PRESENTING PROBLEM: Syncope and collapse [R55]   HOSPITAL COURSE: History of Present Illness:  57-year-old man known to me for bilateral lung transplant for bronchoalveolar cell carcinoma complicated by bilateral pleural effusions of unknown etiology and mild decrease in pulmonary mechanics, DVT on Eliquis who came to the Emergency Room 3/12/21 with a chief complaint of near syncope.   Patient and woke up in the early morning hours of 3/12/21 to use the restroom.  While urinating, he became very dizzy and nauseated and had a sense like he needed to lay down to rest.  Other than nausea he did not have any other symptoms.  He returned to his bed and fell upon his wife and had decreased level of consciousness but without total loss of consciousness (he was able to hear his wife talking to him but was unable to respond).  This lasted about a minute and slowly he came back to his senses.  After this he felt quite cold and did have some shaking but is not clear whether these were true rigors.  He did not have any preceding fevers nor did he have any fevers in the emergency room.  After about 5-10 minutes he was feeling back to his normal self but want to come into the hospital to get checked out.   He has never had anything like this before.The patient has had chest pressure since his COVID vaccine which he had on Wednesday.  This is been intermittent, mostly positional and better with laying on his side and leaning forward, worse with recumbency.  It is not pleuritic in nature.  No associated shortness of breath.  No other fevers chills sweats.  No sick contacts.   Evaluation in the emergency room was done and a CT scan was done and no pulmonary embolus was found.  No parenchymal abnormalities.  The patient's pleural effusions remain, and her mildly worsened, personally reviewed. Baseline labs were unremarkable for anemia, kidney injury.EKG personally reviewed, normal sinus rhythm. High sensitivity troponin was done and negative.  Family otherwise feels well, no sick contacts, eating well no nausea vomiting diarrhea blood in his stool.   Pt admitted for observation. Continued to feel well VSS, ekg stable, ECHO without acute findings (see below), UA neg, cardiac monitoring uneventful, orthostatics negative, walking in halls and eating well. Appears to have had vaso vagal episode. Will be getting routine head imaging in the coming month with cancer history   See below testing     Care plan upon discharge > To call if any return of symptoms > To hold metformin until Monday due to recent dye load > Blood cultures  Pending, low clinical suspicion   > To change H2 blocker to PPI due to GERD on 3 month esophagram > Follow up in clinic when return from break > Dr discussing with pulmonary team most recent CT (see below) and treatment plan moving forward   Brief exam: awake, alert, oriented, not in any distress. PERRL, EMOI, tongue midline. Upper and lower extremities at full strength 5/5 in the arms, hands, dorsi flex and flexion at the ankles, knees and legs. Sensation not tested.    Brief history and medical decision making: s/p bilateral lung transplant for bronchoalveolar cell carcinoma complicated by bilateral loculated pleural effusion, DVT on eliquis presenting post syncopal event.  Syncopal event without evidence of seizure like activity, fast recovery, and no sudden changes consistent with an acute cardiac event. Thus symptoms were likely due to vasovagal event possibly post COVID_19 related side effect (headache, achy muscles, not feeling well overall). He has no neurologic deficit, CTA thorax without PE, negative EKG, troponin and echocardiogram. He is not on antihypertensives and blood pressures have been normal. Given his initial diagnosis of BAC, there may be concern for metastatic disease, though symptoms have not persisted and he has no focal deficit. He also received contrast for his CTA today, thus will defer further imaging for now.   Syncope: - defer 2nd dose of COVID-19 vaccine as its effectiveness in transplant patient is not established and patient potentially had an adverse event.  - oral hydration encouraged - monitor for additional ongoing neurologic symptoms such as headaches, vision changes, neck stiffness, fevers, night sweats, weight loss, weakness or paraesthesias - patient advised to avoid driving until further evaluation - consider MRI brain with and without contrast if any symptoms persist or reoccur   Complex loculated pleural effusion