Sex: F
Vaccine: UNK
Symptoms: Echocardiogram abnormal, Electrocardiogram abnormal, Exposure to SARS-CoV-2, Oropharyngeal pain, Pericardial effusion
Clinical narrative: Date of Admission: 12/10/2023   Date of Discharge: 12/11/2023   Issues to be Addressed at Follow-up: 1. Refer to cardiology in network 2. Monitor response to colchicine, naproxen 3. Repeat echo in 1 month   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 11/14/2023 to 12/15/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) PERICARDIAL EFFUSION   ? TYPE 2 MI   ? COVID-19 DISEASE   ? CHEST PAIN     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition: Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.     Reason for Hospital Admission (Admitting Diagnosis):  Chief Complaint: Chest pain   History of Present Illness: Patient's children were having upper respiratory symptoms last week and tested positive for COVID-19.  On 12/5 patient developed sore throat so she tested with a home test and tested positive for COVID-19.  Patient never developed GI or respiratory symptoms except some mild cough.  Overall, patient feels improvement from COVID-19 except she developed chest pain yesterday.  Patient notes that it comes and goes and improved with ibuprofen yesterday.  Patient woke up with chest pain and was concerned enough to come to the ER to be evaluated.   In the ER, patient was found to have elevated troponin but negative imaging for PE or pneumonia. Cardiology was consulted and thought patient may have myocarditis from COVID-19 infection.  Given uptrending troponin, he also recommended echocardiogram.   Prior to this, patient is otherwise healthy and does not take medications regularly.  She has 2 children at home-infant and 2-1/2-year-old- and active.   Hospital Course and Significant Findings: Pt was admitted for observation of COVID myocarditis vs pericarditis. Troponin elevation was attributed to demand ischemia. ACS was not suspected. Pt was started on colchicine, motrin, and crestor. Troponin was trended overnight, which peaked at 946. EKG showed sinus tachycardia with no ischemic changes.   Pt was given RDV. Decadron was not indicated due to absence of hypoxemia.   On day 2, pt reported resolution of chest pain and improvement in cough and sore throat. Pt remained stable on RA with no respiratory distress. TTE showed normal EF, small pericardia effusion, no tamponade. BB was not started due to soft BP at baseline.   Pt was discharged home in stable condition with colchicine for 3 months, naproxen for 2 weeks, and crestor for 3-6 months, per cardiology rec. Recommendation was made for repeat echo in 1 month. Instruction was provided on avoiding over exertion.   Vital signs: BP 93/68  | Pulse 106  | Temp 98.3 °F (36.8 °C)  | Resp 16  | Ht 5' 6"  | Wt 72.6 kg (160 lb)  | SpO2 99%  | Breastfeeding No  | BMI 25.82 kg/m²    Physical exam on day of discharge: General appearance - NAD HEENT - normocephalic, atraumatic Neuro - alert, conversational/answers questions appropriately Heart - normal rate, regular rhythm, normal S1-S2. No murmurs/gallops/rubs Lungs - normal work of breathing on RA. CTAB. No crackles/wheezes/rhonchi Abdomen - normoactive BS, soft, non distended, nontender Extremities - no edema Skin - warm, dry   Primary Procedures:  None   Secondary Procedures: None   Complications: none   Consults:  CARDIOLOGY - INITIAL INPATIENT CONSULTATION. CARDIOLOGY - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full code     Note Details  Author (M.D.) File Time 12/14/2023 11:50 PM Author Type Physician Status Signed (M.D.) Specialty Hospital Medicine Hospital Acct  Admit Date 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023  ED to Hosp-Admission (Discharged) on 12/10/2023   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   PERICARDIAL EFFUSION  TYPE 2 MI  COVID-19 DISEASE  CHEST PAIN Care Timeline  12/10   Admitted from ED (Observation) 1649 12/11   Discharged 1730  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/11/2023)   Discharge Orders TRANSTHORACIC ECHO (TTE) COMPLETE CARD, CV Medication List at Discharge   colchicine 0.6 mg Oral 2 TIMES A DAY  naproxen 500 mg Oral 2 TIMES A DAY  rosuvastatin calcium 10 mg Oral DAILY PT  NOT SHOWING Vaccinated