Age: 34.0
Sex: M
Vaccine: COVID19
Symptoms: Influenza like illness, Middle insomnia, Myopericarditis, Pain in jaw, Pneumonia
Clinical narrative: Date of Admission: 12/7/2023   Date of Discharge: Expected 12/9   Issues to be Addressed at Follow-up: 1.  Cardiology will arrange future coronary evaluation   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   12/7/2023  7:30 PM MRSA SCREENING CULTURE In process NARES   12/7/2023 10:21 AM TROPONIN I, HIGH SENSITIVITY In process --       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) COVID-19 DISEASE   ? COMMUNITY ACQUIRED PNEUMONIA   ? ELEVATED TROPONIN I     Resolved Hospital Problems   Diagnosis Date Resolved ? ACUTE NON ST ELEVATION MI 12/07/2023     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings: 37 Y old male with a past medical history notable for possible H pylori induced gastritis who presents with acute chest pain that started at 1 am the day of admission.  The patient says that he was sleeping and then awoke with at ~ 1 am with jaw pain and left sided chest pain radiating to left arm.   The patient does also indicate that he has been dealing with flu-like since Sunday.   Headaches, low grade fever, and coughing.    Patient last vaccinated against COVID in 2021 with Moderna.    Wife had COVID 1 month ago.    Admitted with COVID and elevated troponin.  Initially on heparing gtt, ASA, and statin due to possible NSTEMI, but after review with cardiology, felt to be myopericarditis.  Troponins trended and improved.  Remdesevir X 3 days given cardiac complication, despite not otherwise symptomatic or hypoxic.   Was found to have probable consolidation, so also treated for CAP for 5 days.   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  Covid   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. CARDIOLOGY - INITIAL INPATIENT CONSULTATION. CARDIOLOGY - ONGOING INPATIENT CONSULTATION. 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 12/8/2023 12:58 PM Author Type Physician Status Addendum Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct # Admit Date 12/7/2023  ED to Hosp-Admission (Discharged) on 12/7/2023  ED to Hosp-Admission (Discharged) on 12/7/2023   Revision History   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   COVID-19 DISEASE  ACUTE NON ST ELEVATION MI Resolved  COMMUNITY ACQUIRED PNEUMONIA  ELEVATED TROPONIN I Care Timeline  12/07   Admitted from ED 0720 12/09   Discharged 1850  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 12/9/2023) Medication List at Discharge   acetaminophen 650 mg Oral EVERY 4 HOURS AS NEEDED  cefpodoxime proxetil 200 mg Oral 2 TIMES A DAY  doxycycline monohydrate 100 mg Oral EVERY 12 HOURS