Age: 19.0
Sex: M
Vaccine: ANTH, SMALL, ANTH, SMALL
Symptoms: Headache, Hyperhidrosis, Injection site erythema, Injection site induration, Injection site pain
Clinical narrative: The pt. received his primary SPV in his upper left arm on 6/10/14 at 0900. He also received AVA #1 in his right upper arm at the same time. He was in his normal state of good health at the time-no respiratory or GI illnesses within the last 30 days. Within a couple days the pt. noted redness, swelling, induration and pain at the SPV injection site and left axillary lymph node tenderness consistent with a robust take. The pt. did not note any redness, swelling or pain at the AVA injection site. Additionally, he noted generalized muscle aches, joint pain and a headache when exercising. On 6/19/14 at 1900 he noted substernal chest pressure (2/10) and SOB while exercising. His symptoms resolved quickly with rest. On 6/20/14 while running he noted difficulty breathing and chest pressure (6/10). The pt. completed the run finishing in first place-his symptoms lasted a total of 30 minutes and resolved when he rested. During the remainder of day he noted about 4 episodes of chest pressure which lasted at 20 minutes each-the pain worsened with deep breaths and he was also lightheaded. On 6/21/14 after experiencing chest pressure (8/10), palpitations, SOB, N and lightheadedness for 3  hours he went to the ER. The pt. states that his symptoms worsened with lying flat, lying on his side and deep breathing; the symptoms improved with sitting up-leaning forward but made it 'harder to breath". The pt.'s Troponin I was 4.3, CRP was 21.2 and ESR was 19 and his EKG showed Sinus Bradycardia/Sinus Arrythmia with ST elevation. A bedside echo showed no WMA, and no pericardial effusion. The pt. was given TORADOL 30mg IV with pain relief. The pt. was evaluated by the Cardiologist and admitted with the diagnosis of myopericarditis. The pt. was started on Ibuprofen 400mg q6h. The pt. reported that he had a few brief episodes of mild chest pressure (1-2/10) while in the hospital. The pt.'s Troponin I peaked at 23.12 on 6/21/14 at 1854. According to the discharge summary the Troponin I was 1.5 (this lab is not visible in the EMR-the last recorded Troponin I was 15.81 on 6/22/14 at 0254). An echocardiogram was done on 6/22/14: EF 55-60% (see details below). The pt. was discharged on 6/24/14 with a recommendation for 10 days of convalescent leave, a profile for limited duty and a cardiology follow-up appointment on 6/30/14. At his appt. on 6/30/14 he reported experiencing at 4 episodes of mild (3/10) substernal chest pressure daily. These episodes lasted a "few minutes" each, resolved without treatment and were accompanied by N and lightheadedness. The pt. denies palpitations, radiation of the pain, diaphoresis, SOB or V. The pt. reported taking Ibuprofen 400mg q4-6 prn. PE was noted as "normal". The EKG showed Sinus Bradycardia. Troponin I was 0.2. As of 7/22/14 the pt states that he continues to experience intermittent mild (3/10) substernal chest pressure associated with N and lightheadedness lasting for a few minutes to several hours. He denies SOB, palpitations, diaphoresis, radiation of the pain or V. The pt. states that he continues to take the Ibuprofen prn. Encouraged the pt. to take the Ibuprofen qid with food until his pain has resolved. The pt. is scheduled to follow-up with the Cardiologist in mid-August for a possible stress test. Suggested that the pt. be placed on a Holter monitor to evaluated his lightheadedness.