Received May 15, 2026
| Type | Name | Manufacturer | Dose | Lot | Route / Site |
|---|---|---|---|---|---|
| COVID19 | COVID19 (COVID19 (MODERNA)) | MODERNA | 1 | 3053854 | IM / LA |
On 5/12/26 patient received her COVID vaccine at PCP office. That night, Temp of 101. She was crying and seemed to feel miserable. No URI sx, rash, vomiting, diarrhea. Next morning she seemed to be acting herself. Mom checked her temperature intermittently with Tmax 99. That night ate dinner, unsure how much she drank. Patient usually will drink water well throughout the day so parents aren't typically keeping track, but they felt like she was taking in baseline volume. Mother gave patient a dose of Tylenol before bed, not for fever, but she didn't want patient to be uncomfortable overnight. The morning of admission around 0900, parents were cleaning when they heard her crying, then they crying stopped. Mom went to check on her, as she opened the door she saw patient laying there with her eyes open. Usually when mom opens the doors, patient and brother will say "hi" but patient didn't do that. Mom tried to shake patient, her eyes were open but didn't seem to be focusing (no deviation), would slowly blink. Extremities were pretty still at her side, but mom did notice that she would occasionally move her foot. Usual color. Forehead scanner 96. Dad picked her up and held her in his lap, they noted that she was awake and able to sit up unassisted, but still seemed tired and not herself. Parents called 911. EMS arrived in about 15 minutes, GCS 12. Glucose 68. Mom said they gave patient an injection for her blood sugar. Repeat glucose up to 160. Parents deny any possible ingestion. Brother, who shares a room with patient, has been acting appropriately. No recent falls or head injuries. No prior episodes like this. No prior history of seizures.
none
none
multivitamin
none
ER Course: Initial temp 95 -> improved to 98.7. HR 115. RR 28. BP 91/52. Sat 100% RA. Tired appearing on exam. RN noted she didn't react much to urine cath. Monitored for over 2 hours, starting to come to and return to baseline (pointing at things, mimicking vacuum cleaner noises) but not fully. Glucose 129 WBC 7.4 (N56, M11, L31), H/H 11.9/35.3, platelets 179 (mildly low) Na 135, CO2 16, AG 19, LFTs nml CRP 13 UA with s.g. 1.024, 1+ glucose, 3+ ketones, neg LE, neg nit, 2-5 WBC, 0-2 RBC, no bacteria UDS negative Blood culture sent EKG with t wave abnormalities Troponin 6, normal. Emesis x1. Ultrasound neg for intussusception. Triple swab neg. Diagnostic studies ECG (5/15/2026): Normal sinus rhythm Abnormal, notched T wave Mildly prolonged QTc Ventricular Rate: 92 BPM P-R Interval: 130 ms QRS Duration: 64 ms Q-T Interval: 376 ms QTC Calculation(Bazett): 471 ms P Axis: 34 degrees R Axis: 77 degrees T Axis: 35 degrees ECG (5/14/2026): Normal sinus rhythm Prolonged QT Abnormal T wave with a notched wave-form Ventricular Rate: 124 BPM P-R Interval: 120 ms QRS Duration: 70 ms Q-T Interval: 336 ms QTC Calculation(Bazett): 481 ms P Axis: 52 degrees R Axis: 86 degrees T Axis: 56 degrees Laboratory Results (last 24H): Recent Results (from the past 24 hours) GLUCOSE (POCT) Collection Time: 05/14/26 4:30 PM Result Value Glucose via Glucometer 123 (H) RENAL FUNCTION PANEL Collection Time: 05/15/26 6:35 AM Result Value Sodium 138 Potassium 4.2 Chloride 109 (H) CO2 20 (L) Anion Gap 9 BUN 5 (L) Creatinine 0.18 (L) Glucose 91 Calcium 9.0 Albumin 3.5 Phosphorus 4.1 eGFR CKD-EPI Cr 2021 Note: 2021 CKD-EPI is not validated for patients less than 18 years old, consider NKF Pediatric eGFR calculator. MAGNESIUM LEVEL Collection Time: 05/15/26 6:35 AM Result Value Magnesium 1.7 URINALYSIS, COMPLETE Collection Time: 05/15/26 10:55 AM Result Value Color Yellow Appearance: Clear Specific Gravity 1.006 Leukocyte Esterase Negative Nitrite Negative pH 7.5 Protein Negative GLUCOSE Negative Ketones Negative Urobilinogen 0.2 Bilirubin Negative Blood Negative WBC 0-2 RBC 0-2 Bacteria None Squamous Ep None Hyaline Casts None Imaging: US ABDOMEN, LIMITED Result Date: 5/14/2026 Impression: 1. No evidence of intussusception. 2. Echogenic mobile debris within the urinary bladder which can be seen in the setting of concentrated urine, infection or less likely hemorrhage.