Age: 20.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Brain natriuretic peptide normal, C-reactive protein increased, Chest X-ray abnormal, Chest pain, Chills
Clinical narrative: Admission HPI: Right-sided chest pain began 2 days prior to admission (3/19) after getting out of car, without identifiable trigger. Pain was sharp, pleuritic, and worst with movement; didn't feel it when still. Pain not responsive to ibuprofen or heating packs. Reported 30-60 seconds of self-resolving heart racing during ocular migraine which has been his baseline for years. Not associated with SOB (at rest or with exercise), palpitations, presyncope, or syncope. No viral URI symptoms, N/V, or rash. He did receive his 2nd Moderna COVID vaccine about 1 week PTA, followed by 36hrs of fevers, chills, and body aches. Given persistence of pain, Patient asked his parents to present to urgent care.   In UC, he was noted to tachycardic with CXR with bibasilar atelectasis and b/l effusions, per report. Given continued tachycardia, decision was made to transfer to ED to r/o PE.      In ED, tachycardic to 104-116 and tachypneic 22-26. Had one episode of tachycardia to 182 iso ocular migraine. Endorsed chest pain but points to R middle abdomen when asked where worst. Exam was unremarkable. He received 1 dose of morphine which reduced pain from 10/10 to 0/10. Labs notable for leukocytosis (14.61), thrombocytopenia (422), elevated d-dimer (1.56), and elevated CRP (5.6). Otherwise normal chem and coags. COVID/RVP negative. CXR unremarkable. CTPA showed scattered PEs in b/l lower lobes with small pulmonary infarct in RML. No evidence of right heart strain. Heme was consulted who recommended starting him on lovenox and sending lupus anti-coagulant. Cardiology was consulted who recommended EKG, BNP, and troponin, all of which were normal and reassuring against right heart strain. ECHO was therefore deferred to the AM. The decision was made to admit.   Upon arrival to the floor, Patient was tachycardic 114 and tachypneic to 22, otherwise stable vitals. He denied any pain since morphine. Denied any unexpected weight loss; reports that car ride was short. Mom reports that Patient has been less active d/t cold weather and baseball being on hold. Denies family or personal history of clots. Last seizure ~13 years ago.  Hospital Course: (3/21 - 3/22)  Patient was admitted to the hematology service. He was therapeutically anticoagulated with LMWH injections and his anti-Xa level prior to discharge was 0.92. (goal 0.5-1.0) Lower extremity ultrasound with Doppler showed patent veins and no evidence of DVT and upper extremity ultrasound showed no evidence of DVT, though there was potential evidence of collateralization seen in mid and distal third of right subclavian vein and left internal jugular vein. Since this was an unprovoked PE, a full thrombophilia workup was sent and will be followed up by the outpatient hematology clinic. Cardiology consulted regarding possibility of right heart strain and the tachycardia during migraine episodes. Echocardiogram performed on 3/22 was technically limited but showed no gross abnormalities. The cardiology team requested a repeat echo scheduled outpatient for 1-2 months after discharge.