Age: 17.0
Sex: M
Vaccine: COVID19, COVID19, COVID19
Symptoms: Pain, Troponin increased
Clinical narrative: History of Present Illness 17-year-old male who denies any major medical problems presents to the ER concern for chest pain.  The patient states that he stayed up all night and he woke up this morning around 12:30 p.m., around 1 hour prior to arrival and he was having a tightness in his chest.  The tightness is constant, seems to go down his left arm.  He has never had this happen before.  He received his Pfizer vaccination for COVID-19 on Friday of last week and he feels like he has had some aches since that time.  He has been taking Motrin for this and this morning he also took Motrin but there is no significant relief.  He has no significant shortness of breath, no nausea vomiting, no diaphoresis.  I spoke with him privately and he denies any history of cocaine abuse.  Per his mother he has healthy, no major medical problems.  He has not recently had any other concerns or recent review systems.  No history of having blood clots or DVTs.  Medical Decision Making: History examination as above.  Patient presents our concern for tightness in his chest with some radiation to his left arm over the past 1 hour.  His EKG does show J-point elevation but he has no risk factors, he is hemodynamically stable well-appearing on examination.  He has no shortness of breath, nausea, diaphoresis.  Differential includes myopericarditis, early repolarization.  Feel that the likelihood of STEMI, ACS is low.  Will obtain a troponin as a part of his workup, chest x-ray for evaluation of cardiac silhouette size, bedside ultrasound.  I do not suspect that he has a PE.  He has no tachycardia tachypnea hypoxia.  No external findings of suggest a DVT on examination.  I do not suspect that he has cardiac tamponade, CHF, pulmonary process such as pneumothorax, pneumonia based on his history.  Do not suspect a GI etiology.  Will monitor closely here in the ER and re-evaluate.  Time 2:30 p.m..  The patient's troponin is elevated at 7. I consult with Cardiology and I spoke with Dr- we reviewed the patient's EKG, his presentation, his history.  He feels this is secondary to myocarditis from likely the COVID-19 vaccination.  I have added a viral PCR as well as a part of his workup.  He does not recommend activation the cath lab, he does not feel this is a STEMI.  I do agree based on the history and the patient's appears this time.  He recommended a formal echocardiogram as well. -I spoke with the ultrasound technician at bedside and there is no evidence of wall motion abnormality.  This is consistent with my examination. -given the patient's elevated troponin we do not have capabilities of caring for him here.  Not have Pediatric Cardiology, we do not have a PICU if the patient's condition were to worsen.  There for the patient requires transfer to tertiary center. -will consult with another hospital for transfer.  Time 3:22 p.m..  I spoke with Dr, he accepts for transfer.  No recommendations for medications at this time.  The patient is chest pain-free, hemodynamically stable.  Spoke with the ultrasound technician there is no evidence of cardiac wall abnormality, pending official interpretation with our cardiologist. -asked for emergent transfer because I do not want the pain to be waiting here in the ER with possible worsening condition, worsening troponin elevation without cardiology consultation at a pediatric specific hospital.  I do not want him to have the chance of deteriorating at this facility and therefore I do feel that he warrants emergent transfer as opposed to routine where he could wait here in the ER for hours.  I do feel that benefits outweigh the risk and I spoke with the patient and his family about this and they agree.  Critical Care: 55 minutes.  Emergent evaluation on presentation given his EKG showing STEMI per computer interpretation.  Time spent for multiple re-evaluations, discussion with Cardiology and outside hospital consultants, time spent with documentation.  Time spent with family.  Complex medical decision making. Serious life threatening disease process. Potential for death and increased morbidity. Exclusive of procedure time.