Presented to ED on 4/14/21:   Pt is a 64 y.o. female w/ PMH significant for HLD, proteinuria, hx ischemic bowel on daily asa, migraines p/w dizziness and hear fluttering.  Patient states for the last 2 days has been having intermittent fluttering in her chest, no chest pain or shortness of breath.  Also endorses since yesterday positional vertigo, sudden and severe in nature.  Was associated with 2 episodes of emesis today.  Denies any hearing loss, tinnitus, recent illness, fevers, history of vertigo, headache.  No leg swelling, hemoptysis, recent surgery or travel, history of blood clots, hormone use.  No abdominal pain, diarrhea, urinary symptoms.  Denies any recent changes in her medications, denies heavy caffeine use, denies any alcohol or drug use. Patient was seen earlier today at urgent care where she was found to have ventricular bigeminy so was sent to the ED.  Was also given 25 milligrams meclizine with minimal relief in her symptoms. Remaining review of systems and physical exam as detailed; Dx:  Central versus peripheral vertigo including BPPV, labyrinthitis, ventricular arrhythmia, migraine, less likely to be ACS, PE, infection/gastroenteritis: MDM/COURSE: EKG with PVCs/ventricular bigeminy, troponin negative, CBC, BMP, electrolytes; neurology consult, MRI vertigo protocol neg -> recommended daily ASA, neurology followup oupatient given fluids, monitored on telemetry here without any issues will dc with strict return precautions, instructions to followup with PCP for possible holter monitor/cardiology referral; This patient was presented to and discussed with an attending emergency physician; a treatment plan and disposition were collaboratively agreed upon. History Chief Complaint Patient presents with, Irregular Heart Beat; Dizziness, N/V, and fluttering in chest. pt in and out of ventricular bigeminy. Dizziness; The history is provided by the patient and medical records. Other; This is a new problem. The current episode started 2 days ago. The problem occurs hourly. The problem has not changed since onset.Pertinent negatives include no chest pain, no abdominal pain, no headaches and no shortness of breath. Nothing aggravates the symptoms. Nothing relieves the symptoms. She has tried nothing for the symptoms. Past Medical History: Diagnosis Date; Dry eyes; Hypercholesteremia; MVA (motor vehicle accident) 01/29/2017; Proteinuria; Past Surgical History: Procedure Laterality Date; COLONOSCOPY; MASS EXCISION Left 04/24/2018; Excision of left lateral ankle mass; SIGMOIDOSCOPY (FLEX SIG) (IMAGES) 2/10/2015; Procedure: SIGMOIDOSCOPY, FLEXIBLE; W/BX, SINGLE/MULTIPLE;  Surgeon: MD;  Location: YNH AMBULATORY PROCEDURE CENTER;  Service: Internal Medicine; TONSILLECTOMY 21 yo; Socioeconomic History Marital status: Married; Occupational History; Comment: currently on leave-long term disability 1/2017 Tobacco Use; Smoking status: Never Smoker; Smokeless tobacco: Never Used; Substance and Sexual Activity Alcohol use: Yes; Alcohol/week: 0.0 standard drinks; Comment: occ; Drug use: No; Sexual activity: Not Currently Partners: Male; Social History Narrative; Divorced.  Then married 2012. Review of Systems: Constitutional: Negative for fever. HENT: Negative for congestion. Eyes: Negative for visual disturbance. Respiratory: Negative for shortness of breath. Cardiovascular: Positive for palpitations. Negative for chest pain. Gastrointestinal: Negative for abdominal pain. Genitourinary: Negative for dysuria. Musculoskeletal: Negative for back pain. Skin: Negative for rash. Neurological: Positive for dizziness. Negative for headaches. Psychiatric/Behavioral: Negative for agitation.  BP (!) 151/86  | Pulse 65  | Temp 97.2 °F (36.2 °C)  | Resp 16  | SpO2 98%; Physical Exam; Vitals signs and nursing note reviewed. Constitutional: General: She is not in acute distress. Appearance: She is well-developed.  HENT: Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal. Eyes: Pupils: Pupils are equal, round, and reactive to light. Comments: Bidirectional nystagmus Corrective saccade on head impulse test, neg test of skew; Neck: Musculoskeletal: Neck supple. Cardiovascular:  Rate and Rhythm: Normal rate and regular rhythm. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. Abdominal: Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness.  Musculoskeletal: General: No tenderness. Right lower leg: No edema. Left lower leg: No edema.  Skin: General: Skin is warm and dry. Neurological: Mental Status: She is alert. Cranial Nerves: No cranial nerve deficit. Sensory: No sensory deficit. Motor: No weakness. Coordination: Coordination normal. Psychiatric: Behavior: Behavior normal. ED COURSE; Reviewed previous: previous chart; Interpreted by ED Provider: pulse oximetry, ECG and labs; Consults: NEURO; Patient Reevaluation: Attending Supervised: Resident; I saw and examined the patient. I agree with the findings and plan of care as documented in the resident's note. Of note pt sent from YHP for palpitatins and vertigo. No relief with meclizine at YHP.  BP (!) 167/90  | Pulse 62  | Temp 98.1 °F (36.7 °C) (Oral)  | Resp 18  | SpO2 99%; Pt had MRI that was normal and was seen by neuro. Can be DC home. Patient progress: stable; Clinical Impressions as of Apr 14 2302; Dizziness; Palpitations; ED Disposition; Discharge F/u visit with PCP;  On 4/16/21 visit she relayed sensation of hiccups in chest happening at random x 2 months and for past 5 days has fluttering in chest accompanied by a sense of imbalance. ECG showed ventricular bigeminy and follow up ECG showed frequent PVCs. I advised TTE,48-hour Holter, Sress test, advised to cut her usuall tea or coffee in evening after Holter, Metoprolol 25mg bid as needed fluttering in chest but start after Holter, ECASA 81mg daily as she has been taking, and cardiology referral. Stress test 5/5/21did not show obstructive coronary arteries but did show calcifications in left anterior descending artery and right coronary artery. TTE 5/5/21 was unremarkable. Holter 4/19-21 showed NSR with exceptionally high VE and occ SVE.  5/13/21: Given coronary calcifications, I advised changing simvastatin from 20mg to 80mg to push LDL < 70. Overall she feels "a lot better." She can still feel some flutters, mostly in mornings and pulse feels faint when palpating (she does not feel faint). If feels a lot of these then she takes one tab of metoprolol and this helps over 2 days.  Advised to take metoprolol 25mg XL daily. She would like to taje in evenings to prevent flutters in amShe has f/u with Dr in 5/25/21. Cardiologist f/u:  is a 64 y.o. year old female s/p ED visit on 4/14/2021 for intermittent fluttering in her chest, presenting for evaluation of high density PVCs. She notices palpitations mostly when lying down and getting up in the morning.  She reports developing the palpitations and fatigue, 5-6 days after getting her second COVID (Pfizer) vaccine on 4/6/2021. She currently takes metoprolol 25 mg once daily at night which she believes is helping the flutters. She had one prior presyncopal episode during the night and a feeling of losing her balance. No tachycardia or syncope. She does not have high BP. She denies chest pain, pressure or tightness with exertion. She has occasional SOB with exertion and a cough which occurs in the morning with clear phlegm, but she reports no postnasal drip. She also reports a hiccup sensation that occurs in the morning. She does not have fever, shills or sweats. MEDICATIONS: aspirin, 81 mg, Oral, Daily; cyanocobalamin, 1,000 mcg, Oral, Daily; metoprolol succinate XL, 25 mg, Oral, Daily; multivitamin, 1 capsule, Oral, Daily; naproxen sodium, 440 mg, Oral, BID PRN; ramipriL, 5 mg, Oral, Daily; simvastatin, 80 mg, Oral, Daily; PAST MEDICAL HISTORY: patient has a past medical history of Dry eyes, Hypercholesteremia, MVA (motor vehicle accident) (01/29/2017), and Proteinuria. ALLERGIES: has No Known Allergies. FAMILY HISTORY: family history includes Cancer in her father; Cataracts in her maternal grandfather and paternal grandmother; Colon cancer in her maternal grandmother; Colon polyps in her brother and mother; Diabetes in her maternal grandfather; Glaucoma in her maternal grandfather and paternal grandmother; Hypertension in her brother and father; Retinal detachment in her maternal grandfather; Thyroid disease in her cousin. There is no history of Strabismus, Stroke, Amblyopia, Blindness, or Macular degen. High cholesterol and high triglycerides in father, CHF in maternal grandfather in 60s and heart attack in 50s. SOCIAL HISTORY: She drinks 1 cup of coffee or tea in the morning. She has 2 children and 7 grandchildren. REVIEW OF SYSTEMS: Positive dizziness, palpitations, fatigue secondary to COVID vaccine, prior presyncopal episode, prior vomiting episode, occasional cough with production of clear phlegm, hiccup sensation. 13 pt review of systems otherwise negative. PHYSICAL EXAM:130/80, pulse 71, weight 90.9 kg, SpO2 97 %. Lungs:  Clear to auscultation bilaterally. Cardiovascular:  No LV or RV heave.  No murmurs, gallops, or rubs. Abdomen:  Nontender.  No hepatomegaly or ascites. Extremities: Warm and well perfused.  No peripheral edema. ECG 5/25/2021: NSR 68, QT interval 433 corrected for heart rate; Echo 5/5/2021: Normal left ventricular cavity size.  Normal left ventricle wall thickness.  Normal left ventricular systolic function.  LVEF calculated by biplane Simpson's was 66%.  Abnormal tissue Doppler suggestive of abnormal diastolic function. Normal right ventricular cavity size and systolic function.  Estimated right ventricular systolic pressure is 31 mmHg. Left atrium is normal in size.  Right atrium is normal in size. Mild mitral regurgitation. Mild tricuspid regurgitation. No evidence of pericardial effusion. No prior study available for comparison. NM Myocardial Perfusion SPECT 5/5/2021: Normal SPECT myocardial perfusion study following exercise at a good workload for age and gender.  Perfusion imaging was normal.  Left ventricular ejection fraction was normal with normal wall motion.  The left ventricle was normal in size.  Stress electrocardiogram was without ischemic changes.  Frequent PVCs at baseline are suppressed at higher heart rates during exercise, and return in recovery.  The patient exercised for a total of 7 minutes and 14 seconds using the Bruce protocol.  Exercise capacity was 8.9 METs.  CT performed for attenuation correction showed moderate coronary artery calcification in the left anterior descending artery and right coronary artery.  Non-cardiac findings of the CT are described in a separate report from Radiology.  No prior study available for comparison. Holter Monitor 4/23/2021: The predominant rhythm was sinus bradycardia to sinus tachycardia with frequent ventricular ectopy. The maximum heart rate recorded was 164 bpm, Day 1 / 04:19:25 pm, the minimum heart rate recorded was 51 bpm, Day 2 / 05:29:44 am and the average heart rate was 89 bpm. There were 40020 PVCs with a burden of 15.52%. There were 4 occurrences of ventricular tachycardia with the longest episode 3 beats, Day 1 / 07:11:46 pm and the fastest episode 119 bpm, Day 1 / 05:26:28 pm; There were 27 PSVCs with a burden of 0.01%. There were 2 occurrences of supraventricular tachycardia with the longest episode 4 beats, Day 1 / 04:19:29 pm and the fastest episode 164 bpm, Day 1 / 04:19:29 pm. Diary events were entered. There were 9 patient triggered events. Lipid Panel With Reflex to Direct LDL 4/8/2021: Total Cholesterol: 212 mg/dL; HDL: 72 mg/dL; Triglycerides: 115 mg/dL; LDL: 117 mg/dL; IMPRESSION: High density PVCs that have a predominant  LBBB configuration likely originating from the right ventricular alpha tract. The minor episodes of non-sustained ventricular tachycardia on her Holter were slow with rates of 120 bpm. The suppression of the PVCs during exercise is a favorable finding and she has normal LV and RV function. She does have coronary calcification but no evidence of inducible ischemia. She does not have bundle branch block or AV block to suggest sarcoid. No family history of arrhythmia or cardiomyopathy.  The timing related to her prior COVID vaccine is curious. The possibility of vaccine-related myocarditis seems low but needs to be excluded, thus she will have a cardiac MRI. She will continue the metoprolol which seems to be helping symptomatically and start magnesium supplementation which might help diminish the PVC density. She should minimize caffeine. Coronary calcification on statin. Minor PACs. RECOMMENDATIONS: Eliminate caffeine. Repeat Holter monitor. Cardiac MRI. Start magnesium oxide 400 mg QD. Continue beta blocker. Follow up in 1 month.