Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New diagnosis of suspected or confirmed myocarditis OR follow-up for established myocarditis
(Specify) Symptoms of myocarditis can vary and may be absent in early stages. Common complaints include:
Chest pain (sharp, stabbing, or pleuritic)
Palpitations (feeling the heartbeat)
Shortness of breath
Fatigue
Lightheadedness or dizziness (symptoms suggestive of low blood pressure)
Swollen ankles (in severe cases)
History of Present Illness:
Onset, duration, and severity of symptoms.
Recent viral illness (common trigger for myocarditis).
Activity level at symptom onset (may suggest exertion-related myocarditis).
History of exposure to toxins or medications potentially causing myocarditis (rare).
Past Medical History:
Underlying medical conditions that may increase risk (e.g., autoimmune diseases).
Prior history of myocarditis.
Family History:
Family history of heart muscle disease (uncommon).
Medications:
List all current medications, including any recently started medications.
Social History:
Recent travel or exposures that could increase risk of viral illness.
History of recreational drug use (cocaine or amphetamines can trigger myocarditis).
Physical Exam:
Vital signs: Assess for fever, tachycardia (fast heart rate), tachypnea (rapid breathing), hypotension (low blood pressure).
Cardiovascular examination: Listen for heart murmurs (may indicate abnormal heart valves due to inflammation). Assess for jugular venous distention (JVD) and peripheral edema (signs of heart failure in severe cases).
Respiratory examination: Assess for lung sounds and signs of fluid buildup in the lungs (pulmonary edema).
Laboratory Tests:
Complete blood count (CBC): May show elevated white blood cells suggestive of infection.
Electrolytes: May show abnormalities due to dehydration or heart failure.
Troponin I or T: Cardiac biomarkers elevated in myocardial injury. Serial measurements may be helpful to assess trends.
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): Elevated levels indicate inflammation (not specific for myocarditis).
Viral testing (depending on suspected cause): May be done to identify a specific viral infection.
Imaging Studies:
Chest X-ray: May show signs of lung congestion (in severe cases).
Electrocardiogram (ECG): May show abnormal heart rhythms or changes suggestive of myocardial injury.
Echocardiogram: Essential for evaluating heart function, chamber size, and presence of pericardial effusion (fluid around the heart). May show decreased left ventricular ejection fraction (LVEF) in severe cases.
Cardiac MRI (may not be readily available in all settings): Can provide detailed imaging of the heart muscle and help differentiate myocarditis from other conditions.
Assessment:
Suspected myocarditis: Based on clinical presentation (chest pain, shortness of breath, possible fever) and supportive findings on laboratory tests (elevated troponin) or imaging studies (echocardiogram abnormalities).
Confirmed myocarditis: Requires evidence of myocardial inflammation, typically on cardiac MRI. Endomyocardial biopsy (tissue sampling from the heart) is the most definitive diagnostic test but is an invasive procedure not routinely performed.
Differential Diagnoses:
Consider other conditions that can cause similar symptoms:
Pericarditis (inflammation of the sac around the heart)
Acute coronary syndrome (heart attack)
Pulmonary embolism (blood clot in the lungs)
Costochondritis (inflammation of chest wall cartilage)
Anxiety
Plan:
Treatment:
Rest: Restriction of physical activity to allow for heart muscle healing.
Medications:
Anti-inflammatory medications (e.g., ibuprofen) to reduce inflammation.
Diuretics (water pills) to remove excess fluid in severe cases.
Beta-blockers or ACE inhibitors (in some cases) to improve heart function.
In severe cases: Hospitalization with medications to support heart function and manage complications (e.g., heart failure, arrhythmias).