Age: 39.0
Sex: F
Vaccine: COVID19
Symptoms: Urine abnormality, Urine analysis, Urine bilirubin decreased, Urine ketone body present, Urine leukocyte esterase
Clinical narrative: Patient presents with ? Altered Mental Status ? Headache     HPI Patient presents to ER by EMS ambulance after family called 911 as patient was incomprehensible with slurred speech and moaning on the phone this evening. On arrival of EMS patient was asleep in bed and reportedly unresponsive other that to localize to pain. EMS transferred patient to ER. On arrival to ER patient had GCS 7. Reportedly patient is locum nurse who works in a Nursing Home and patient reportedly received COVID vaccination 2 days ago and that night reportedly began complaining to family on the phone of headache, nasal congestion, sore throat, cough, fever, chills, nausea, emesis, myalgias, and lethargy. Per the medical record patient has history of seizures, migraines, and sciatica. No other information is known on patient arrival to ER.  1. Peripheral IV right dorsal hand placed by EMS in route to ER. 2. On arrival to ER GCS 7 (E1M5V1) and roving eye movements with episodic lateral conjugate and at times disconjugate gaze concerning for seizure activity. Arms and legs with moderately increased tone but no clonic movements and patient able to localize bilaterally. 3. Ativan 1 mg IVP for seizure, then further 2 mg IVP for persistent seizure. 4. Fosphenytoin 1,000 mg IVPB in ER for loading dose of antiseizure medication.  5. Patient had significant improvement following completion of Ativan 3 mg IVP and GCS improved to 14 (E3M6V5) from GCS of 7 (E1M5V1). 6. Patient able to communicate after improvement as above and reports she has had headache or migraine for past several days as well as dysuria with bilateral CVA pain and has significant pain on percussion of bilateral CVA and moderate pain on palpation of bilateral flanks. No nuchal rigidity or pain with ROM of neck.  Additionally, she complains of severe headache and diffuse pain of back and abdomen/pelvis. She reports a history of seizures in the past and reports she had one last month and was treated at a hospital in her home state. She denies antiseizure medications. Additionally, patient reports nonproductive cough, sore throat, nasal congestion, fever, chills, myalgias, lethargy, nausea, and episodic emesis over the past 2 days. She has anterograde amnesia following seizure and does not recall events. 7. Normal saline 1,000 mL IV bolus, then 100 mL/hour in ER. 8. CT of head with and without contrast performed and negative for intracranial hemorrhage, lesions, stroke, or other acute pathology. 9. CT of chest/abdomen/pelvis with IV contrast shows no acute pathology or notable abnormalities. 10. Lactic acid drawn and normal. 11. UA and urine microscopy collected by straight catheterization and culture collected and pending. 12. Blood cultures x 2 collected and pending. 12. Rocephin 2 mg IVPB in ER after blood cultures collected.  13. Vancomycin 20 mg/kg (1,500 mg) IVPB following Rocephin.  14. Dexamethasone 10 mg IVP in ER. 15. Duoneb nebulizer in ER. 16. Called to discuss with patient's daughter and the family's preferred contact who is 23 years old. She reports patient had COVID vaccination 2 days ago and beginning that night patient has complained of headache, fever, chills, nonproductive cough, sore throat, nasal congestion, myalgias, and lethargy. Additionally, she reports patient has history of seizures on at least 1 occasion in the past a few months ago but is not on antiseizure medications. She reports patient had MRI and MRA of her brain at that time and reportedly and intracranial aneurysm was identified at that time. 17. Called to request transfer to another facility and spoke with hospitalist who states there is no neurologist there and suggests transfer to larger tertiary care facility with neurology.  18. Called to request transfer and accepted by ER provider. 19. Transfer by ALS ground ambulance with telemetry, pulse oximetry, O2 to keep > 02%, vitals every 30 minutes, normal saline at 100 mL/hour, Rocephin 2 grams IVPB, vancomycin 20 mg/kg (1,500 mg) IVPB in ER.    DISPOSITION Patient Stabilized and Transferred Data Unavailable Wed Dec 30, 2020  2:12 AM CST