Age: 43.0
Sex: M
Vaccine: ANTH, HEP, ANTH, HEP
Symptoms: Myocardial infarction, Pharyngitis, Rhinitis, Rhinorrhoea
Clinical narrative: This report is to follow-up on his history of MI temporally associated with receipt of vaccines and to report his development of increased dyspnea on exertion, a paralyzed left hemidiaphragm, right lower lobe nodule, and patchy interstitial disease.  History of Present Illness: Patient is a 43 yo male with a history of hyperlipidemia and family history of premature coronary artery disease who had an Inferior MI (99% occlusion of RCA) with subsequent stent placement in December 2003.  He is now undergoing pulmonary evaluation for a paralyzed left hemidiaphragm, right lower lobe nodule, and patchy interstitial disease.    Cardiac: He initially reported in Feb 2003 to report his condition, and he now returns for follow-up.  He had received his primary smallpox vaccine, Hep A #1, Hep B #1, MMR, IPV, TD, Typhoid, Anthrax and Influenza on 14 Oct 03 with report of mild cold-like symptoms and continued baseline shortness of breath, but no chest pain.  He received Anthrax #2 on 27 Oct 03 with no report of systemic symptoms.  He received Anthrax #2 and Hep B #2 on 01 Dec 03 and developed chest pain on 02 Dec 03.  He was admitted on this date and transferred on 03 Dec 03 where he underwent cardiac catheterization which showed subtotal occlusion of the mid right coronary artery with thrombus.  He was treated with percutaneous transluminal coronary angioplasty and stent of this vessel.  (Please see VHC summary dated 03 Feb 03 for further information.)  He had a normal stress test on 05 Feb 04.    Since his last follow-up with the VHC 29 March 04, he reports occasional chest pain that occurs once or twice a day an average of every other day.  He notices the chest pain more often when he is walking but reports that it can also occur at rest.  He describes it as a sharp, non-radiating pain on the left side of his chest that is a 6 on the pain scale (0-no pain to 10-worst pain ever).  He states that it lasts about 4-5 seconds and then resolves on its own.  He has NTG SL spray but has not required its use.  He does not note any worsening with inspiration or position change.  He denies any fatigue, cough, or pedal edema.  His previous report of dizziness resolved after discontinuation of Altace.    Pulmonology: He had a chest x-ray (12/2/03) that showed left hemidiaphragmatic elevation or uncertain etiology or chronicity.  He then had a Chest CT with contrast (12/02/03) that showed marked elevation of the left hemidiaphragm, bilateral basilar, patchy, parenchymal opacification with a "ground glass" appearance which did not appear to be associated with bronchiectasis.  The CT also showed a single noncalcified 5 mm nodule evident within the right lower lobe peripherally.  A follow-up Chest X-ray on 12/3/03 showed left lower lobe subsegmental atelectasis.    He was referred to a pulmonology specialist for follow-up of the Abnormal Chest CT results.  He last saw the doctor on 04 May 04 and has a diagnosis of paralyzed left hemidiaphragm, right lower lobe nodule, and patchy interstitial disease.  He underwent a transbronchial biopsy of right middle lobe and lingula on 27 Apr 04 and the biopsy result showed focal increased nonspecific fibrosis and chronic inflammation and no evidence of malignancy.  The patient is scheduled for a fluoroscopy on 06 May 04 and he will also be scheduled for an open lung biopsy for further evaluation.  He reports that the doctor has discussed with him the possibility of starting steroids after his open lung biopsy.  He continues to experience shortness of breath that is worse with exertion, particularly with walking up a flight of steps.  He denies any dyspnea at rest or nocturnal dyspnea.  He denies any history of asthma, emphysema, or COPD.  He is a non-smoker but reports that he is around a lot of secondhand smoke.  He denies any exposure to birds or farm animals.  He has exposure to cats, 1 dog, and ferrets in his home.  He reports that he believes he was exposed to mold when he lived in the barracks from Oct 2003 to Dec 2003, as he had to have his mattress exchanged due to mold and noted mold in the bathrooms.  He denies any exposure to humidifiers, standing water, saunas or Jacuzzis, dry wall, or old carpeting.  In 1992, he was in a motor vehicle accident and suffered from left anterior chest wall injuries with significant bruising but no pneumothorax.   He reports that his weight is currently at 193 pounds (height is 72 inches with BMI=26.2), and he weighed an average of 181 prior to his MI (BMI=24.5).  He reports that his energy level is good, and he is trying to increase his physical activity.  He currently walks ½ mile to 1 mile a day.  (Previously, he ran a couple of miles each day.)  He is now averaging 30 push-ups and 30 sit-ups every other day.  (Previously, he did 50-100 push-ups and 50-100 sit-ups every other day.)    He remains in Med Hold and will be undergoing a medical board evaluation.