Age: 17.0
Sex: F
Vaccine: COVID19
Symptoms: N-terminal prohormone brain natriuretic peptide increased, Pain, Pallor, Palpitations, Presyncope
Clinical narrative: Patient is a 17 year old female admitted from the ED for midsternal to left-sided chest pain. She reports that her pain sarted yesterday morning and it woke her up. She describes the pain as a 4/10 pain. She took tylenol and it got a little bit better. Her pain was worse this morning to 6/10. She said pain was also worse with lying down and better when sitting up. She was also experiencing SOB, dizziness, pre-syncope. +palpitations and chest tightness which was mostly on the left with pressure and squeezing feeling, radiating to the right occasionally. Mom brought her to ED this morning. In the ED she had an elevated troponin and slightly elevated Nt pro BNP. She received Covid booster 5 days ago. Only recent illness noted is from a double AOM on 1/9.    Pertinent results: Elevated troponin  Medication given: None    Recent history of travel: No Contact with sick person:  No Recent immunizations:  Covid booster 1/30/22   REVIEW OF SYSTEMS GENERAL: Positive for: decreased activity Negative for: change in appetitite, fever, chills, diaphoresis, fatigue, irritability, excessive weight loss, excessive weight gain PSYCH/BEHAVIOR: Positive for: none Negative for: agitation, behavioral problems, confusion, hallucinations NEURO: Positive for: dizziness, presyncopal Negative for: head injury, seizures, change in gait EYES: Positive for: none Negative for: photophobia, pain, discharge, redness ENT: Positive for: none Negative for: congestion, ear discharge, hoarseness, sore throat RESPIRATORY: Positive for: chest tightness, shortness of breath Negative for: cough, wheezing CARDIOVASCULAR: Positive for: chest pain, palpitations, dyspnea on exertion Negative for: cyanosis, swelling of feet GASTRO: Positive for: none Negative for: abdominal pain, nausea, vomiting, diarrhea GU: Positive for: none Negative for: decreased urine output, frequency, urgency ENDOCRINE: Positive for: none Negative for: cold intolerance, heat intolerance MUSCULOSKELETAL: Positive for: none Negative for: joint pain, joint swelling, limitiation of movement, muscle pain, back pain SKIN: Positive for: pallor Negative for: rash HEME: Positive for: pallor Negative for: easy bruising, excessive bleeding  Problem List   Troponin level elevated POA: Yes   Active Problems:   Troponin level elevated POA: Yes   Patient is a previously healthy 17 year old healthy female with 2 days of acute chest pain and elevated troponin. BNP mildly elevated. Otherwise reassuring clinical exam. EKG showing early repolarization. Differential is most concerning for for Acute Myocarditis, pericarditis of unknown etiology, likely related to viral illness or possible recent Covid booster administration.  Plan to trend troponin with ECG Q 6 hours and follow up ECHO. Further plan detailed below.    PLAN CNS -Neurochecks q4h and prn changes -Resume home Concerta 72 mg and OCP (mom will bring in from home)   RESP - Maintain POX >93%, continuous pox - Send RVP (Rapid flu, RSV and COVID negative)   CVS - Continuous cardiorespiratory monitor, q1h VS per PICU routine - Consult to peds cardiology - ECHO today - Trend troponin Q 6 hours with ECG   - If further increasing troponins, may need cardiac MRI   FEN/GI - NPO until results of echo to evaluate for pericardial effusion - IVF NS at 80% at 60 ml/hr    RENAL - Strict I&Os   ID - monitor fever curve, follow up RVP    LINES/TUBES/RESTRAINTS - PIV     Plan of care discussed with Provider, RN, Patient, Family/Significant Other: mother and Consultants: cardiology  Cardiology Note:  History of Present Illness:   Patient is a 17 year old female with history of ADHD who presents with left sided chest pain. Her chest pain first started yesterday AM, waking he reform sleep. The pain is described as pressure, and is worse when laying down and better when leaning forward. She took a tylenol and got a bit better, but developed shortness of breath with activity and with rest, dizziness, and feeling like she will pass out. Admits to heart pounding with chest pain. Brought to ED by mother, where she was foun to have an elevated troponin, mildly elevated NTproBNP, and otherwise normal labs. ECG showed early repolarization. Of note, patient received her third COVID booster this past weekend, and had a bilateral ear infection early January.      ACTIVE PROBLEM LIST: Active Hospital Problems   Diagnosis Date Noted ? Troponin level elevated 02/03/2022     REVIEW OF SYSTEMS:  All other systems were reviewed and found to be negative unless otherwise stated above.  CXR:   Lines, tubes, and devices:  None.   Lungs and pleura:  No focal consolidation.. No pleural effusion. No  pneumothorax.   Cardiomediastinal silhouette:  Normal cardiomediastinal silhouette.   Bones and soft tissues:  No osseous abnormality.   ECG:   NSR with early repolarization   ECHO:   1. No structural abnormalities.  2. Trivial tricuspid regurgitation.  3. Normal left ventricular size and wall thickness with qualitatively normal  systolic and diastolic function. LVEF 2D 60%. Average global strain -19%.  4. Normal right ventricular size with qualitatively normal systolic function.  5. No arch obstruction.  6. 3/4 pulmonary veins seen.  7. No pericardial effusion.    Cardiac Diagnosis:  Perimyocarditis   Impression:    Patient is a 17 year old female with history of ADHD admitted with chest pain associated with shortness of breath and elevated troponin concerning for perimyocarditis. BNP and CRP mildly elevated, and active troponin leak suggests acute inflammatory process. Echocardiogram demonstrated normal cardiac structure and function.  Unclear etiology, potentially viral or related to recent immunization. RVP in process. Overall plan to control pain, trend troponins, monitor hemodynamics. Troponin leak still trending up, if continues to increase overnight will plan for cardiac MRI in the morning to assess for scar burden and consideration of IVIG and steroids.     Plan/ Recommendations:   CNS - Ibuprofen q6h - Tylenol PRN   CV - RVP pending   PULM - CRM, monitor hemodynamics - Trend troponin T q6h with ECG             - If uptrending overnight, will order cMRI in the AM     FEN/GI - Regular diet - Strict I/O   HEM/ID - Monitor fever curve     Lines, Drains, and Airways     Line           Peripheral 02/03/22 0849 Right Antecubital 20 Gauge <1 day             Please page pediatric cardiology fellow on call with concerns.