Age: 17.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Neutrophil count, Neutrophil count increased, Platelet count normal, Protein total increased, Prothrombin time prolonged
Clinical narrative: Per ED Provider note, "This patient is a 17 y.o. male with PMH of congenital heart disease (single ventricle defect) on daily ASA and nadolol s/p open heart surgery x3, ITP, and depression who presents to the ED accompanied by his father for evaluation s/p transient episode of right-sided weakness and numbness this morning. Reports waking up at 8:30AM and fell upon getting out of bed. No significant head trauma or injury. Reports having expressive aphasia and total right-sided weakness as well as an episode of bladder incontinence. This persisted for 15 minutes then patient was able to get back into bed and sleep for 4 more hours. Episode was unwitnessed and he has never experienced something like this before. Pt denies any known seizure activity. Right-sided weakness and aphasia have since resolved. He now reports minimal numbness on his right side (arm worse than leg) that is gradually resolving. Pt reports he has had a dull headache in a band-like distribution around his head for the past week which is largely unchanged, 5/10 in intensity, worse in the mornings and improves during the day. No associated photophobia, phonophobia, fever, neck stiffness, rash, or vision changes. Reports history of self-diagnosed migraines with visual auras and nausea on a monthly basis but states current HA feels different. Also reports nausea since yesterday and has been dry heaving today but denies any vomiting. He received his second COVID vaccination (Pfizer) yesterday. He has never seen a neurologist but his father has arranged the pt to follow-up with neurologist Dr. as an out-patient tomorrow for MRI of brain and EEG. No FHx of brain tumor, aneurysm, or other neurological condition. No history of blood clots but pt has been on Coumadin for his heart condition in the past. Pt did smoke a joint of cannabis last night, no other recent alcohol or drug use.      There are no other complaints. There are no other exacerbating or alleviating factors. There are no other reported associated signs or symptoms."  ROS: Review of Systems  Constitutional: Negative for chills and fever.  HENT: Negative for ear pain, hearing loss, sore throat, trouble swallowing and voice change.   Eyes: Negative for photophobia and visual disturbance.  Respiratory: Negative for cough and shortness of breath.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Positive for nausea. Negative for abdominal distention, abdominal pain, diarrhea and vomiting.  Genitourinary: Negative for difficulty urinating.  Musculoskeletal: Negative for arthralgias, back pain, neck pain and neck stiffness.  Skin: Negative for rash.  Neurological: Positive for speech difficulty (resolved), weakness (right-sided, resolved), numbness (right-sided) and headaches. Negative for dizziness.   All patient encounters were conducted with the provider wearing the following PPE: Surgical mask.     1:39 PM Upon initial evaluation, H&P are performed. Informed the patient and his father of plan for further evaluation and treatment including CT brain and basic labs. They are in agreement with plans. All questions and concerns are addressed.   3:10 PM Notified by radiology regarding CT brain results. Updated patient and his father on results and plan for transfer to hospital.     3:28 PM Discussed this case with neurologist Dr., who requests we consult neurology team at hospital.     3:34 PM Dr. at hospital accepts patient for admission.   4:07 PM Discussed this case with patient's cardiology team at hospital. They request patient be started on heparin.  .