Age: 55.0
Sex: M
Vaccine: COVID19
Symptoms: Electrocardiogram change, Epistaxis, Fatigue, Fibrin D dimer normal, Flushing
Clinical narrative: Patient is a 55 year old male with no past medical history who presents with complaint of sudden onset of left-sided nonradiating chest discomfort of sudden onset approximately 1 hour prior to presentation while doing administrative work at rest.    He describes the pain as a dull heaviness sensation and approximate 3/10 pain severity.  Chest discomfort was associated with a feeling of flushing that was quite transient but chest discomfort was persistent.  Patient immediately presented to the ED for further evaluation.  He denies experiencing any chest pain upon waking up this morning.  Does note that he did have a transient episode of epistaxis on his way to work for which he had to pull over and apply pressure to his nose but this subsequently subsided and he attributed this to dry air as he has experienced epistaxis in the past but with less severity previously.   In the ER, vital signs noted for BP 133/76, pulse ranging 91-114, respiratory rate 16-20, 96% on room air.  Initial laboratory parameters were completely normal including normal CBC, CMP, LFT, lipase, UA, and normal D-dimer.  Initial troponin was negative x1.  EKG with sinus tachycardia, heart rate of 115.  Noted Q waves inferiorly.  No acute ST or T wave changes appreciated.  Chest x-ray with mild increased density in the left lower lobe.  Given this, patient was tested for rapid Covid which was negative but PCR was positive for COVID.  CT of the chest noted for focal subsegmental groundglass infiltrate at the superior segment of the LLL, likely infectious versus inflammatory.  Also noted small nonspecific groundglass attenuation with focal septal thickening at the right upper lobe which could be infectious or inflammatory, bibasilar atelectasis.  Patient was treated with aspirin 324 mg in the ED.  Of note, patient actually just received the COVID-19 vaccination on 12/24/20.  He denies any shortness of breath, no cough, denies any nausea or vomiting, denies any change in taste or smell nor change in appetite.  Does note 1 single episode of loose stool but otherwise denies any diarrhea.  Does report that he had approximate 48 to 72-hour period of fatigue and soreness at the site of the left deltoid injection following the vaccination but otherwise no further symptoms.  It is also noted that he does have a positive family history of coronary artery disease as his dad had an MI at the age of 49.  Patient has never undergone a cardiac catheterization in the past but does report having a negative stress test at the age of 42.  He is being admitted under the hospitalist service for further management  Patient was initially admitted under observation for chest pain obs.  However patient's Covid test came back positive and patient also had dynamic EKG changes concerning for possible unstable angina.  Patient was treated with aspirin Plavix full-strength Lovenox along with beta-blocker and a cardiology consult.  Serial troponins were negative.  Echocardiogram revealed normal EF of 55 to 60% with no hemodynamically significant valvular disease.  Cardiology felt that patient likely has underlying coronary artery disease have recommended discharge home with aspirin and Plavix with outpatient stress testing given his positive Covid testing.  At the time of discharge patient denied any chest pain or shortness of breath.  Patient was borderline diabetic with a hemoglobin A1c of 6.1.  Patient was discharged home with Metformin along with glucometer, glucose strip, lancets.  Given patient's tachycardia patient's Metformin 25 mg twice daily was changed to Toprol 25 mg daily. (Please note clarification in comparison to discharge home med list.  Toprol XL 25 mg daily was called to pharmacy in place of the metoprolol.)