Age: 36.0
Sex: M
Vaccine: COVID19
Symptoms: Influenza like illness, International normalised ratio, Low density lipoprotein normal, Musculoskeletal discomfort, Myocarditis
Clinical narrative: Cardiology Consult:   Patient ID: (Name) Date of birth: (Date) Primary Care Provider: (Name), MD Admitting Provider: (Name), MD   Admitted: 5/22/2021 Reason for Admission:  Chest pain   SUMMARIZED H&P:  Patient is a 36 year old male with no significant past medical history, healthy gentleman, that presents post covid vaccine with chest pain.  He got his second dose of Moderna vaccine on Wednesday and then later that evening developed fevers, chills, body aches and flu likely symptoms.  They continued through Thursday evening.  He was taking ibuprofen but was having a hard time swallowing it.  He started developing neck and chest discomfort and initially thought it was due to difficulty with pills.    Symptoms continued through Friday despite the flu like symptoms improving.  They talked to a family member that recommended they present for presentation.     On presentation EKG showed diffuse ST elevation with PR depression.  PR elevation in V4.  Troponin peaked at 16.57 and is now 6.59.   Echo with normal EF and no effusion.   He was started on colchicine yesterday. Tele without any arrhythmias. He reports that symptoms were worse when laying down or taking deep breaths.  Has not had any symptoms today.    No history of heart disease, exertional symptoms or family history of early CAD   Patient Active Problem List:    Skin lesion of left leg    Anisometropic amblyopia of right eye    Myopia of both eyes with astigmatism    NSTEMI (non-ST elevated myocardial infarction)     PMH:  has no past medical history on file.   PSH:  has a past surgical history that includes pr create eardrum opening,gen anesth (11/06).   FH: family history is not on file.   SH:  reports that he has never smoked. He has never used smokeless tobacco. Social History   Occupational History ? Not on file Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used Substance and Sexual Activity ? Alcohol use: Not on file ? Drug use: Not on file ? Sexual activity: Not on file     Allergies:  has No Known Allergies.   Medications: Prior to Admission medications  Medication Sig Start Date End Date Taking? Authorizing Provider fexofenadine (ALLEGRA) 180 MG tablet Take 180 mg by mouth once daily as needed      Yes Provider, Historical, MD FIBER PO Take 1 tablet by mouth once daily     Yes Provider, Historical, MD ibuprofen (MOTRIN) 200 MG tablet Take 200-600 mg by mouth every 6 hours as needed for Pain      Yes Provider, Historical, MD     Review of Systems: A 10 point ROS was obtained and was otherwise negative except for chest pressure   Physical Exam: GENERAL: thin, well-appearing individual in no apparent distress. Vital Signs:*BP 98/70  Pulse 79  Temp 96.3 °F (35.7 °C) (Oral)  Resp 18  Ht 5' 11" (1.803 m)  Wt 156 lb 6.4 oz (70.9 kg)  SpO2 98%  BMI 21.81 kg/m2Body mass index is 21.81 kg/m². EYES: EOM intact bilaterally.  EARS: hearing is grossly intact.  NOSE: patent and moist. OROPHARYNX: moist and pink.  NECK: supple, no masses, no adenopathy, no thyromegaly, no JVD, no carotid bruits.  LUNGS: Clear to auscultation bilaterally.  No rhonchi, rales or wheezes.  HEART: Regular rate and rhythm, normal S1 and S2, no murmur(s). No rubs or gallops.  ABDOMEN: Soft, nondistended. Nontender to deep palpation. No palpable masses,  or organomegaly. Positive bowel sounds.  EXTREMITIES: No clubbing,cyanosis. no pedal edema.  CIRCULATION: 2+ pedal pulses bilaterally.  SKIN: No rashes or open lesions.  NEURO/PYSCH: No gross focal deficits. Alert and oriented x 3.  Appropriate affect and mood.     Most recent diagnostics and Labs: Recent Labs Component Name 05/23/21 0808 CHOLESTEROL 142 TRIGLYCERIDE 60 HDL 44 LDL 86 NONHDL 98   Recent Labs Component Name 05/23/21 0808 05/22/21 1415 WBC 6.0 9.1   Recent Labs Component Name 05/23/21 0808 05/22/21 1415 SODIUM 141 140 POTASSIUM 3.8 4.0 CHLORIDE 104 102 CO2 32* 27* BUN 11 8 CREATININE 0.90 0.9 CALCIUM 9.4 9.2 GFR >90 >90   No results for input(s): APT, INR in the last 87600 hours.    Echo: ? Ejection fraction is 5560%. Question extremely mild area of inferoapical hypokinesis. ? There is no clinically significant regurgitation or stenosis. ? Pulmonary arterial systolic pressure is within the normal range. ? No significant pericardial effusion.     IMPRESSION: Myopericarditis 2/2 covid vaccine             - EKG changes and positive troponin             - No evidence of effusion             - troponin trending down and symptoms are improving   PLAN: I reviewed findings with patient and his fiancé.  We discussed pathophysiology and treatment.  Since he had a difficult time with ibuprofen, we will treat with colchicine for 6 weeks at 0.6mg BID.  Discussed side effect of diarrhea.   I reviewed recommendations for avoiding strenuous activity and contact sports for 1 month due to cardiac inflammation.   I reviewed risk of cardiac arrhythmias with myopericarditis and do recommend continuing with metoprolol on discharge.   Recommend follow up with general cardiology in 4-6 weeks for follow up    Thank you, (Name), DO  Cardiac Electrophysiology