Age: 17.0
Sex: M
Vaccine: COVID19
Symptoms: Anion gap, Basophil count normal, Basophil percentage decreased, Blood calcium normal, Blood chloride normal
Clinical narrative: Patient is an otherwise healthy 17-year-old male who is presenting with recurrent symptoms of pericarditis in the setting of receiving the Pfizer vaccine 2 days ago.  He has uncomfortable substernal pain here, but is otherwise well-appearing with normal vital signs and a normal exam.  Bedside ultrasound showed what seem to be a trace effusion but grossly normal function.  EKG appears normal to me.  Inflammatory markers and troponin negative.  I reached out to cardiology given that he continues to have the symptoms and with his history.  They looked at his EKG and are questioning whether or not there is some interval PR depression.  They would like to get a formal echocardiogram. Tylenol and ibuprofen for pain.  Echocardiogram with trivial effusion, good function.  Patient was signed out to me as noted above.  Patient remained stable with good control of his pain.  Cardiology plans to follow-up with him as an outpatient on Monday or Tuesday at the beginning of next week.  They also advised that he have outpatient follow-up with rheumatology which they will help arrange.  The patient knows to return if he has increasing pain, shortness of breath or other change in symptoms.  Patient is discharged home with a prescription for naproxen to be taken twice daily over the next week.    Final Diagnosis  1. Pericarditis I31.9  Follow up January 2022: January 25.  He is being seen in follow-up for possible pericarditis.     Patient's medical history has been outlined in previous notes to your office.  He was last evaluated in our clinic on December 21 at which time an echocardiogram showed no pericardial effusion.  At that time the CRP was 0.06 and ESR 38.  Naprosyn and famotidine were discontinued at that time and colchicine 0.6 mg once a day was continued.     In the intervening time period Patient has remained symptom-free.  He reports no fever, chest pain, palpitations dizziness or syncope.     On physical examination patient appeared well.  His weight was 64.1 kg, height 175.5 cm, pulse rate 51, respiratory rate 18 and blood pressure 116/71 in the right arm.  The transcutaneous oxygen saturation was 100%.  Examination of his heart demonstrated a normal precordial activity single S1 and physiologically split S2.  There was no S3, S4 or ejection click.  There was no pericardial friction rub.  There was no murmur.  The breath sounds were clear.  There was no organomegaly.     An electrocardiogram demonstrated normal sinus rhythm and was within normal limits.  An echocardiogram showed normal cardiac anatomy and function.  Biventricular size and systolic function were normal.  The 4 cardiac valves had normal function.  There was no pericardial effusion.     Laboratory studies included CRP <0.06 and ESR 8.     Patient was judged to have a normal cardiac status.  I recommended that colchicine be discontinued at this time.  Followup was left to an as-needed basis.  Because of his brother's medical diagnosis I recommended that patient be evaluated by our Rheumatology Service.  The parents informed me that an appointment has been arranged.