Age: 88.0
Sex: F
Vaccine: COVID19
Symptoms: Bacterial test positive, Blood chloride normal, Blood glucose normal, Blood lactic acid increased, Blood magnesium normal
Clinical narrative: Chief Complaint Patient presents with Seizure 88-year-old female with past medical history of type 2 diabetes, hypertension, senile dementia, and baseline deficits due to a past CVA presents to the emergency department for nursing home concern of high blood pressure, fever, and seizure-like activity. Nursing home reports that she had 2 episodes of seizures with a fever which began this morning. Patient did get COVID vaccination in her left deltoid yesterday. When I call nursing home to get report, RN reported that when CNA went to get vitals today she had an elevated temperature at 102 and witnessed a seizure. RN went into assess patient and reported that patient had a clonic seizure for nearly 30 seconds in which her oxygen saturation dropped to 86 during convulsions and came up to 99% shortly after. With seizure and fever, they did have concern to send her to the emergency department. Initial EKG shows normal sinus rhythm at 73 bpm with left anterior fascicular block and left ventricular hypertrophy with less than 1 mm of ST segment elevation in lead III and aVR. CBC shows slightly elevated white blood cell count at 13.4. CMP is remarkable for chloride of 101 and a glucose of 162 otherwise unremarkable. Initial lactic lactic acid is 3.0. Initial troponin is elevated at 0.143. Urine microscopic shows moderate bacteria and mucus as well as amorphous urate crystals present. COVID and flu are negative. D-dimer is negative and magnesium is normal. CT head shows no acute intracranial process. CT chest shows no acute chest process with moderate cardiomegaly and CT abdomen pelvis shows no acute abdominal or pelvic process. Radiology techs did report that patient had an episode in the CT room of what seemed like mild convulsions for less than 30 seconds but returned to normal. Even with elevation of lactic acid and slight elevation of leukocytes, minimal concern for sepsis due to no definitive cause of infection. Without fever, minimal concern for meningitis although difficult to examine in specific patient. Troponin is elevated with a negative D-dimer but not definitive changes on EKG concerning for ACS. Will trend troponins. Repeat troponin elevated slightly at 0.177 and repeat lactic acid is within normal limits at 1.8. Repeat EKG shows no changes from initial with normal sinus rhythm at 60 bpm with left anterior fascicular block and LVH. Less than 1 mm of ST segment elevation in lead III and aVR. I discussed with patient's husband that there is concern for further processes including rule out for stroke with a CTA to check for occlusion, could transfer to cardiology for further cardiac workup to rule out cardiac cause, and the other possibility of meningitis which would require lumbar puncture and culture of CSF, although unlikely, is on the differential. Husband of patient declines saying he would like to make sure she is comfortable and would like no heroics that would cause her any more pain or discomfort. Made him aware that we will make sure she stays comfortable and does not continue to have any seizures. We will monitor her white blood cell count and make sure she shows no signs of systemic infection including fever, chills, hypotension, tachycardia, or continued elevation of her white cell count. He does consent and agree with this treatment plan. Without being able to definitively rule out competing differentials. I do believe symptoms of convulsions and leukocytosis are due to COVID-vaccine reaction which may have transiently raised her troponin due to the convulsions. Patient will be admitted to observation for troponin trends and monitoring to make sure of no more seizure like activity.