Age: 34.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Headache, Painful respiration, Pericarditis
Clinical narrative: Basic Information Time seen: Date & time 05/16/2021 04:38:00. History source: Patient, EMS. Arrival mode: Ambulance. History limitation: None.  History of Present Illness The patient presents with chest pain. The onset was 5 hours ago. The course/duration of symptoms is constant. Location: generalized.  Time seen: Date & time 05/17/2021 10:20:00. History source: Patient, EMS, interpreter. Arrival mode: Ambulance. History limitation: Language barrier.  History of Present Illness The patient presents with 34-year-old male returns for continued chest pain. Apparently, seen in the emergency department at our institution and admitted followed by discharge. Today, he followed up with  an urgent care clinic where they felt he is having acute EKG changes consistent with an ST elevation MI, called EMS and he is transferred to our emergency department for further evaluation. Impression and Plan Diagnosis Chest pain rule out acute coronary syndrome/pericarditis.  Time seen: Date & time 12/13/2021 10:18:00. History source: Patient, interpreter. History limitation: Language barrier.  History of Present Illness The patient presents with 35-year-old male presents ambulatory with complaint of anterior chest wall pain x2 days. States this is consistent with prior pericarditis he had approximately 6 months ago. Has some mild shortness of breath and headache but denies fever or chills. No cough. Has been vaccinated for COVID-19. Pain is nonradiating and does not cause diaphoresis or nausea. Denies any recent surgical procedures, long distance travel or hormonal replacement therapy.. The onset was 2 days ago. The course/duration of symptoms is constant. Location: anterior. Radiating pain: none. The character of symptoms is achy. The degree at onset was minimal. The degree at maximum was moderate. The degree at present is minimal. The exacerbating factor is exertion. The relieving factor is rest. Risk factors consist of Pericarditis. Prior episodes: Pericarditis.  Impression and Plan Diagnosis Chest pain rule out acute coronary syndrome Probable pericarditis  Additional information: Chief Complaint: chest pain (04/12/22 09:25:00), ED Mode of Arrival: Ambulatory/WC/Carried (04/12/22 09:25:00).  History of Present Illness The onset was 1 days ago. The course/duration of symptoms is constant. Location: Generalized substernal. Radiating pain: none. The character of symptoms is sharp. The degree at onset was moderate. The degree at maximum was moderate. The degree at present is moderate. There are exacerbating factors including movement, breathing and coughing. The relieving factor is leaning forward. Risk factors consist of hyperlipidemia, not coronary artery disease, not hypertension, not diabetes mellitus, not smoking, not obesity, not pulmonary embolism, not deep vein thrombosis and not family history of coronary artery disease. Prior episodes: none. Therapy today None. Associated symptoms: denies shortness of breath. 35-year-old with history of pericarditis presents today with chest pain. States it feels like his previous episode of pericarditis. Is dependent on certain movements and position. Its worse when he takes a deep breath or coughs. Pain is sharp, nonradiating. Denies any recent colds or congestion. No fevers. He has had intermittent cough. Vaccinated for COVID. No leg swelling or calf pain.  Impression and Plan Diagnosis Acute pericarditis Plan Condition: Stable. Disposition: Discharged: to home. Patient was given the following educational materials: Pericarditis, Pericarditis, Pericarditis, Pericarditis, Acetaminophen; Hydrocodone tablets or capsules, Acetaminophen; Hydrocodone tablets or capsules, Pericarditis, Pericarditis, Pericarditis, Pericarditis, Acetaminophen; Hydrocodone tablets or capsules, Pericarditis, Pericarditis, Pericarditis, Pericarditis. Follow up with: Within 3 - 5 Days cardiologist Call to arrange an appointment; Follow up with primary care provider Within 3 - 5 Days, cardiologist Within 3 - 5 Days cardiologist Call to arrange an appointment; Follow up with primary care provider Within 3 - 5 Days make an appointment with your primary doctor to refer you to a rheumatologist for your recurrent pericarditis