Age: 29.0
Sex: F
Vaccine: COVID19
Symptoms: Anion gap normal, Anxiety, Aura, Base excess, Basophil count normal
Clinical narrative: Patient is a 29 yo F with PMHx of psoriasis who presented for dose #1 of Pfizer vaccine, she received her vaccine without issues and was being monitored for 15 minutes as recommended. Within her first 10 minutes of being monitored patient notified the staff that she felt warm, within one minute from her complaint of feeling warm she had a full general tonic clonic seizure in her chair for about 15 seconds with associated diaphoresis and thready pulse. Seizure activity broke spontaneously and pt was AO x 3. 911 was called immediately, she was transferred to our medical observation area for further monitoring and examination.   Her initial vitals after seizure activity T: 97.5, HR 69, BP 130/77, 02: 98%, BS within first 10 minutes of monitor without food/water was 134.    Exam: GEN: AO x 3 HENT: nc/at, anicteric sclera, EOMI CV: regular, nl s1, s2, no mrg PULM: clear bilaterally NEURO: grossly intact SKIN: clammy   Upon further questioning pt states she had a similar response while in college to Yellow Fever vaccine but never had an evaluation. She has had vasovagal events with other vaccines and blood draws. She denies any neurological history other than seizure like activity with Yellow Fever vaccine.    She states she had an aura with tunnel vision and feeling warm similar to when she had Yellow Fever vaccine.   She denied any nausea, she was alert and oriented x 3 after resolution of seizure activity. She was transported to ED for further evaluation. Report was provided to  at ED.  Seen by Neuro on 4/23/21: Interim History: Patient is a 30 yr, right-handed woman with no significant medical history who is referred for evaluation of an episode of LOC.   The episode occurred on 4/9/2021,10 minutes after receiving the 1st dose of the COVID-19 Pfizer vaccine. She reports feeing anxious after receiving the dose because of the history of having passed out after receiving vaccines. As with the previous events, she felt "hot and clammy" and had tunnel vision before losing consciousness for approximately 15 seconds.  She was told that she "shook all over" for a few second. Upon regaining consciousness, she was oriented almost immediately and was not confused. The episode occurred while sitting.    Patient reports a history of at least 5 syncopal events, since age 12 yr, with 4 of these occurring while sitting and 2 while standing. All of the evens have occurred either after receiving vaccines in 2016 or undergoing medical procedures. Two of the events also include shaking movements but none have been associated with tongue biting, urinary incontinence or post event confusion.    She also reports a  history of episodes of lightheadedness with postural changes but denies palpitations, CP or SOB.  She has never had a neurological or cardiac evaluation.    There is a history of a mild concussion while playing soccer. There is no history of CNS infections, febrile seizures or family history of neurological disease.   Other Medications: ?  adapalene, APPLY TOPICALLY NIGHTLY. APPLY A THIN LAYER AT NIGHT TO ACNE-PRONE AREAS. START EVERY -OTHER NIGHT AND ADVANCE AS TOLERATED ?  clindamycin-benzoyl peroxide, APPLY TOPICALLY TWO TIMES A DAY   Problems: has Vasovagal syncope on their problem list.   Permission to discuss medical information with:    Referring MD / Other MD(s):                                                        Current Providers PCP: APRN Referring Provider: APRN Care Team Provider: APRN   Allergies: Allergies Allergen Reactions ? Pfizer Covid-19 Vaccine (Eua) [Covid-19 Vacc,Mrna(Pfizer)(Pf)] Seizures ? Bactrim [Sulfamethoxazole-Trimethoprim] Rash   Medical History:  has a past medical history of Psoriasis and Vasovagal syncope.   Psychiatric History: none   Family History: family history includes Depression in her brother; Heart murmur in her mother; Hypertension in her father.   Social History:     Social History   Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used Substance Use Topics ? Alcohol use: Yes     Alcohol/week: 0.0 - 2.0 standard drinks     Review of Systems: ROS   Objective: BP (!) 166/99  | Pulse (!) 105  | Temp 97.7 °F (36.5 °C)  | Resp 14  | Ht 5' 7" (1.702 m)  | Wt 56.7 kg  | SpO2 99%  | BMI 19.58 kg/m²    The BP obtained after the consultation was 145/89   Neurologic Exam Physical Exam General: well appearing, well nourished, no distress, normal affect, cooperative. No rashes or skin lesions.  Peripheral pulses intact throughout. Mental Status: Orientation: Alert, oriented to time, place and person. Memory: Remote and delayed recall intact.. Language: Speech fluent. Able to name, repeat and follow three step commands.   CN: II: Full visual fields, fundi normal, PERRL.  III, IV, VI: EOMs full, no nystagmus. V, VII: Facial sensation and movement intact. VIII: Hearing intact. IX, X: Palate elevates normally.  XI: Normal.  XII: Tongue midline.    Motor: Normal bulk and tone. 5/5 power throughout. No pronator drift. FFMs quick and accurate bilaterally.    Coordination:  Normal FTN.  No tremor.   Sensation intact to light touch in all 4.    Reflexes:  3/4 and symmetric throughout with downgoing toes.   Gait: Normal, including tandem   Romberg: Negative   Assessment Patient  is a 30 yr old woman with a recent episode of LOC that is consistent with convulsive syncope, despite occurring while sitting, 10 minutes after receiving the first dose of the COVID-19 vaccines. She has a history of similar episodes occurring after vaccinations or medical procedures. She reports episodes of pre-syncope and postural lightheadedness. She does not have risk factors for epilepsy and the episodes have an atypical duration for convulsive seizures.   In my opinion, the recent event is not an allergic reaction to the vaccine and there is no contraindication for receiving the 2nd dose.    Plan: I suggested taking lorazepam 1 mg prior to getting the 2nd dose of the COVID vaccine and to consider consultation with a cardiologist at some future time (but not required prior to obtaining the 2nd dose).   I did not recommend an EEG or brain MRI scan.   Follow-up will be on a PRN bases.