Age: 16.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Electrocardiogram abnormal, Fluid intake reduced, Headache, Hypophagia, Immunoglobulin therapy
Clinical narrative: HISTORY OF PRESENT ILLNESS:  Patient is a 16-year 4-month-old previously well male admitted to the ICU from the emergency room at Hospital where he presented with a 1 day history of chest pain.  3 days prior to admission Patient had his second Pfizer Covid vaccine.  The evening of receiving the vaccine he started to have elevated temperature for 2 days to as high as 103.  He did not take any medication and it has self resolved.  2 days prior to admission he had occipital headache.  He also had decreased p.o. intake of fluids and food.  He started to have sternal chest pain that felt pressure like starting 11 AM yesterday morning.  This abated but came back in the middle of the afternoon.  He had some nausea and retching that self resolved.  He was able to eat dinner last night but had recurrence of chest pain about 9:00 that he described as a 7.5 to 8.5/10 on a pain scale.  With this he was brought in for evaluation.  On EKG he has no evidence of ST elevation and troponin is markedly elevated at nearly 28,000.  Cardiology was contacted and recommended admission echocardiogram this morning as well as initiation of aspirin. ASSESSMENT: Patient is a 16-year 4-month-old male with chest pain associated with myocarditis of at this point undetermined etiology but suspect post Covid vaccination    Discharge Summary  HPI: Patient is a 16-year 4-month-old male admitted early on 8/20/2021 with chest pain, elevated troponin and abnormal EKG 3 days following second Pfizer Covid vaccine.   Physical Exam today: He is alert active conversational no acute distress.  GCS 15.  No neurologic deficit.  Heart has a regular rate and rhythm with normal S1 and S2.  Lungs are completely clear with equal breath sounds bilaterally symmetrical.  Abdomen is soft flat benign exam with no hepatosplenomegaly.  Peripheral pulses +2/4 with capillary refill of 2 seconds   Hospital Course by Systems:  CNS: He had occipital headache the day prior to admission.  He has had no significant headaches since.  He had very limited chest pain the first day of admission but has had no subsequent chest pain.  CV: The a.m. after admission he had an echocardiogram that was normal.  Troponins have been followed serially starting at 28,000 (normal reference range <76) decreasing 4 hours later without therapy to 23,000.  Echocardiogram showed normal function and no pericardial effusions.  Initial EKG showed ST elevation.  After consult with cardiology he was given IVIG 2 g/kg.  The a.m. after infusion his troponin increased to 25,000.  Repeat echo was again normal with vigorous function.  Troponin this morning is down to 14,000.  CRP started at 10 and is down to 3.5.  BNP and ferritins have been normal.  He is discharged today with follow-up troponin, BNP, CRP and ferritin to be obtained on an outpatient basis tomorrow.  He will see Dr. on Tuesday with echocardiogram.  Our office will arrange for cardiac MRI and cardiac Covid team Hospital to see him this week.  Limited physical activity with no strenuous activity this week.  No caffeine.  He will continue with ibuprofen 400 mg 3 times daily and 3 baby aspirin (243 mg) daily.  Pulm: From a respiratory standpoint he has had excellent saturations on room air with no need for supplementation  FEN/GI: He has been eating well throughout  Renal: Urine output has been satisfactory though incompletely collected  Hematologic: No acute issues Endocrine: free T4 normal at 1.12 and TSH slightly elevated at 5.67  ID: Respiratory PCR including Covid was negative at the time of admission.  Monospot negative.  Covid IgG was positive as expected following first Covid vaccine on 7/23/2021.  It is felt felt that his myocarditis is related to Covid vaccine.  PS: I reviewed all of the above issues with father.  Questions were answered including mother's over the phone.  If he has any recurrent chest pain he is to return.   Medications:  Current Facility-Administered Medications Medication ? aspirin chewable tablet 243 mg ? ibuprofen (MOTRIN) tablet 400 mg ? lidocaine cream 4 % dressing kit ? ondansetron (ZOFRAN) injection 8 mg   Current Outpatient Medications Medication Sig ? aspirin 81 MG chewable tablet Chew 3 tablets (243 mg total) by mouth daily. ? ibuprofen 400 MG tablet Take 1 tablet (400 mg total) by mouth 3 (three) times daily for 10 days.       Assessment: Patient is a 16-year 4-month-old male with myocarditis secondary to Covid vaccine