Age: 25.0
Sex: M
Vaccine: SMALL
Symptoms: Skin ulcer
Clinical narrative: On Friday, 4/21/06, pt awoke with chest pain around 07:00. Describes pain as dull aching, pressure-type substernal chest pain. Initially, chest pain level of intensity rated as 4/10, and with 3 hours, chest pain 'died down' to about 2/10. Able to carry out ADLs that day, but did experience intermittent fleeting episodes of chest pain throughout the day that never lasted > 15 minutes. Denies accompanying symptoms on 4/21/06. Went to bed around 22:00 on 4/21 and awoke with recurrence of chest pain around 01:00, at that time, level of pain intensity rated as a level 7/10; reports 'it hurt to breathe', but denies shortness of breath; pain peaked at 10/10 around 03:00; unable to get comfortable due to pain; positioning did not seem to affect pain. Service member also describes experiencing a dull headache and bilateral shoulder aching with tingling in both hands (when he took Motrin that AM, he had difficulty opening the bottle because he had difficulty with his grip). Around 06:00, his level of pain had decreased to about 8/10. Pt took 2 ibuprofen 400mg and called 911 and layed on the floor until the ambulance arrived around 06:45. He reports the headache and shoulder pain and hand tingling resolved by the time the ambulance arrived. He was taken to the hospital. (No records available). 25 year old pt was referred to us on 4/24/06. (The following history was obtained during a bedside interview taking place on 4/25/06. Medical records available on day of intervue were also reviewed). He describes his health prior to 4/06 as "very good". Following a smallpox briefing, he recalls receiving his first smallpox vaccine on 4/12/05 in his left arm (3 jabs). The smallpox vaccine was the only vaccine and he was told he had "a take". Also, around that time, he describes the site as "welled up" with some redness on the underside of his upper left arm with some streaking toward his axilla and swollen, tender axillary lymph nodes. He also describes some skin irritation from the tape holding his dressing in place and a satellite lesion below his smallpox site. On post-vaccine day 13, the vaccination site is still scabbed, as well as the satellite lesion. Between day of vaccine and day 13, he denies experiencing any fever, generalized body aches, or significant fatigue. Around 4/19/06, he was out in the rain and cool weather; he reports he felt chilled and was shivering and this continued even after he was dry and warm, but resolved by Thursday morning, 4/20. On Friday, 4/21/06, he awoke with chest pain around 07:00. He describes the pain as dull, aching, pressure-type substernal chest pain. He was admitted to CCU at the hospital on Monday, 4/24 where he was monitored and treated with Toradol for pain prn. On 4/25, he was transferred to the step-down unit and started on TID Motrin. He had an Echocardiogram done today and will be having a cardiac MRI on 4/27/06. 4/26/06; Probable myocarditis, 9 days post-SPV. Denies unusual childhood illnesses. He experienced an episode of bronchitis as a child and subsequently used an inhaler x 1 month, but was never diagnosed with asthma. Experienced a few episodes of mild wheezing throughout childhood, but all symptoms had resolved by the time he came into service. Has a profile for folliculitis. History of conjunctivitis of right eye. Fractured left elbow and sprained his right knee s/p fall while roller skating. Re-injured his right knee while playing basketball last year. Has been placed on a profile treated with Naprosyn (later changed to Ibuprofen due to stomach irritation), and has been going to PT, including ultrasound treatments. Diagnosed with Patellofemoral Syndrome. Codeine-hives, facial swelling; yellow jacket sting-hives, facial swelling. Periodic sneezing and itchy eyes; attributes to "pollens"; does not treat with OTC medications. Occasional neck stiffness after driving long distances. Reports exposure to TB, but no history of positive TB skin test. SPV vaccination site-L deltoid region, with 2 small scabs (vaccine site: about 1cm: satellite lesion: about .5cm). Per 60 day follow up: See attached records has not had stress test done at this time.