Age: 23.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Abdominal pain, Abdominal pain upper, Arteriogram coronary normal, Atrioventricular block second degree, Blood cannabinoids
Clinical narrative: In summary this is a 23-year-old relatively healthy gentleman with no prior medical history who came in with chest pain as well as abdominal pain and troponin elevation.  Differential included pulmonary embolism embolism which was ruled out by CTA.   Troponin is flat at 0.04 despite normal renal function.    Limited echo was performed yesterday showing RV dilation and elevated Rvsp. CT pulmonary embolism showed no pulmonary embolism however did show reflux into the hepatic vein.    Given such is concerning for possible pulmonary hypertension as well as severe TR   Therefore we will order a complete echocardiogram today to evaluate for valvular disease as well as tricuspid regurg and pulmonary hypertension. BNP added on to a.m. labs.    Additionally there is question was troponin elevation etiology.  Given the young age can consider spontaneous coronary dissection or anomalous coronary artery.  Review of system is unrevealing for any history of autoimmune disease or vasculitis. CRP 1.0 not remarkably elevated   Will discuss with whether to pursue a gated coronary CTA or left heart catheterization to evaluate for SCAD and anomousl coronary artery. If those are unrevealing the last step would be a cardiac MRI to evaluate for myocarditis or infiltrative disease   Patient's pulmonary embolism CT was performed yesterday. With a 24 hours before given the dye load.  In the interim would hydrate with normal saline.    Continue aspirin Lipid: TG  49; LDL 84     -CTA showing normal coronaries origin, no dissection -will obtain cardiac MRI tonight for evaluation of myocarditis.  -can be discharged tomorrow AM Discussed with Dr. and Dr. . Follow-up Dr.      FINAL RECOMMENDATIONS PENDING ATTENDING ADDENDUM    Cardiology Fellow   Attending Addendum:    I have seen and examined the patient and agree with the findings, assessment and plan as noted with the following additions/modifications: Patient is a 23 yo student who developed acute epigastric pain after a 5 mile run that lasted several hours. Troponins were mildly elevated and he is admitted for evaluation. No further pain. No prior episodes of pain. He started back running last fall. He runs about 7 miles 3x/week and less mileage on off days. No prior chest pain, tachycardia or syncope with running. No underlying viral illness or increased stress. The day was not particularly notable - he doesn't recall being dehydrated or fatigued; in fact he felt great running. Family hx notable for MGM with heart disease in her 60s. Otherwise, no other heart disease. Exam normal. Telemetry with Wenckebach during sleep which is a benign finding due to increased vagal tone. No ectopy or other arrhythmias. Thus far, all tests have been normal. CTA negative for PE (d-dimer was elevated). Coronary CTA shows no coronary anomalies and normal epicardial arteries. Echo with mildly dilated RV and RA which ca be normal in an athlete. Overall, I have a low suspicion for myocarditis but will complete work-up with MRA. His troponins did come down within 48 hours and this may be secondary to a high-intensity run as can be seen with high HRs, endurance training - and possibly potentiated by dehydration.  - await MRI of hear - will look into observed return to exercise     Hospital Course:  23 yo man with PMH of LOC in high school when standing, admitted wit acute onset epigastric abdominal pain after a run, found to have mild elevation in troponin, flat at 0.04, dynamic EKG changes admitted or work-up     1. Acute epigastric abdominal pain/elevated troponin: The patient was chest pain free from the time of treatment with Pepcid, magic mouthwash, and Toradol in ED. His echo is without wall motion abnormalities, troponin is flat and remains chest pain free. The patient had a CT PE protocol study and CTA coronary without acute findings. He had a cardiac MRI which showed no acute myocarditis but may have had some delayed contrast enhancement and may represent prior myocarditis. He was started on low dose lisinopril 2.5 mg po daily for cardio-protection, will reduce physical activity with slow return to activity, and follow with cardiology with an urgent exercise stress test as an outpatient. His u tox shows cannabinoids and no other intoxicants, His lipid panel wnl, HDL 65, LDL 84, His TSH is wnl. His CRP and ESR is wnl.      2. Left axillary lymphadenopathy: Discussed with patient lymph nodes seen on CT scan in left axilla and left pectoral region. Patient cofnirmed he had a COVID 19 Moderna vaccine at pharmacy in the left arm on 4/3/2021. System documentation notes in the right axilla, but patient is clear that he had the vaccine in the left arm. Axillary lymphadenopathy is not surprising in this situation.     3. Small 4 mm nodules noted on CT scan: The patient had no infectious symptoms, no cough, no fever, and no elevated WBC. He does smoke marijuana but has no tobacco use. He can follow with PCP to further risk stratify the nodules, either with PPD, and consideration of repeat scan in 6-12 months as needed.     4. Mild bilateral gynecomastia: I informed patient this has been found. He is not bothered by this finding and it seems an incidental finding. He can follow with his PCP for further evaluation as needed for this finding.