Age: 19.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Platelet count normal, Protein total normal, Protein urine absent, Prothrombin time shortened, Red blood cell count normal
Clinical narrative: DATE OF SERVICE: 01/02/2022  CHIEF COMPLAINT: Chest pain and muscle aches.  HISTORY OF PRESENT ILLNESS: This 19-year-old gentleman with a past medical history of no significant medical issues except adenoidectomy and tonsillectomy, being followed by Dr. in the outpatient setting and planning to see Dr.  soon, had a booster dose of Pfizer vaccine. Initial vaccine was in February. Patient had a booster on Wednesday, and subsequently the patient had some myalgia, other symptoms, and the patient complains of chest pain, particularly with lying flat. The patient came to  Hospital.  EKG showed right bundle branch block and Cardiology performed a cardiac catheterization. Cardiac catheterization showed normal coronaries but features of some mildly elevated left-sided filling pressures and mild anterolateral hypokinesis, ejection fraction 55%, suggestive of myocarditis, and the patient was admitted for further evaluation and treatment. There is no history of any fever, rigors or chills. No history of headache, loss of consciousness, seizures.  The troponins were elevated.  PAST MEDICAL HISTORY: History of adenoidectomy, tonsillectomy.  MEDICATIONS: Tylenol.  ALLERGIES: NONE.  FAMILY HISTORY: No history of heart disease or strokes in the family.  SOCIAL HISTORY: No history of smoking. No history of alcohol intake.  REVIEW OF SYSTEMS: ENT:  No diminished hearing. No diminished vision. CARDIOVASCULAR SYSTEM: As mentioned earlier. RESPIRATORY SYSTEM: As mentioned earlier. GI: No nausea, vomiting, diarrhea. GU:  No dysuria. NERVOUS SYSTEM: No numbness, weakness. ALLERGY/IMMUNOLOGY:  No asthma or hay fever. MUSCULOSKELETAL: As mentioned earlier. HEMATOLOGY/ONCOLOGY:  No history of anemia. ENDOCRINE: No history of diabetes or hypothyroidism. CONSTITUTIONAL: As mentioned earlier. DERMATOLOGY:  Negative. RHEUMATOLOGY: Negative. PSYCHIATRY: As mentioned earlier.  PHYSICAL EXAMINATION: Patient is alert, oriented x3.  The pulse is 63, blood pressure 106/64, respirations 16, temperature normal, pulse ox 99% on room air. HEENT: Conjunctivae normal. NECK: No jugular venous distention. CARDIOVASCULAR: S1, S2 muffled. RESPIRATION: Breath sounds diminished at the bases.  No rhonchi. No crackles. ABDOMEN: Soft, nontender. No mass palpable. LEGS: No edema. No swelling. NERVOUS SYSTEM: Higher functions as mentioned earlier. Moves all 4 limbs.  No focal motor or sensory deficit. LYMPHATICS: No lymph node palpable in neck, axillae or groin. SKIN: No ulcer, rash, bleeding. JOINTS: No active deforming arthropathy.  LABS: WBC 13, hemoglobin 16.9.  D-dimer is 1.  ASSESSMENT: 1. Chest pain, status post cardiac catheterization showing normal coronaries and possibly myocarditis with mild anterolateral hypokinesis. 2. Recent COVID-19 booster vaccination, Pfizer. 3. Increased white count. 4. Elevated D-dimer. 5. Elevated AST and ALT. 6. Troponin 26.600. 7. History of adenoidectomy and tonsillectomy.  RECOMMENDATIONS AND DISCUSSION: In this 19-year-old gentleman who presented with multiple medical issues, had a cardiac catheterization which showed normal coronaries. Patient most likely had myocarditis secondary to vaccination. COVID-19 is negative at this time. I recommend repeat testing tomorrow. The D-dimer is elevated; I would also recommend a CT angio of the chest as well as ultrasound of the legs to complete the workup.  Otherwise, recommend close followup in the outpatient setting with primary physician as well as Cardiology.    FINAL DIAGNOSES: 1. Chest pain, status post cardiac cath showing normal coronaries and possible myocarditis with mild antral basal hypokinesia. 2. Basal lateral hypokinesis with 2D echo no ejection fraction. 3. Myopericarditis. 4. Recent Covid 19 booster vaccination, Pfizer. 5. Increased WBC. 6. Elevated D-dimer. 7. Increased AST/ALT. 8. Troponin 26. 9. History of adenoidectomy and tonsillectomy.  DISCHARGE DISPOSITION: The patient is being discharged in stable condition with guarded prognosis.  HISTORY OF PRESENT ILLNESS: This 19-year-old gentleman with a past medical history of multiple medical problems admitted with chest pain.  Myocardial infarction ruled out and cardiac catheterization was normal.  Patient recently received a booster dose of Covid vaccine. Patient had features of possible myopericarditis as listed treated symptomatically. Patient improved significantly.  Patient discharged in stable condition with guarded prognosis.  On exam, vitals stable.  Cardiovascular S1, S2. Abdomen soft. Nervous system: No focal deficits.  DISCHARGE ADVICE AND MEDICATIONS: 1. Diet is cardiac. 2. Activity limited until followup. 3. Follow up with Dr. as recommended. 4. Follow up with Cardiology as recommended. 5. Tylenol 1000 mg q.6 p.r.n. 6. Aspirin 81 mg daily. 7. Colcrys 0.6 mg p.o. b.i.d. for 1 week per Cardiology. 8. Cozaar 12.5 mg q.h.s. 9. Motrin 400 mg q.8 p.r.n. 10.Toprol-XL 25 mg p.o. daily. Once again the patient discharged in stable condition with guarded prognosis.