Age: 25.0
Sex: M
Vaccine: ANTH, JEVX, SMALL, TYP
Symptoms: Streptococcus test negative, Troponin I increased, Viral infection, White blood cell count increased
Clinical narrative: On 2 May 2019 (9 days post-receipt of SPV), onset of fever and chills - felt "like burning up". He also felt fatigued and achy, and had a headache. Also, onset of constant, nonradiating, substernal chest pain (CP). Pain intensity rated as 7-8/10. Pain was worse with lying supine and deep breaths. Pain decreased slightly with leaning forward. Describes sensation of heart pounding hard and racing (HR 118). Also, felt "like I couldn't get enough air". He denied nausea, vomiting, diaphoresis, and lightheadedness. Sought evaluation for chest pain - Emergency Dept (ED), 2 May 2019: Vital signs: BP 135/77, HR 118, RR 20, Temp 101. Physical exam was within normal limits. Dx'd with Acute Viral Syndrome and prescribed Z-pack, Tylenol, and Motrin. That night, patient reports taking Tylenol and Motrin as prescribed. However, he was unable to sleep due to pain. On 3 May 2019, patient's symptoms continued (CP 8-9/10), and that evening, he returned to the ED (3 May 2019): Patient denied sore throat, cough, pedal edema, dizziness, headache, or rashes. His CP was treated with Toradol w/o symptom relief. In the ED, patient had ECG changes and an elevated Troponin-I. He was diagnosed w/ myopericarditis and was transferred and admitted to Hospital. During phone consultation on 9 May 2019, while patient still hospitalized, he reported he continued to experience ongoing CP, but less severe. He reported his CP was treated with Fentanyl. High dose ASA and colchicine were initiated while hospitalized. On 10 May 2019, Patient was evaluated in his Primary Care Clinic. He reported feeling "much better". He denied chest pain, shortness of breath, dizziness, feelings of heart racing, and headache. He was instructed to take Colchicine 0.6 mg 2x/day (x 3 months), Ibuprofen 600 mg 3x/day, and Zantac 150 mg 2x/day. He was placed on a limited duty profile for 2 weeks, with an activity restriction for 3 months. === Follow-up in May 2020: still symptomatic and awaiting Cardiology and Pulmonology evaluations, but due to COVID-19 restrictions, he is not sure when he will be evaluated. Has profile to "exercise at his own pace"; he can jog at a slow pace for about 1 mile, but then becomes short of breath and will experience sharp, substernal chest pain (7/10) that lasts less than 1 minute. He also reports these brief episodes of chest pain at rest. He sometimes notes his heart is racing, but denies irregular heart beat or pedal edema. Patient's last Cardiology evaluation was in Jul 2019. He failed his health test in Oct 2019. He is not taking any routine medications. He denies any significant changes in his health history - denies new diagnoses or conditions requiring evaluation; no recent surgeries === Per Cardiology, Aug 2020:  IMPRESSION/PROBLEM LIST: 1. Prior history of myopericarditis. a. During 2019. b. Believed to be secondary to the smallpox vaccination. c. Echocardiography, cardiac MR imaging, exercise stress testing, and cardiac CT coronary angiography have been unremarkable. d. The patient has been followed and managed by Cardiology. 2. Chronic chest pain. 3. Dyspnea. 4. Hyperlipidemia. 5. Past tobacco use (cigarettes). 6. A medical evaluation has been initiated. PLAN: ----At this time, no further cardiovascular evaluations, tests, studies, or investigations are required. ----At this time, from a cardiovascular perspective, the patient has no physical or duty limitations/restrictions. ----Aggressive risk factor modification. ----Continued smoking cessation. ----Heart healthy diet. The patient will be referred to Nutrition. Fasting bloodwork should be checked after at least 4 months of following strict dietary changes and therapeutic lifestyle modifications. ----The patient should never again receive the smallpox vaccination. ----The patient should be evaluated for non-cardiac etiologies for his symptoms. This evaluation is deferred to the patient's PCM.