Age: 22.0
Sex: F
Vaccine: COVID19
Symptoms: ACTH stimulation test normal, Adrenal insufficiency, Blood thyroid stimulating hormone normal, Computerised tomogram head normal, Cortisol decreased
Clinical narrative: ER Report Dr. 10/24/21 Chief Complaint  Pt reports having tremors that have progressively gotten worse over 3 hrs. Started with a head tic, EMS found her in full convulsion. Pt only has the head tic @ this time but has lost movement in her BLE.                                                                                                                                10/24 Neurology Note Excerpt IMPRESSION:   Visual distortion. Bilateral upper and lower extremity weakness, with give-way phenomenon. Tremor/vibration sensation, generalized. Five months postpartum. Eczema. Depression/anxiety/panic attacks. PTSD.   PLAN:  Her CT scan of the head is unremarkable.  On neurological examination she is exhibiting weakness of both of her legs as well as her arms, however there is a give-way component to her examination which raises the possibility of her symptoms being related to a non-neurologic cause.  The time course of her symptoms is not consistent with a Guillain-Barre syndrome.  She had sudden onset of her symptoms and also has preserved reflexes.  She had her first COVID-19 vaccine 48 hours prior to the onset of her events, however I am unsure as to whether that is related to her current symptomatology.  She has had a TeleNeurology consultation. Recommendation has been made for an MRI of her brain as well as her spine.   She will need the services of Physical Therapy and Occupational Therapy.                                                                                                                                                                               10/27/21 Assessment/Plan   22YF with past medical history of anxiety/panic attacks, PTSD, depression, asthma who presented to ED on 10/24 with low-grade headache and swirling sensation in her head while showering and noticed difficulty with her vision.  She developed tremors in her arms and legs and then whole body tremors as well as vibration sensation.  She called EMS upon attempting to ambulate she noted marked weakness in her legs and shuffling gait.  She had the first Pfizer Covid vaccination shot on 10/23.  Telemetry neurology was consulted and recommends brain MRI as well as entire spine.  Brain, cervical, thoracic, lumbar MRI is all negative.  Head CT without contrast negative.  Neurology did evaluate the patient and did not feel that there was was consistent with Guillain barre as she does have preserved reflexes.  Telemetry neurology did recommend lumbar LP however, after further evaluation w/ neurology inpatient, the exam is not consistent w/ recommending further evaluation at this time. They do recommend PT/OT evaluation and monitor progression, as well as BH consult.  #Severe Cortisol deficiency vs crisis- possibly 2/2 to vaccine? vs other cause.  -F/u on stim testing -Hydrocortisone bolus, followed by 50mg Q6hr  -Monitor effect, may need to taper in am.  #Significant b/l UE and LE weakness, worse in hands and feet w/ hyperreflexia - 2/2 to above, along w/ possible slight contribution of VitB12 deficiency?  -Appreciate Neurology recommends, Brain MRI, lumbar, thoracic, cervical imaging all negative. -TSH nl.                                                                                                                                                                                                                                                                                                      Date of Discharge Summary 10/29/1021 Final Diagnoses 1 bilateral lower extremity greater than upper extremity weakness with visual distortion as well as tremors/vibration sensation of unclear etiology                                                                                                                                                                                                                                                                                                           Hospital Course  -Bilateral lower extremity greater than upper extremity weakness with visual distortion as well as tremors and vibration sensation of unclear etiology: Patient had her first at Pfizer Covid vaccination shot in October 23rd.  She was seen here initially by telemetry neurology and had MRI of the brain as well as her entire spine all of which were negative.  She was seen by inpatient neurology consult who did not feel that this was consistent with Guillain Barre syndrome with patient having preserved reflexes.  The random cortisol level was very low but cosyntropin stimulation test was normal test.  Initially patient was started on a stress dose of hydrocortisone with initial impression of adrenal insufficiency which was weaned off fast with normal cosyntropin stimulation test.  Her lab works including TSH and B12 level liver enzymes and blood chemistry as well as CBC were all normal.  Patient did progress with improvement of working with physical and occupational therapist and on day of discharge from physical therapy standpoint she could be discharged home with family assist for childcare and ADLs to allow patient to gradually progress tolerance to normal level of activity. - Patient was continued on her home medication Wellbutrin for underlying depression, anxiety and PTSD. - Transient hypoglycemia: This resolved with improved oral intake. - History of psoriasis: Patient was continued on her home medications with no evidence of active flareup.