Age: 39.0
Sex: F
Vaccine: COVID19
Symptoms: Magnetic resonance imaging head abnormal, Platelet count normal, Post lumbar puncture syndrome, Presyncope, Spinal pain
Clinical narrative: J&J COVID Vaccine EUA  J&J Vaccine 4/10/2021  4/13/21: Believes she is having a reaction to her Johnson and Johnson COVID-19 vaccination.  This vaccination was given on 04/10/2021. Patient is 39-year-old female with a past medical history significant for ulcerative colitis that has been in remission since the patient was 21 years of age, epileptic seizures on Vimpat and clonazepam. Patient comes in as a transfer with a chief complaint of possible reaction to Johnson and Johnson COVID-19 vaccine.  Patient presents with multiple complaints.  The patient states that upon receiving the vaccine on 04/10/2021 she suddenly developed presyncopal episodes where she felt like she was about to pass out but that subsided later on.  12 hours following the shot she had intense headache which was frontal and then later on travel to the back of her head and traveled down her spine. Patient described the headache to be the worse headache of her life, stated that it was worse than going through labor.  Patient stated that she received morphine which helped her with the headache. Patient also complained of chest pain which was left-sided with no radiation, constant.  No history of previous myocardial infarctions. Her troponins that were conducted were negative. Patient also complained of experiencing blood in her stool. She stated that when she wiped herself on the morning of 04/13/2021 she experience blood on the toilet paper and blood in the bowel.  However, her stool occult blood that was conducted was negative. Patient is being followed by Neurology, she contacted her neurologist and they recommended to come to the ED with concerns of thromboembolism.  Patient's D-dimer was negative. Patient denied any recent travel anywhere or coming into contact with anyone sick. She denied developing any fevers cough shortness of breath abdominal pain nausea vomiting or any urinary concerns.  4/15/21: Patient is a 39-year-old female with a past medical history significant for ulcerative colitis that has been in remission since the patient was 21 years of age, epileptic seizures on Vimpat and clonazepam. Patient comes in as a transfer with a chief complaint of possible reaction to Johnson and Johnson COVID-19 vaccine.  Headache:  MRI brain and MRI venogram was ordered.  MRI brain did show concerning signed for idiopathic intracranial hypertension.  Neurology was consulted.  Patient had high volume LP.  Patient responded well post LP.  Patient will be discharged on topiramate with a taper instructions per neurology.  Patient will make appointment with Ophthalmology.  Patient will follow up with Neurology as well. Chest pain concerning for ACS: Negative troponin.  EKG normal sinus rhythm. Concern for vaccine reaction:  Patient has J&J vaccine.  No clots were noted. Patient's symptoms are most likely are secondary to idiopathic intracranial hypertension and history of migraines.  4/16/2021: 39-year-old female presents emergency room with chief complaint of headache.  Onset this morning. Headache is generalized. Headache is constant.  Headache is worth with position change. Such as moving head side to side or with changing from lying to sitting and sitting to standing.  Headache improves with lying supine.  To has tried pushing fluids, taking over-the-counter medication, and also increasing her caffeine intake to offset the headache.  She denies any of these helping with her symptoms. Patient's pain is right an 8 out of 10. The patient denies anything additional alleviating and or aggravating factors to chief complaint.  Today when the patient's headache started.  She contacted her neurologist. She was told to come to the emergency department for a blood patch.  The patient added that her neurologist felt that she needs a blood patch not only because of the recent lumbar puncture but because there was at minimum 25 mL of spinal fluid removed at the time of her lumbar puncture. This lumbar puncture occurred under fluoroscopy.  However, they had difficulty getting the pressure gauge on thus, more than 25 mL was removed..  Pain Pain Scale:   8 /10. Timing: constant.  gradual. Character: mild.  4/19/21: patient reports intense headaches she attributes to the spinal tap. Ketorolac, DHE, ondansetron given.