Age: 13.0
Sex: M
Vaccine: COVID19
Symptoms: Echocardiogram normal, Ejection fraction decreased, Electrocardiogram ST segment elevation, Epstein-Barr virus antibody positive, Fibrin D dimer increased
Clinical narrative: Admission Date/Time: 07/19/2021 20:06:00 Discharge Date/Time: 07/23/2021 11:31:21  Chief Complaint  chest pain  Patient Narrative ILLNESS SEVERITY:   The patient is stable, returning to baseline.   PATIENT SUMMARY:  Reason for Hospitalization: Chest discomfort, myocarditis.    Admission HPI: a 13 year old boy with a history of hypertension and mild intermittent asthma who is presenting with several hours of shortness of breath and chest discomfort with deep breaths.   2 days ago prior to presentation, he developed a low grade fever that lasted for 1 day. He did not measure a temperature but took some Motrin. At the same time he was experiencing abdominal pain and diarrhea, the latter of which has persisted. He does not think the diarrhea has been bloody but is unable to describe the color or consistency. The day of presentation, he began experiencing mid-sternal chest discomfort that sometimes worsened with deep breaths, though not every deep breath. It was associated with a mild headache. He denies palpitations, light headedness, orthopnea, or syncope. No other symptoms of illness including cough, congestion, runny nose, itchy eyes, rash, wheezing, or emesis. No known sick contacts. Given the nature of his chest pain, he presented to the ED for further evaluation.  Of note, he received his 2nd Pfizer Covid vaccine on July 7. He experienced some mild arm discomfort afterwards but no fevers/myalgias/chest pain in the following days.   In the ED, he was well appearing with normal vital signs. He denied any active chest pain or shortness of breath, though continued to endorse mild abdominal discomfort. An EKG was performed which was notable for diffusely elevated ST segments, particularly in leads II and III.  Labs are significant for elevated troponin to 0.13, d-dimer to 1.05, ESR of 76, CRP of 9.35, WBC 9, Hgb 11.9, and negative covid antibodies. CXR was benign. Decision was made to admit to Cardiology for close monitoring and further workup.  PMH: significant for elevated blood pressures in the past, seen in Nephrology clinic in 2019 with unremarkable workup including renal ultrasound, blood and urine studies. Believed to be in large part attributed to anxiety, though does have a family history of ESRD.  Surg: T&A at 4-5 years of age  Allergies: NKA  Meds: only PRN albuterol (last used 1 year ago)  Fam history: + for ESRD, negative for cardiac or autoimmune diseases  Social: everyone at home healthy, nobody has had COVID. Going into 8th grade, wants to learn about space  Hospital Course: He was admitted to the cardiology floor for continued monitoring of his troponin levels and EKG. His chest pain resolved shortly after admission and he remained asymptomatic through admission. The morning after his admission, his troponin was stable at 0.12 and echocardiogram showed no abnormalities with normal function. Troponins were trended and remained stable. Inflammatory markers were trended and improved. Cardiac MRI performed prior to treatment showed a small area over the posterior LV free wall of late gadolinium enhancement. EKG showed stable ST elevation in inferior and lateral leads. Presentation was most consistent with viral myocarditis.  Given increasing troponin, he was treated with IVIG (2g/kgx1) and steroids (5 day total). His inflammatory markers down trended and resolution of symptoms throughout admission (ESR falsely elevated after IVIG), and had improvement in his troponin after treatment with IVIG and steroids. EKG were stable during admission.  By time of discharge, patient was well-appearing, vitals stable, demonstrating good PO intake. Chest pain was fully resolved. Follow up with cardiology in place. Discharge instructions and return precautions reviewed with patient and parent, who expressed good understanding and agreement with plan.  Given history of elevated blood pressures, also demonstrated during admission here, and evaluation by nephrology in past, he was set up with nephrology follow up as an outpatient.  Reasons for new, changed, and discontinued medications: none Reasons for new, changed, and discontinued equipment: NA Relevant Diagnostic Images/Studies: CXR on 7/19 IMPRESSION: Normal chest examination.  Diagnosis List  1. Shortness of breath, 07/20/2021 2. Myocarditis, 07/20/2021  Patient Instructions  He was admitted for management of myocarditis thought to be due to a virus. He had multiple EKGs, echocardiograms, and a cardiac MRI which showed mild changes but overall good heart function. His chest pain and heart studies improved throughout his stay and he was safe for discharge home.   He should take the following medications when going home:  - Prednisolone 30 mg twice per day, with last dose on 7/26 in the morning  - Famotidine 20mg twice per day, while taking steroids.  It is important for him to minimize activity that raises his heart rate for the next 3 months. This will be discussed in more detail at his cardiology appointment. Until then, no strenuous exercise.   8/5/2021 clinic follow up: Cardiology Diagnostics     EKG: WNL  Echo: Normal function LV short-axis % area change 50.2 % -0.9 54.4 44.9 63.9  LV ejection fraction (area-length) 57.1 % -1.4 63.0 55.0 72.0   Labs noted in right hand column. CRP still elevated (higher than at discharge).      Assessment/Plan  Since his discharge, he has had headaches every almost every day. He thinks this is improving slowly but he has had about 2-3 headaches a day. He has had Tylenol and Motrin and this helps. He describes the pain as 4-5 /10 on the pain scale. He has not had any chest pain, no dizziness, no palpitations, no syncope. His mother says he is crankier than usual and she is concerned about his headache. The patient is 75% back to normal in terms of energy; 100% back to baseline in terms of appetite; 100% back to normal in terms of sleep; 100% back to baseline in terms of cognition and 50 % back to normal in terms of personality/mood.   In summary, he is a 13 yo boy with a recent history of myocarditis. The etiology (viral vs late-post vaccine) is unclear. His LV function has always been WNL but he had an elevated troponin and evidence of myocarditis by Cardiac MRI with LGE. His BP had been noted to be somewhat high. This was checked today by auscultation and was 114/64 RA adult cuff.