Age: 36.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Skin exfoliation, Syncope, Tachycardia, Temperature intolerance, Tenderness
Clinical narrative: Patient received Pfizer COVID-19 vaccine on 12/27/2021 and 01/17/2021.  Previously checked for COVID-19 infection 12/13/2020, 01/23/2021 and 04/06/2021 and was negative on each test.  On 01/18/2021, patient states she had low-grade fever, fatigue, myalgia. Took Tylenol.     Patient contacted office on 01/22/2021 stating the night prior (1/21/2021)her heart rate was up to 209 and had numbness and tingling in both upper extremities.  Also with sharp pain down her legs and her hands were very cold.  Patient had started taking a Kelp supplement on 01/21/2021 which was recommended by a provider.  Reported later reported that she "felt like a truck hit her."  She also noted onset of chest pain.   She went to  urgent care for evaluation 1/22/2021.     Patient felt lightheaded while in urgent care as she was about to have her blood pressure taken and passed out for approximately 2-3 minutes.  Ammonia inhalant was used and patient woke up.  During evaluation by physician, patient had another few seconds of loss of consciousness.  No tonic clonic movements.  No tongue biting.  Patient was seen at urgent care and had syncope times 4 episodes.  Patient was not postictal.  No evidence of seizure-like activity.  No urinary incontinence or tongue biting.  She felt like she was going to pass out and mention to the urgent care staff .  Patient was transferred to the ED for further evaluation.  Was admitted under observation. It was felt that the initial episodes  of syncope may have had a psychogenic component due to history of pseudoseizures/convulsive syncope.  Cardiac enzymes were negative.  Ultrasound negative for DVT.  D-dimer negative.  Chest pain was reportedly reproducible on admission.  Was given diagnosis of costochondritis. Received Toradol, tramadol, Ativan.   Orthostatics were performed in the morning after admission for observation and she passed out while standing.  Was given 1 L IV fluids with resolution of orthostasis and blood pressure subsequently remained stable.   There was report of tachycardia.  It was felt that the tachycardia was due to reflex tachycardia in the setting of vasovagal syncope. Patient discharged on ibuprofen and Tylenol p.r.n. COVID-19 test negative at that time.   Patient also admitted to Hospital 01/31/2021 through 02/01/2021 due to chest pain.  Also had seizure-like activity in CT scan.  Seen by Neurology.   Patient was able to remember what she thought to be ?seizure?.   She was asked to raise her arms while getting her CT and when she did she feel that her ?arms got frozen?.  And that she could not talk while she was still hearing people around.  She said "everything went south".  She remembered the attending and her getting back to normal immediately afterwards.  When patient seen by nurse on the medical floor nurse has described her to be alert oriented x3.  CT brain: No acute abnormalities Driver's license has been suspended for at least 6 months through 08/2021.   On follow-up visit via video visit 02/18/2021, patient reported ongoing shortness of breath at at rest as well as chest pain also with palpitations.  Also noted lightheadedness with ambulation.  Patient seen by Cardiology 03/12/2021.  Holter monitor 03/16/2021 with few isolated PACs.  Pharmacologic stress test 03/2021 negative for ischemia with EF 70%.  2D echo (03/16/2021) with normal EF.  No significant valvular abnormalities found.  Suggested chest pain may be due to costochondritis.     Seen in the office on follow-up 04/01/2021.  Noted coldness of hands and feet since 01/22/2021.  Ultrasound bilateral lower extremities negative for DVT 01/2021. Onset of discoloration of feet 03/26/2021.  Also noted occasional muscle spasms and cramping of the right lower extremity below the knee.  Noted particularly metatarsals and lateral surface of right lower extremity.  Referred for lower extremity PVR ( 4/7/2021) showed elevated arterial pressures throughout both lower extremities suggesting non-compressibility. ABIs therefore unreliable.  Strong pulsatile waveforms are maintained metatarsal region bilaterally suggesting no evidence of a arterial insufficiency at rest.  Flat line digital waveforms suggest small vessel occlusive disease or vasospasm.  X-rays of the toes negative for significant abnormality.  Patient referred to vascular surgery for urgent evaluation.   patient also refer to Rheumatology on 04/07/2021.   On follow-up 04/07/2021 patient continue to note ongoing chest pain as well as shortness of breath.  Patient started on aspirin 81 mg p.o. Daily on 03/25/2021.  Shortness of breath is constant, unable to walk prolonged distances.  Distal 2nd digits bilateral feet are deeper purple in color compared with prior visit 04/01/2021.  Noted paresthesias of entire body from head to toes.  Noted cold intolerance for few weeks intermittently.  Notes discoloration hands from wrist to fingers and below knees to toes.  States her extremities are ?freezing.?  Was using a heating pad. States when she washes her hand in warm water the discoloration improved.   During hospitalization CTA chest ( 01/31/2021) was negative for PE.  Showed nonspecific, bilateral axillary subcentimeter lymph nodes. Minimal right breast calcification.   Patient states she had mammogram performed 01/2021 and no significant abnormalities found.  Patient followed at doctors.  Hematology/Oncology aware of CT chest findings. Notably patient received COVID-19 vaccination prior to CT chest.  Repeat CT chest requested by insurance however denied by insurance company.  Left axillary ultrasound 04/26/2021 showed small axillary lymph nodes which have a relatively benign morphology. The largest node is actually decreased mildly in size when compared to 01/31/2021.  Right axillary ultrasound 04/26/2021 showed  small axillary lymph nodes as seen previously with 1 top normal size round lymph node with an indeterminate morphology but unchanged in size when compared to 01/31/2021.   Patient has not been able to work since 04/01/2021 due to overall symptoms.  Previously was working from home.  Also works as an MA but discontinued in 02/2021 with onset of symptoms in 01/2021.   On evaluation 04/07/2021 patient noted to have tenderness palpation along left lower quadrant.   Initial CT abdomen and pelvis was denied by insurance company.  Abdominal ultrasound 04/13/2021 unremarkable.   Patient seen by vascular surgery on 04/12/2021 and recommended patient to start applying nitroglycerin to toes as well as initiation of a Plavix 75 mg daily.  Also agreed with referral to Rheumatology.  Patient has not yet received an appointment.  Information was faxed to Rheumatology however referral was also placed by vascular surgery to rheumatology group.   On evaluation in office 04/28/2021, patient reported chest pain all night where she "felt like something sitting on her chest" with associated shortness of breath.  Radiated to neck.  Also noted intermittent palpitations which can last for 5 minutes with associated chest pain.  Notes left groin pain for the last 2 days.  Symptoms lasted 2 hours, from 11:00 p.m. to approximately 1:00 a.m. and patient subsequently fell asleep.  On awakening patient continues to notes chest tightness but less.  Patient feels weak today.  While patient was being examined on the examination table patient appeared weak and stated that she felt like she was going to pass out.  Then noted left arm numbness.  When asked to raise arms, left arm elevation less compared with right.  However subsequently patient had difficulty elevating both arms.  Patient also not moving both lower extremities to command.  With cranial nerve testing, cranial nerves 2-12 intact except patient was unable to smile on command however while patient was crying facial muscles appeared symmetric.  Repeat BP 120/78 with heart rate 75 and O2 sats 99% on room air.  Blood pressure repeated another 5 minutes was 115/75 with heart rate of 76. patient referred to the ER for immediate evaluation by ambulance.  Patient has been admitted to the hospital since 04/28/2021.   On 4/28/2021, patient noted bruising along right brachial area, right upper extremity distally as well as left medial thigh.     Noted dry patch along dorsum of left foot with associated redness for the last 3 days.   Purplish discoloration of 2nd left digit and 2nd right digit had subsided since this weekend prior to visit 4/28/2021 and area is now scaly on both toes.  Has been using nitroglycerin b.i.d. to toes since 04/12/2021 at recommendation of vascular surgery.  States per patient's coloration of feet bilaterally improves with exposure to warm water.  Also has been elevating the lower extremities.   Noted significant constipation for which patient was seen by GI.  Has been using Metamucil and MiraLax.  States constipation persists.  States she has to use a step stool to elevate her legs when trying to have a bowel movement.  States she spent a long time in the bathroom when she has to have a bowel movement.  Also notes bright red blood per rectum with each BM with wiping as well as on the stool.  States she did not have bright red blood per rectum at time of recent GI evaluation.  EGD/colonoscopy was initially scheduled for 05/14/2021 prior to admission to hospital.