Pt well until approximately 2:55am when she passed out in bathroom according to her husband. Pt was diaphoretic. Denied dyspnea, chest pain, fever, redness, or difficulty breathing.    Patient:  Age:  76 Years  Additional information for Item 18:  Date/Time:  01/22/21 03:19   Time of my initial contact with patient:  0319   Mode of Arrival:  Ambulance   Private Medical Doctor:   Triage Narrative:  Pt. bib medics from home after near syncopal event in bathroom, lowered herself ot the ground, no LOC/trauma. BP on medic arrival was 86/50 HR in 50s, improved to 100/68 w/ lying down and 250ml bolus. Received 1st covid vax today, has felt weak w/ diarrhea since then. Denies pain, skin pale/w/d, AxOx3, resp e/u.       Chief Complaint:  Syncope/Near syncope   History of Present Illness:  This is a 76-year-old female with history of CAD status post remote PCI, previous CVA on Plavix, hysterectomy, migraines who presents ER today for a syncopal event.  Patient was given her first dose of Covid vaccine earlier today, per patient's primary doctor found in prior to arrival she had been very hesitant because she was concerned for triggering migraines, this was clear with her neurologist that she was pretreated with Benadryl, she states that she initially felt fine after vaccine administration, she states however later in the evening she developed 4 episodes of loose watery bowel movements and crampy abdominal pain, she states she was feeling tired and so she laid down to go to bed, she states that she woke up feeling as if she had to have another diarrheal episode, she reports that when she stood up and went to the bathroom she was not feeling well, she reports feeling very lightheaded while on the toilet and trying to have a bowel movement, she attempted to stand up however felt acutely lightheaded, she states that she sat back down the toilet and slumped down and woke up on the ground.  She denies any pain other than her abdominal pain and a sensation that she has had further bowel movements.  Per EMS patient was noted to be hypotensive on arrival 86/50 with heart rate in the 50s, this improved with laying flat on the gurney and given a 250 cc bolus.  Patient has been seen in the past for syncopal events with postural changing.  She denies any new medication changes, she states that she had been drinking water throughout the day but has had a poor appetite no dysuria frequency urgency no headache head injury neck pain back pain new numbness tingling or weakness in arms or legs no difficulty with speech  Problem List & Past Medical/Surgical History:  CAD (coronary artery disease)                                                Dysuria                                                                      Hysterectomy                                                                 Migraine                                                                     Potential stroke                                                             Stent                                                                         Family History:  No related illness  Social History:  The patient does not smoke tobacco or abuse alcohol.    Allergies:   Imitrex  morphine (Nausea)  shellfish  traMADol   Medications:  Available Med List Reviewed   Review of Systems:  All other systems reviewed and are negative except per HPI     Physical Exam:    Vital Signs  BP: 151/93 mmHg   Temp (Oral): 36.4 DegC ( 97.5 DegF)   HR: 73 bpm   Resp: 18 br/min   SpO2: 97 %  GENERAL:  Patient appears well developed, well nourished.  HEENT:  Normocephalic and atraumatic. EOMI. No scleral icterus.  Airway is patent  NECK:  Supple Trachea is midline.  No midline tenderness full range of motion without pain or discomfort  RESP: Lungs are clear to auscultation bilaterally. No wheezing, rhonchi, rales  CARDIOVASCULAR:  Regular rate and rhythm 2+ radial and DP pulses symmetric bilaterally  GASTROINTESTINAL:  Abdomen is soft, mild diffuse tenderness and nondistended. No rebound, no guarding. No pulsatile mass appreciated.  BACK: No CVA or spinal midline tenderness to palpation  MUSCULOSKELETAL:  No clubbing, cyanosis, or edema.  No calf tenderness to palpation.  SKIN:  Warm and dry.  No external evidence of trauma  NEURO: The patient is alert and oriented x3, not confused. Speech not slurred. Normal facial symmetry. No subjective facial numbness. No vision changes. EOMI. Upper and lower extremitites with 5/5 strength globally. Normal sensation noted over all extremities. No subjective dizziness. Finger-to-nose testing normal. Normal gait.  PSYCHIATRIC:  Alert and appropriate.  Test Results:  Labs Results  01/22/21 03:38       134 L 102 9                109        4.2 23 0.6        01/22/21 03:38        12.9         9.6   355         37.8              01/22/21 05:20    Cardiac Studies          Troponin-HS  <2.0         01/22/21 03:38    Hematology          WBC  9.6       HGB  12.9       HCT  37.8       PLT  355       MCV  94       RBC  4.03       MCH  32       MCHC  34.2       RDW  13.1       MPV  6.1 L       Neutrophils  55       Lymphocytes  34       Monocytes  8       Eosinophils  2       Basophils  1       Neut Absolute  5.2       Lymph Absolute  3.3       Mono Absolute  0.8       Eos Absolute  0.2       Baso Absolute  0.1     Cardiac Studies          Troponin-HS  <2.0     Chemistry          Calcium Lvl  8.1 L       Anion Gap  9       Sodium Lvl  134 L       Potassium Lvl  4.2       Chloride  102       CO2  23       Glucose Lvl  109       BUN  9       Creatinine  0.6       Alk Phos  75       ALT  13       AST  15       Bili Total  0.4       Total Protein  5.8 L       Albumin Lvl  3.5       LAB >60       LAB >60         01/22/21 03:17    Chemistry          Gluc POC  106        Gluc POC    106   (01/22/21 03:17)         Diagnostic Results  Preliminary CT head reveals no acute intracranial abnormality  Preliminary CT abdomen pelvis revealed no acute intracranial abnormality other than hiatal hernia  Chest x-ray is negative for acute pulmonary pathology   EKG Results  EKG obtained at 0323 interpreted by me reveals normal sinus rhythm, patient has diffuse T wave flattening which appears similar to previous no STEMI, no ectopy no heart block no WPW Brugada prolonged QTC  Emergency Department Course and Procedures:  Medications, IV's and Blood Products Ordered  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus)  1,000 mL once IV Bolus, Reason for Infusion = Abnormal fluid losses    Other Orders  Nursing to Initiate Saline lock Insertion Careset (Stat)  Oxygen Therapy (Titrate for SaO2 > 95%)   Reexamination/Reevaluation:  Critical Care Note  The high probability of sudden, clinically significant deterioration in the patient's condition required the highest level of my preparedness to intervene urgently.   Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: cardiac failure, circulatory failure, CNS failure or compromise, dehydration, hepatic failure, endocrine crisis, metabolic crisis, renal failure, sepsis, respiratory failure, shock, toxidrome and trauma.  I provided critical care services requiring my management in the following manner: chart data review, documentation time, medication orders and management, re-evaluations, vital signs assessments and reviewing monitor data, and ordering and reviewing lab tests.  Aggregate Critical care time was 30 minutes.  My time did not include minutes spent treating any other patient simultaneously or on activities that did not directly contribute to the patient's treatment.  It did not include time spent performing other reported procedures.  Medical Decision Making:  This is a 76-year-old female who presented ER today for evaluation of syncope.  Patient was reportedly mildly hypotensive which improved with IV fluids.  I suspect that patient had dehydration given 4 episodes of large watery stools.  Patient had no recent antibiotic use and has no C. difficile risk factors, suspect this may be related to her Covid vaccine, she had no evidence to suggest anaphylactic shock, patient felt better after IV fluid bolus was able to ambulate around the emergency department without lightheadedness or near syncope.  She had troponins x2 which were negative, her EKG was nonischemic and there was no evidence of ectopy or arrhythmia.  Patient did have syncope and fell onto her side, she denies discrete head injury although patient is anticoagulated, CT head was obtained to rule out intracranial hemorrhage given the syncopal event.  Patient CT abd/pelvix was negative for obvious cause of patient's abdominal tenderness may be related to her diarrheal illness patient will be prescribed Bentyl.  She will call her primary care doctor in the morning to arrange close follow-up.  She understands need for aggressive oral hydration at home.  She will have low threshold to return should she develop lightheadedness syncope chest pain shortness of breath palpitations worsening abdominal pain bloody or dark stools any new or concerning symptoms.  The patient presented to the emergency department with potentially life or limb-threatening symptoms.      After my history, examination, and workup have decided that the patient is stable.    My impression is that they are safe to go home at this time.  I have reviewed ED return precautions with the patient. They understand to return if they are concerned for any reason.   They will follow-up with their PCP in 1-2 days.        Impression:  Syncope, hypotensionimproved, dehydration  Plan:   Discharge   Follow Up    Within: 1-2 days    Comments: Please call your doctor in the morning to arrange follow-up with your primary care doctor in the next 24 hours.  Please stay well-hydrated and eat regular meals.  Please take Bentyl as needed for abdominal cramping with diarrhea.  Please return to the ER if you develop worsening abdominal pain, feelings of lightheadedness passing out any new or concerning symptoms.    Patient Education  Syncope, Easy-to-Read  Diarrhea, Adult    Discharge Meds  dicyclomine  10 mg 1 cap, PO, QID, 20 cap  Referral for suspected pre-hypertension or hypertension was given.           Please note: Unless specifically stated, all procedures mentioned, tests done and medications given were performed/interpreted by the emergency physician, or were under the direct supervision of the emergency physician.  This ED Note was completed using voice-recognition transcription and may contain inadvertent errors.  Additional information for Item 9: