Age: 16.0
Sex: F
Vaccine: FLU4, HPV9, MNQ
Symptoms: Anti-thyroid antibody, Arthralgia, Blood iron, Blood thyroid stimulating hormone, C-reactive protein
Clinical narrative: Following a well visit that included a lab draw and three vaccinations, patient had a syncopal episode that I suspect may have been due to a vasovagal response to pain or a side effect of vaccination. The event was reported to me (ARNP) immediately by our staff and my nurse. LPN reported that the patient was sitting on the exam table for the blood draw from her left AC and then received her TDaP and flu vaccines. Then she received the HPV vaccine and was told to lie down for 15 minutes after. Just as LPN turned to set the vaccine/lab draw tray to the side, the patient let out a small sound and then fell forward from the exam table. Based on the reported mechanism of the fall and the areas in which the patient reported pain (knees and forehead), suspect she first hit her knees and then her head. LOC less than 30 seconds as the nurse reports she immediately returned to consciousness. Mother of patient was just outside of the room making a phone call regarding her own mother when the event happened. Mother of patient was immediately back in the room following the event. Patient was monitored for approximately 1 hour following the event with plans for close follow up. She reported localized knee pain bilaterally, headache, and nausea immediately following the event. Reported pain at 10/10. Patient's legs were elevated and she remained in a lying position with both mother and myself present for 15 minutes. She received a dose of ZOFRAN to help with her nausea and remained in a lying position on the floor with her head cushioned and feet elevated on a chair. 15 minutes later she was slowly brought to a position sitting on the floor and leaning against the cabinets. She received a dose of acetaminophen. Mother was present with the patient. She was rechecked by me 15 minutes later and pain was reassessed and reported to be 6/10. A neurological examination was then performed, first with the patient sitting in a chair and then slowly standing. Nonfocal neurological examination. However, I suspected she may be experiencing early signs of a concussion given the fall and her symptoms of dizziness, headache, and nausea, so I thoroughly discussed concussion protocol with patient and parent. Both verbalized understanding. After the event I had started a VAERS report, but I do not think it was completed as I can't find a confirmation in my records which is why I am reporting this now as it came to my attention that there was not a completed report. Concussion symptoms were slow to resolve. Patient was examined and had three follow up visits for the concussion, the last of which was February 7th, 2018. We had discussed having her see a concussion specialist but per phone conversations things were improving. Patient then was not seen in clinic again until 11/16/2018 with a chief complaint of difficulty focusing and headaches. She previously had a 504 plan at school following the concussion, and the parent was wondering about if she needed additional time for assignments once she starts college. I referred her to neurology and she has an appointment for evaluation 1/14/19.