Admission Date/Time: 08/27/2021 16:38:00  Discharge Date/Time: 08/30/2021 18:29:53  Chief Complaint   Post Covid Vaccine Myocarditis  Patient Narrative         ILLNESS SEVERITY:   The patient is returning to baseline, requires assessment.   PATIENT SUMMARY:  Reason for Hospitalization:     Chest Pain    Admission HPI: Patient is a previously healthy 16 year old female who presented to an outside hospital with < 24 hours of chest pain and shortness of breath, and was subsequently transferred to our ED due to concern for post-vaccine myocarditis. She is accompanied by her mother who helps provide the history.  Patient received her second dose of the Pfizer COVID vaccine on Tuesday 8/24. Afterwards, she had she had arm and ipsilateral neck soreness, as well as a headache. The soreness resolved, but the headache has persisted. She was still able to go to work and do her usual activities. Last night, however, she had onset of acute, sharp, 8/10 mid-sternal chest pain. The chest pain was worse with movement and with deep inspiration. The pain eventually went away without intervention, and she went to sleep. After awaking this morning, she had recurrence of the same chest pain. She also developed shortness of breath, which she describes as having difficulty getting air in. These symptoms prompted evaluation at Hospital (see course summary below). Her chest pain and shortness of breath seemed to resolve around noon, and she currently feels the chest pain maybe coming back slightly.  On review of systems, there have been no recent fevers, cough, congestion, wheezing, abdominal pain, nausea, vomiting, diarrhea, constipation, swelling/ edema, or new rash. She has had a rash on her back for a few months that does not bother her, and it has not been evaluated by anyone yet. She is not the most active person, but denied any exertional symptoms while walking around at work over the past few days. There has been no recent trauma, muscle overuse, or sick contacts. Of note, patient had no side effects after her first dose of the vaccine. A 14-point review of systems was negative aside from that noted above.  ED Course: - Normal vital signs and exam - No medications given - CTA- negative for PE, notable for possible hepatosplenomegaly - EKG- c/f T wave inversions in V1-V3, and ST depression in V5-V6 - CBC: 8.7 > 12.4 / 37.8 < 217, N68, L19, M11, E2, B0 - BMP: Na 137, K 3.8, Cl 106, CO2 26, BUN 12, Cr 0.59, Glu 90, Ca 8.7 - LFTs: Alb 3.2, TPro 7.0, TBili 0.3, ALT 21, AST 15, AlkPhos 53 - Troponin 0.528 (elevated, scale and units unknown) - CRP 2.5  Past Medical History: - No prior hospitalizations  Past Surgical History: - None  Medications: - OCP started a few months ago  Diet: - No restrictions  Allergies: - NKDA  Immunizations: - IUTD including COVID vaccine x2  Family History: - Negative for cardiomyopathy, sudden cardiac death, arrhythmia, or congenital heart disease  Social History: - Has a younger sister - Works at (baby clothing store) - Will enter 11th grade in the fall  Hospital Course (8/27-8/30): Patient was admitted for monitoring in setting of evidence of post COVID vaccine myocarditis after presenting with elevated troponin and chest pain.  Echocardiogram was performed and confirmed normal valve function, normal biventricular systolic function, and no pericardial effusion.  Cardiac exam was benign and telemetry was negative for arrhythmia.  Chest pain, which was not exertional, resolved with tylenol and ibuprofen; last episode was 8/27 night.  Troponin has remained elevated, max was 0.45 on 8/29; most recent was 0.22 on 8/30. CRP was mildly elevated at 1.4-1.5; other labs were WNL.  COVID PCR and COVID Ab testing were negative.  Given reassuring exam, telemetry, and normal cardiac function by echo, IVIG was not indicated and patient received no specific treatment, but remained inpatient for close cardiac monitoring.   Patient had a Cardiac MRI which did show late gadolinium enhancement but was  was stable for DC.   As we have seen with other patients, her reaction to the 2nd COVID vaccine resulted in a mild inflammatory state with mildly elevated CRP and troponin and no other symptoms or abnormal cardiac testing findings.     Patient was discharged home in her baseline condition.   She will follow up in one week for a clinic visit, ECHO and repeat troponin.  The Cardiology Outpatient team will reach out to the family for an appointment.  Reasons for new, changed, and discontinued medications:  NA  Reasons for new, changed, and discontinued equipment: NA   Relevant Diagnostic Images/Studies:  BCH read of CT Scan 8/27/2021: IMPRESSION:  1. No pulmonary embolus. 2. Dependent round glass opacity and mosaic attenuation likely reflecting a combination of atelectasis and air trapping. No consolidative pneumonia. 3. Asymmetric left axillary lymphadenopathy and surrounding fat stranding. This can be observed following Covid vaccination and correlation with the sidedness of vaccination is recommended.  ECHO 8/27/2021: o Normal valvular function. o Qualitatively normal right ventricular size and global systolic function. o Normal left ventricular size and global systolic function. o Normal coronary artery origins. No aneurysms of the proximal coronary arteries. o No pericardial effusion. o Not seen: systemic veins, pulmonary veins, arch branching, and complete interrogation for septal defects.Study  ECHO 8/30/21: o Normal valvar function. o Normal left ventricular size and systolic function. o Normal left ventricular diastolic function indices. o Qualitatively good right ventricular systolic function.o No pericardial effusion.  CARDIAC MRI 8/30/21: Normal biventricular size and systolic function. Mid-wall late gadolinium enhancement involving the basal inferior and inferolateral wall with no associated regional wall motion abnormality. Borderline elevated native T1 measurement, and elevated extracellular volume fraction measurement. No significant valvular dysfunction. No coronary artery aneurysms.   No pericardial effusion.    Tests Pending  No tests pending at time of discharge    These tests will be followed by the Primary Service at Discharge after Discharge  Vitals and Discharge Physical  T: 37.0  °C   HR: 80 (Monitored)  RR: 20  BP: 112/65  SpO2: 98%  HT: 157.48 cm  WT: 68.8 kg  BMI: 27.5   Discharge Physical Exam  GEN: conversant, in NAD CVS: S1, S2 RRR, no m/g/r RESP: LSCTAB; no SOB or DOE FEN: abd flat, soft, NT, no HSM EXT: WWP with good pulses NEURO: no focal considerations  Diagnosis List  1. Myocarditis, 08/28/2021 2. Chest pain, 08/28/2021  Procedure History  No Procedure History  Social History  Smoking Status      No Smoking Status Documented  Allergies  No known allergies  Laboratory Results Returned 48 Hours Prior to Discharge   Labs Last 48 Hours      Event Name  Event Result  Date/Time   Troponin T 0.22 ng/mL Critical 08/30/21  Troponin T 0.44 ng/mL Critical 08/30/21  Troponin T 0.47 ng/mL Critical 08/29/21