Age: 64.0
Sex: F
Vaccine: COVID19
Symptoms: Platelet count normal, Protein total normal, Red blood cells urine positive, SARS-CoV-2 test negative, Sleep disorder
Clinical narrative: Patient claims "3 days" after vaccination she developed headache that worsened over the next two days to include dizziness, photophobia, scotomata. However, the state tracking system lists her date of vaccination 10 days prior to the symptom onset. Below is a more detailed description:  This is a 64-year-old female nurse practitioner with coronary artery disease, uncontrolled (untreated) type 2 diabetes, obesity, and remote history of kidney donation who presented yesterday with a 5-day history of nausea and frontal headache with new recent dizziness /lightheadedness when standing.  She describes her headache as starting out as temporal and periorbital and then persisting as a frontal discomfort radiating to the back and down the neck.  Associated with this were complaints of blurry vision, photophobia and scotomata.  She denies any focal weakness or numbness/tingling. There was no vomiting or reports of seizures. She denies no recent problems finding words or bouts of confusion.  She denies a history of arrhythmia or palpitations.  Patient received the first dose of the Moderna COVID-19 vaccination on 4/14/2021 into her right arm, 5 days prior to admission (But state records list 4/7/2021 as the date). She did not take any medication to pre-empt side effects such as NSAID, aspirin, H2 blocker, or Tylenol. Initially she developed a sore arm the night of the vaccination. Three days later the headache developed that did not respond to Tylenol PM although it helped her sleep.  She noted taking more than the recommended dose and had mouth dryness.   Patient denies any past history of COVID exposure and any illness c/w COVID where she was not tested.  She has never had her antibody titer checked.   She recently had a dental procedure for an exposed nerve and had a temporary filling placed.  No antibiotics were given and denies having a dental abscess   She described that one of her sisters developed "blood clots from her heart due to atrial fib" after her Pfizer vaccination.  She denies rashes or stigmata of endocarditis, no fevers, chills, or night sweats.   She describes vaginal itching a few days ago and self treated with an anti-yeast cream (Monistat) that relieved symptoms and does not currently have dysuria, frequency or urgency.  On admission, her UA was abnormal and culture is pending but she received one dose of Rocephin and is still without urinary symptoms.   After admission CT scan and MRI of the brain revealed focal areas of likely small subacute embolic infarcts.  (See report)   Since admission she had a reassuring ECHO and no further worsening.  No evidence for A flutter or fib  Review of Systems  Constitutional: no  fever, no  chills, no  sweats, mild  General weakness Skin: no  Jaundice, no  rash, no  lesions, no  petechiae ENMT: no  ear pain, no  sore throat, moderate  congestion, no  hoarseness  Respiratory: no  shortness of breath, no  cough, no  orthopnea, no  wheezing Cardiovascular: no  chest pain, no  palpitations, no  edema Gastrointestinal: mild  nausea, no  vomiting, no  diarrhea, no  GI bleeding Genitourinary: no  dysuria, no  hematuria, no  discharge, no  pain Musculoskeletal: no  back pain, no  trauma; Some neck discomfort bilaterally R>L Neurologic: moderate  headache, mild  dizziness, no  numbness, mild  weakness Psychiatric: mild  sleeping problems, no  irritability, Describes herself as high strung type A  Heme/Lymph: no  bleeding tendency, no  bruising tendency, no  petechiae, no  swollen nodes Allergy/Immunologic: moderate  seasonal allergies, no  food allergies, no  recurrent infections, no  impaired immunity Additional ROS info: Except as noted in the above Review of Systems and in the History of Present Illness all other systems have been reviewed and are negative or noncontributory  Problem List/Past Medical History  1) Uncontrolled diabetes with a hemoglobin A1c greater than 11; She stopped metformin and has tried to control it with diet alone.  She does not have a PCP  2) Coronary artery disease with 4 stent placements in 2017; noncompliant with aspirin  3) Hyperlipidemia on Crestor  4) History of kidney donation to her late husband.  She reports a stable creatinine  5) Obesity with a BMI of 34.8  Physical Exam  Vitals & Measurements  T: 36.4  °C (Oral)  TMIN: 36.4  °C (Oral)  TMAX: 36.5  °C (Oral)  HR: 86(Peripheral)  RR: 18  BP: 115/72  SpO2: 92%  WT: 92.4 kg  General: alert,  no acute distress  Skin: warm, dry Head: no trauma, normocephalic Neck: Trachea midline, no adenopathy, no tenderness; No bruits  Eye: normal conjunctiva, sclera clear Cardiovascular: regular rate and rhythm, normal peripheral perfusion. No carotid bruits  Respiratory: Lungs CTA, respirations non labored Chest wall: no deformity  Gastrointestinal: non distended,  Extremities: no deformity, no trauma  Neurological: oriented x 4, LOC appropriate for age, CN II-XII intact, motor strength equal & normal bilaterally upper extremity, sensation  equal & normal bilaterally, speech normal Psychiatric: cooperative, affect appropriate for age, normal judgement, normal psychiatric thoughts   Assessment/Plan  This Visit Diagnosis  1. ASB (asymptomatic bacteriuria) R82.71   - No antibiotic treatment recommended   - Do not act on pending urine culture  2. Embolic cerebral infarction I63.40   - Unclear source as echo was clear; no stigmata of endocarditis   - No carotid study as of yet   - She has multiple risk embolic stroke (DM, age, hyperlipidemia, smoking, obesity)   - Unclear if COVID vaccine initiated this process (has a low threshold for a cerebral event)        - There are no national reports regarding this type of side effect in an mRNA vaccine  3. Adverse effect of viral vaccines T50.B95A   - Received COVID Moderna vaccine and symptoms developed 3 days later   - Unclear if vaccine cause symptoms  4. Diabetes mellitus E11.9   - Poorly controlled with Hbg over 11  5. Body mass index (BMI) of 38.0 to 38.9 in adult Z68.38   - Current weight 92.4 kg  6. Tobacco use Z72.0   - Small amount  7. H/O unilateral nephrectomy Z90.5   - Creatinine is currently 6.0   Plan:  * I will report the possible vaccine adverse event to the national system (VAERS)       - This was shared with the patient and she can also file a report       - Recommend that the sister also file a VAERS report  * Await neurology opinion regarding carotid studies  * No further antibiotics since she has no symptoms