Age: 13.0
Sex: F
Vaccine: COVID19
Symptoms: Chest discomfort, Chest pain, Costochondritis, Dyspnoea, Electrocardiogram
Clinical narrative: Patient is a 13-year-old who was transferred from another hospital for chest pain in the setting of Covid vaccination.   She received her second dose of Pfizer vaccine on Tuesday, June 29.  On Wednesday she developed fatigue chest pain shortness of breath weakness, nausea and mild abdominal pain.  She also had a fever to 102.5 Fahrenheit.  mom is a nurse and took her pulse and felt that it was 30 and fast.  She then took 1 with her home equipment it was in the 120s.  She called her neighbor who took her pulse and it was in the 130s.  She then transferred her to another Hospital for further care at hospital her vital sinus evaluation was a temperature of 37.4 pulse 119 respiratory rate is 15 blood pressure 106/62 satting 98% on room air.  On exam she was well appearing with tenderness to palpation of sternum heart rate normal rate and rhythm lungs clear bilaterally and abdominal exam benign. they obtain CBC with white count of 4.8 hemoglobin 12.9 Camm that was unremarkable LFTs are within normal limits troponin that was negative BNP 223 with a normal upper limit of 125 ESR 2 D-dimer 0.697 with upper limit of normal 0.5 and a CRP of 9 with upper limit of normal of 8.1.  UA bland. She was given Toradol for chest pain EKG with sinus tachycardia .  She was given 1/2 L normal saline bolus ondansetron Toradol and started on maintenance IV fluids of D5 NS.  She was then transferred to another hospital for further care .    Upon arrival here she notes improvement in her energy level and all of her pain except for her chest pain.  She describes it as a pressure on top of her chest that is right in the center and is worse with movement and deep breaths.   Of note she had a appendectomy a few years ago that was complicated by surgeons making the bowel and then required her to have a bowel resection.  She has no dietary restrictions and eats by mouth, no GI complications in the long-term.     PMH: as above  PSH: No significant past surgical history  FH: Reviewed and noncontributory to current presentation  SH: Lives with caregivers   Meds: None  Allergies: No known drug allergies  Immunizations: UTD   Review of Systems       Constitutional:  fever, no chills, no sweats,  fatigue Skin: no rash, no lesions,  Eye: no redness ENMT: no ear pain, no sore throat, no congestion, no hoarseness  Respiratory: + shortness of breath, no cough, no wheezing  Cardiovascular: + chest pain, no palpitations,  Gastrointestinal: + nausea, no vomiting, no diarrhea, no GI bleeding  Genitourinary: no dysuria, no hematuria,  Musculoskeletal:  + muscle pain,  Neurologic: no headache, no dizziness, no numbness, no weakness  Psychiatric: no sleeping problems,  Allergy/Immunologic: no recurrent infections,  Additional ROS info: All other systems of a 10 system review are negative.  Briefly, patient is presenting with chest pain, myalgias, and fever in setting of recent covid vaccine (2nd dose Pfizer 2 days ago).  Seen at an outside hospital where labs were notable for mildly elevated BNP and D-dimer, negative troponin, normal LFTs and chemistries.  Chest x-ray reportedly negative.  EKG with T wave inversions in V1 through V4 (read as nonspecific ST changes by their physician), but otherwise normal.  Given the possibility of post Covid vaccine myocarditis or PE, transferred for further management.  Patient states that after Toradol that she received the outside hospital all of her other symptoms have resolved but she continues to have chest pain.     My exam showed: Gen: tired but nontoxic appearing, no acute distress, alert and active; HEENT: PERRL, EOMI, normal conjunctiva, neck supple without LAN; Chest: significant reproducible chest pain; Card: RRR, no murmur, good perfusion, brisk radial pulses bilaterally; Lungs: CTAB, good air entry, no increased WOB; Abd: soft, non-tender, non-distended, no masses; Ext: warm and well perfused, moving all extremities; Skin: no rashes     Chest pain. Overall well appearing with normal exam with reproducible tenderness.  Given recent Covid vaccine, must consider myocarditis, although only mildly elevated BNP and negative troponin at the outside hospital are reassuring, especially given reproducible pain and reassuring EKG.  Symptoms then may represent musculoskeletal etiology such as costochondritis or myositis related to vaccination.  Less likely pneumonia or pneumothorax, but possible.  Low suspicion for PE given lack of persistent tachycardia (tachycardia improved while in ED, currently HR 80s) or hypoxia. EKG obtained which showed T wave inversions in V1-V4 (normal for age).  Bedside ultrasound with normal global function and lack of pericardial effusion.  Labs obtained in BCH ED notable for negative BNP and troponin, along with reassuring lipase given abdominal pain.  Thus, unlikely to be true myocarditis, more likely musculoskeletal etiology such as costochondritis or chest wall pain.  Cardiology will discuss with mom for reassurance.  Final Diagnosis  1. Chest pain R07.9 2. Fever R50.9 3. Fatigue R53.83 4. Shortness of breath R06.00  PLEASE NOTE:  Since the patient is not from here, we do not have access to her vaccination records and cannot supply lot number, etc.