Age: 45.0
Sex: M
Vaccine: COVID19
Symptoms: Antipsychotic drug level below therapeutic, Areflexia, Arteriogram carotid abnormal, Ataxia, Blood creatinine normal
Clinical narrative: Janssen/J&J COVID-19 Vaccine EUA  Miller-Fischer Variant GBS - See continuation page #1 facial diplegia and ataxia  45-year-old male with history of schizophrenia presented with 6-day history of facial diplegia initially evaluated at outside facilities and transferred over here for further management.  There is a concern for Miller Fischer variant GBS.  No history of tick bite no signs of systemic infections.  Patient had a recent COVID-19 vaccine March 6th. On exam patient has pretty severe bilateral facial weakness in the lower motor apparent without any other cranial nerve involvement.  There is numbness in the lateral toes of the right foot and sensory ataxia on exam.  Patellar reflex and Achilles tendons were absent.  Remaining reflexes were present. Multiple labs are pending lumbar puncture is pending.  MRI brain is negative for enhancing lesions of the cranial and intra-articular portions of the facial nerve. After lumbar puncture will probably start the patient on IVIG if there was no signs of infection planning for 5-day course.  Recommend artificial tears and supportive management to prevent corneal ulcers from facial weakness.  OT and speech to see the patient. Assessment:  1.  Acute facial diplegia with bilateral peripheral cranial nerve VII dysfunction concerning for AIDP.  Symptoms started about 1 week ago.  House Brackmann scale 5 bilaterally.  Patient with metallic taste of tongue, pressure in his ears with some pain behind the ears.  Unable to close his eyes, raise his forehead, puff out his cheeks, or purse his lips.  No vibration sense to his chin.  Also noticing new numbness of his right toes and has absent R patellar reflex.  No recent noted infections although possible left mandibular tooth abscess noted on CT imaging and he reports a chronic "rotten tooth".  Patient had a COVID-19 Johnson & Johnson vaccine on March 4.  MRI brain with and without contrast is negative without noted enhancement of the facial nerve root.  Planning lumbar puncture today and then will discuss further treatment.  Will add moisture for his eyes and gabapentin for pain. 2.  Neutrophilic leukocytosis.  Unclear etiology.  May need to have the dentist look at his tooth and consider removal.  Will discuss further. 3.  History of schizophrenia.  Patient denies any acute complaints with this but is anxious to restart his lithium which is okay from our standpoint. 4.  Tobacco use 5.  Hypothyroidism.  Continue home levothyroxine. Plan: - LP, see orders - motor sensory neuropathy panel, b12, ANA, ACE, EBV Ab panel, RPR, Lyme reflexive panel, HIV, TSH, UA -Eyedrops and ointment to bilateral eyes -Gabapentin 100 mg 3 times daily -SLP to see History of Present Illness: 45-year-old male with a history of schizophrenia and tobacco use who presents with facial diplegia for the last 6 to 7 days.  On Saturday night a week ago he had a fullness in his bilateral ears and thought he may have an ear infection.  He woke up Sunday morning (March 21) with bifacial weakness and dysarthria.  He has a metallic taste in his tongue.  He feels somewhat swollen and sore in the posterior area.  He still has a full feeling in his ears but no hearing loss.  He cannot completely close his eyes.  He has no movement of his forehead he cannot puff out his cheeks.  He has had difficulty getting food to back of his mouth to swallow.  His eyes are watering.  He has some occasional stabbing, ice pick pains behind his ears, mild at present.  He feels numb in his perioral area.  Since occurrence this is not worsened or improved.  He denies any illnesses in the last month or 2.  He has had some diaphoresis at home since this occurred.  No palpitations.  No bowel or bladder issues.  No difficulty walking.  Denies shortness of breath.  After transfer here and when he is asked he has noted some numbness in his third through fifth toes on the right foot which is new.  He had a Johnson & Johnson COVID-19 vaccination on March 4.  He has been on lithium since he was a child and recently was placed on Zoloft.  He denies any new mental health issues but stopped his medications when the symptoms occurred as he was concerned there might be a potential side effect.  At the outside hospital he had a CT of the neck which did note lucency around the root of his remaining left mandibular molar suspicious for abscess as well as large dental caries.  He reports knowing he has had a rotten tooth on the back left for a long time.  He is missing most of his upper teeth except a couple molars ("from bad decisions in his young years").  He had gone into the local ED about 3 days ago and they gave him a prescription for amoxicillin, prednisone, Zyrtec and Benadryl.  He had a couple doses of amoxicillin and prednisone before he went back to the ED yesterday with ongoing symptoms. Medical History Past Medical History: Diagnosis Date o Anxiety   o Paranoid schizophrenia  o Smoking status: Current Every Day Smoker     Packs/day: 0.50     Years: 30.00     Pack years: 15.00 Substance and Sexual Activity o Alcohol use: Yes     Frequency: 2-4 times a month o Drug use: Not Currently o Sexual activity: Defer Patient is allergic to geodon [ziprasidone hcl]; haldol [haloperidol]; abilify [aripiprazole]; and latuda [lurasidone]. Review of Systems he has a history of low back pain with right leg radiculopathy for which she had a radiofrequency ablation done in the past. Physical Exam: Current Vital Signs: BP 139/77 (BP Location: Left arm, Patient Position: Lying)  | Pulse 89  | Temp 36.6 °C (97.9 °F) (Oral)  | Resp 18  | Ht 1.702 m (5' 7")  | Wt 110 kg (241 lb 6.5 oz)  | SpO2 97%  | BMI 37.81 kg/m²  Labs: Sodium 137 Potassium 4.4 BUN 16 Creatinine 1.05 Glucose 109 Lithium level 0.2 WBC 16.64 Hemoglobin 14.5  DISCHARGE SUMMARY Hospital Course: 45-year-old male with a history of schizophrenia who had 6 to 7 days now of complaints of upper forehead/facial weakness, eyes watering leading to blurry vision until he wipes away the excess and numbness of his lips and mouth and tongue feeling thick.  He noticed that his speech was a little different and he felt muffled and cottonmouth.  He had a little bit of issue eating as he states that he had to put his food in the back of his throat so that his tongue would not push the food out of his mouth.  He denies any numbness around his maxilla or mandible or cheeks.  He stopped all of his medications abruptly when he had the symptoms as he thought it may be a side effect from something.  He denies any recent environmental or insect exposure.  No fevers or chills.  No URI symptoms.  No ear pain.  No nausea or vomiting. Patient was ultimately diagnosed with Miller Fisher variant GBS secondary to Johnson & Johnson COVID-19 vaccine.  Neurology evaluated and started IVIG treatment for 5 total doses.  He progressively improved with his symptoms throughout the 5 days of hospitalization.  He completed IVIG therapy on 4/1/2021. I personally evaluated the patient on the day of discharge he was doing well and had no complaints.  He is to follow-up with neurology in 1 to 2 months.  FMLA paperwork was filled out.  He was discharged with eye ointment solution and told to protect his eyes.  It was neurology recommendation that he take at least 2 months off of work in order to do so.  I had no changes in my physical examsignificant cranial nerve deficits associated with primary diagnosis.  Otherwise no focal neurologic deficits observed in the upper and lower extremities.  Heart was regular rate and rhythm lungs are clear.  Abdomen had normal bowel sounds and was nontender.  He has no peripheral edema to speak of. Miller-Fischer Variant GBS - F/u with neuro in 1-2months