Primary Service at Discharge - Cardiology Medicine Hospital Course and Discharge Plan Admission Date/Time: 01/24/2023 02:39:00 Discharge Date/Time: 01/28/2023 11:23:55  Chief Complaint  chest pain and troponin leak  Patient Narrative ILLNESS SEVERITY:   The patient has returned to baseline.   PATIENT SUMMARY:  Reason for Hospitalization: chest pain and troponin leak    Admission HPI: Chief Complaint  chest pain, troponin leak  History of Present Illness The patient a 12 yo structurally normal heart with history of anxiety who presents with acute onset chest pain and elevated troponin in the setting of recent COVID booster 1/21.  Per the patient he complained of some malaise and tactile temp on Sunday after his booster but no chest pain.  For these symptoms his mother gave a dose of over the counter cold medication and his symptoms resolved.  On Monday he then work up with 6/10 chest pain, primarily on the right side, worsens with deep breathing, and wakes and wanes.  He denied fever, dizziness, syncope, palpitations, shortness of breath, or edema. He took a dose of ibuprofen but continued with intermittent chest pain.    With his persistent chest pain, he went to urgent care, where an ECG was performed with what is described as a concern for possible RBBB and myocarditis, leading to referral to the first ED. There, troponin was 0.08 (with ULN 0.01), and he was transferred to this hospital's ED for further care.  On arrival to the ED at this hospital he was hemodynamically stable, labs significant for troponin 309.  Family reported sister was COVID + Monday evening.  Again patient denies are viral s/s and his viral panel on admission including COVID was negative.  Per parental report mom stated he had a cold a week prior to his vaccine, but he had no viral symptoms on admission.  His chest pain was improved since arriving to the ED, reporting it as 1/10.  Patient is being admitted for ongoing monitoring, trending troponin, and determining planning for further diagnostic workup.  The patient was admitted to the floor for ongoing monitoring in setting of likely vaccine associated myocarditis. Since admission he has reported no chest pain since 1/24 am with stable vital signs.  His repeat EKG was normal sinus and troponin was downtrending at 203 1/24 12pm.   An Echo performed showed low normal function with no other structural findings.      Hospital Course: The patient was admitted to the cardiology floor for continued monitoring of his troponin levels and EKG. An echocardiogram was performed which showed structurally normal heart and function (see report below). He was started on methylprednisolone IV. He remained asymptomatic with improved chest pain throughout his admission. Cardiac MRI showed small amount of LGE with normal function (see report below). He had normal EKGs. His Troponin levels and inflammatory markers were trending down until 1/26/23 when he had a small increase to 120s. Given this, and noted T-wave flattening on EKG and prior small amount of LGE on cardiac MRI, the decision was made to give him IVIG. He was pre-medicated with Zyrtec and Tylenol and then the 2g/kg (max 100g) dose with the MIS-C/Kawasaki slow transfusion protocol. He tolerated the IVIG infusion well, and repeat labs 1/27 revealed downtrending Troponin. His Echo on 1/27 and his EKG were both normal.  By time of discharge, patient was well-appearing, vitals stable, demonstrating good PO intake. Follow up with cardiology in place for next week (2/1). He was instructed to avoid strenuous exercise. Discharge instructions and return precautions reviewed with patient and parent, who expressed good understanding and agreement   Relevant Diagnostic Images/Studies:   CXR 1/24/23  Reason For Exam  Chest pain  Report  PROCEDURE: XR-Chest 2 Views  REPORT FLAG: None  IMPRESSION: Normal chest examination.  END OF IMPRESSION  INDICATION: Male, 12 years old, chest pain  COMPARISON: None  TECHNIQUE: Two views of the chest.  FINDINGS:  Lungs: Clear.  Heart/mediastinum: Normal contours.  Pleural effusion: None.  Pneumothorax: None.  Osseous/soft tissue structures: Normal.  Included upper abdomen: Normal.    ***** Final Report*****    Leg US 1/24/23  Reason For Exam  Leg pain  Report  PROCEDURE: US BILAT LOWER EXTREMITY VENOUS W/ DOPPLER  REPORT FLAG: None  IMPRESSION:  Normal.  No evidence of deep venous thrombosis.  END OF IMPRESSION  INDICATION: Male, 12 years old, Leg pain  COMPARISON: None  TECHNIQUE: Grayscale sonography with and without compression, as well as color and spectral Doppler imaging, was obtained of the deep venous system of bilateral lower extremities, including external iliac, common femoral, femoral, deep femoral, greater saphenous and popliteal veins.  The IVC was not assessed.  The posterior tibial and peroneal veins in the calf were assessed.  FINDINGS:  All visualized veins are patent, without intraluminal thrombus. Spectral Doppler imaging demonstrates normal venous waveforms.    ***** Final Report*****   Echo 1/24/23 ? Technically difficult examination due to suboptimal echocardiographic windows. ? No major structural abnormalities detected within the visible anatomy. Atrial septum, upper pulmonary veins, right coronary artery not  seen. ? Normal valvular function. ? Normal left ventricular size with borderline global systolic function. No major regional wall motion abnormalities at rest. ? Qualitatively probably normal right ventricular systolic function. ? No pericardial effusion.    Cardiac MRI 1/25/23 ? A localized small area of late gadolinium enhancement in basal inferior segment of left ventricle. ? Normal biventricular size and systolic function. No regional wall motion abnormalities. ? No significant valvular dysfunction. ? Normal coronary origins with no proximal coronary artery aneurysms. ? Trivial pericardial effusion.    Echo 1/27/23 ? Normal valve function. ? Normal biventricular function. ? 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: 36.8  °C  (Temporal Artery)  HR: 58 (Monitored)  RR: 18  BP: 125/74  SpO2: 98%  WT: 72 kg   Discharge Physical Exam     Gen: awake, alert, interactive  HEENT: Normocephalic  CV: RRR, no murmur appreciated, +PP, WWP  Resp: lung sounds clear, easy WOB  Abd: soft, non-tender  Ext: moves all extremities with equal strength  Diagnosis List   1. Chest pain, 01/24/2023  2. Myocarditis, 01/24/2023  Procedure History  No Procedure History  Social History  Smoking Status      No Smoking Status Documented  Allergies   No Known Medication Allergies  Laboratory Results Returned 48 Hours Prior to Discharge       Labs Last 48 Hours      Event Name  Event Result  Date/Time   D-Dimer <0.27 01/27/23  Sodium 136 mmol/L 01/27/23  Potassium 4.19 mmol/L 01/27/23  Chloride 104 mmol/L 01/27/23  CO2 21 mmol/L Low 01/27/23  Anion Gap 10 mmol/L 01/27/23  Glucose Level 112 mg/dL 01/27/23  BUN 13 mg/dL 01/27/23  Creatinine 0.67 mg/dL 01/27/23  Calcium 8.6 mg/dL 01/27/23  B-Type Natriuretic Peptide 72 pg/mL 01/27/23  Troponin T Gen 5 69 ng/L High 01/27/23     Microbiology Results (Last 30 Days)  No Micro Results in past 30 days  Health Care Proxy: Under 18 years old  MOLST: Under 18 years old  Follow-Up and Patient Instructions  Patient Instructions       Follow up with cardiology 2/1 week for EKG and labs.   No strenuous exercise for 2-3 months (until cleared from cardiology).   Plan for exercise test and repeat cardiac MRI.