable diplopia and progressive worsening of symptoms. Has also noted difficulty with ambulation, feeling unsteady and mother describes significant stepping, unsure gait. She denies significant headache, chest pain, shortness of breath, nausea, vomiting, fever, chills, dysuria, incontinence or visual field cuts. She has not had previous similar symptoms. She is up-to-date on her childhood vaccines and has received 2 doses of Moderna COVID-19 vaccine completed on 4/24/21. ED evaluation revealed what appeared to be significant bilateral abducens paralysis. Imaging was pursued with MRA of the brain, MRI of the brain and CT angiogram of the head and neck which have revealed no significant pathology. Case was discussed with the on-call neurologist who felt the patient should be admitted for further evaluation and would like an MRI of the brain with contrast for further investigation. She will be admitted with internuclear opthalmoplegia and other neurologic  symptoms for further evaluation and treatment.   Vaccinations: Pneumovax- Does not meet criteria to receive. Influenza- Will order influenza vaccine. COVID- Yes Moderna 2nd 4/24/21.  Family History: Brother, 17 y.o., being evaluated for possible seizure disorder HTN--father No family history of clotting disorder  Social History: Occasional ETOH Denies marijuana or other illicit drugs No tobacco Student at WVU  Temp- 37.1 °C (98.7 °F), HR- 104, BP- 145/86, RR- 20, SpO2- 98%  Neurologic: Pt has "full" mouth voice, some mild dysarthria, obvious dysconjugate gaze, difficulty with abduction of eyes bilaterally, few beats nystagmus on extreme lateral gaze, ? Bilateral 3rd CN palsy, MM strength 5/5 thru-out exam, no dysdiadochokinesia, heel to shin normal, no past pointing. No truncal ataxia in seated position. Ataxia with standing, unsteady, steppage gait. No major sensory deficit.   Internuclear opthalmoplegia, bilateral --examination of EOM has been somewhat inconsistent and difficult due to significant diplopia and provoked dizziness --patient has other symptoms including ataxia, steppage gait and paresthesias --etiologies would would include multiple sclerosis, ischemic injury, Miller-Fisher syndrome, MG or infectious/inflammatory process --will check MRI of brain with contrast in a.m. with MS protocol --chexk Lyme titer, ANA, dsDNA, CRP, ESR, hypercoagulability studies --may require LP for further investigation and to rule out meningoencephalitis or demyelinating process --consult neurology to direct further investigation and treatment --serial Neuro exam --monitor closely for development of muscle weakness --assess for VAERS reporting if inflammatory etiology discovered  Note by RN: ? double vision, eyes crossed and unable to focus, dizziness, talking "different" (nasally sound to voice, and "weird" feeling when swallowing.