Age: 14.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Beta-2 glycoprotein antibody, CSF pressure increased, Capillary nail refill test, Cardiolipin antibody negative, Cerebrospinal fluid drainage
Clinical narrative: Pt received the pfizer covid vaccine 6/16/21 and 7/21/21.  On 12/29/21 pt had an optometry visit because he was due. He had been prescribed glasses in the past. At that visit he was noted to have papilledema b/l.  Pt was transferred to facility for evaluation. This provide is copying and pasting the most recent note. Parent asked today if his condition was related to covid vaccines.Chief Complaint: Routine follow-up eval - 20 months s/p DVT on rivaroxaban History of Present Illness: Patient and his mother are here together today as usual.  They jointly provide his full history.  He is a now 16 year old male who came to us at age 14 as an inpatient admission following transfer from location for papilledema and increased ICP. CT was negative for intracranial abnormality. LP had elevated opening pressure and fluid was drained with improvement of symptoms after procedure. In house MRI/MRV was obtained and remarkable for "dural venous sinus narrowing/stenosis can be associated with the diagnosis of intracranial hypertension & Filling defect at the right jugular bulb could potentially reflect nonocclusive thrombus or flow related artifact". Neurosurgery and neurology were consulted and CTH/CTV was performed and was significant for "near occlusive thrombus within the proximal right internal jugular vein & presence of extensive transosseous venous collaterals near the right transverse/sigmoid junction suggests chronicity".  Neurology recommended acetazolamide and he remains on this.   He was recently seen by Optho and is able to decrease his diamox dose once again with teh goal to get fully off it.  ICP sxs are fully resolved on repeated checks  Today he is approx 20 months out from anticoagulation start.  He and mom both report that he is doing better in a few different areas.  His mood is improved.  He is having HAs about 1x/week still.  Using Tylenol and NSAIDs.  We again reviewed no NSAIDs.  He doe sfeel like he gets HAs possibly more with increased activity like PE at school and running but he also gets them on restful days at home.  He had a single bruise over his R knee. Positive epistaxis this summer.  Several a week all lasting < 5mins.  Applying tissue only, no pressure. No gingival bleeding.  No blood in hid urine or stool.  Discussed nasal hygiene for prevention of epistaxis. Positive wisdom teeth out while on rivarox.  Education given to family to call with any additional planned medical interventions/surgeries.  No bleeding noted during wisdom teeth extraction x4 b/l.    He is not wearing his glasses which he needs Review of Systems: A 10-point review of systems was performed and results were negative except for any positive results as per my HPI above Physical Exam: Vitals & Measurements Temperature:  37.2 Heart Rate:  80 Systolic BP Sitting:  112 Diastolic BP Sitting:  72 Dosing Weight:   63.8 kg Height:  171.1 cm Body Mass Index:   21.79 BMI Percentile :   67.40 GENERAL: Well appearing, nontoxic, interactive HEENT: Normocephalic atraumatic, EOMI, moist oral mucosa, no lesions noted  NECK: Supple, non-tender, no lymphadenopathy. LUNGS: Clear to auscultation, non-labored respiration, no wheezes, rales or rhonchi. CV: Normal rate, regular rhythm, no murmur, 2+ distal pulses Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no hepatomegaly, no splenomegaly. Musculoskeletal: Normal range of motion and strength, no tenderness or swelling. Skin: Skin is warm, dry, no rashes or lesions, and capillary refill less than 2 seconds. Assessment/Plan: Patient is a now 16 year old male transferred from location for papilledema and increased ICP, found to have an unprovoked CHRONIC thrombus at initial presentation within the proximal right internal jugular vein, with neurology, neurosurgery, and optho following.  Patient lacked risk factors for clotting such as dehydration, immobility, hormones, smoking, or obesity. Hereditary work-up including full hypercoagulation eval NEGATIVE.  Needs life long anticoagulation due to congenital malformation . 1. Jugular vein thrombosis -Continue Rivaroxaban 20mg daily - NeuroSGy and NueroSGYVascular do not need additional imaging. It is at our descretion - As clot continues to evolve Repeat MRI/A in 1 year Feb 2024 - Complete Hypercoagulable work-up is NEGATIVE  RTC with doc visit q 6 moths - okay to coordinate with NeuroSGY or Optho -Emailed for Neuropsych Eval - prev internally accepted but mom unclear on scheduling.  I will follow-up 2. Papilledema due to raised intracranial pressure - Followed ongoing by Ophtho - last seen yesterday Aug 2023 - Abel to DECREASE acetazolamide - Now acetazolamide 250 mg po BID until follow-up with Optho; they will see again in 2 months Care Planning and Communication: Plan of care discussed with a parent. Interpreter services used during encounter: N/A, patient or caregiver. ___ I, MD personally spent 45 total minutes in face-to-face and non-face-to-face time on the date of the encounter (exclusive of activities normally performed by clinical staff).   I completed the activities below that are marked Yes. Please see above note for details:  Preparing to see the patient (e.g., review of tests). Yes Obtaining and/or reviewing separately obtained history. Yes Performing medically appropriate exam and/or evaluation. Yes Counseling and educating the patient/family/caregiver. Yes Ordering medications, tests, or procedures. Yes Referring and communicating with other health professionals. Yes Documenting clinical information in the electronic or other health record. Yes Independently interpreting results (not separately reported and billed) and Communicating results. Yes Care coordination (not separately reported and billed). Yes Allergies: No Known Allergies Medications: acetaZOLAMIDE (acetaZOLAMIDE 250 mg oral tablet) 2 tab (500 mg), By Mouth, BID rivaroxaban (rivaroxaban 20 mg oral tablet) 1 tab (20 mg), By Mouth, q evening Problem List: Jugular vein thrombosis Papilledema due to raised intracranial pressure Family History: Reports All Negative: Father, Mother, Brother, Sister, Maternal Grandfather, Maternal Grandmother, Paternal Grandfather, Paternal Grandmother, Children, None Patient is Adopted: No Social History: Smoking Status - 06/08/2023 Pediatric patient: No tobacco exposure in the home; None (never smoked) Alcohol Never, 02/28/2022 Employment/School Student, 02/28/2022 Home/Environment Lives with Mother., 02/28/2022 Physical Activity Exercise frequency: Never., 02/28/2022 Substance Abuse Never, 02/28/2022 Tobacco None (never smoked), 02/28/2022 Results: APNTRP Event Date: 06/08/2023 10:52:00 Updated: 6/23/2023 08:17 APAS Interp CASE:  PATIENT:        INTERPRETATION: DUPLICATE ORDER. PLEASE SEE CONCURRENTLY ORDERED PATH INTERPRETATION.   COMMENT: The charges associated with this interpretation are removed.     MD.  Pathologist  Electronically signed 6/22/2023 11:59:54 PM   Case interpreted at: Reference Laboratory  Technical services performed at: Reference Laboratory  HCNTRP Event Date: 06/08/2023 10:52:00 Updated: 6/23/2023 08:17 Hypercoag Interp  PATIENT:        INTERPRETATION: NO EVIDENCE OF EVALUATED GENETIC OR ACQUIRED RISK FACTORS FOR THROMBOSIS (See Comment)   CLINICAL HISTORY: 16-year-old male with history of intracranial hypertension secondary to a spontaneous right internal jugular vein thrombosis, currently treated with rivaroxaban and followed by hematology. Patient lacked risk factors for clotting such as dehydration, immobility, hormones, smoking, or obesity. Prior testing on 1/3/2022 for antiphospholipid antibodies, Factor II (20210G>A) and Factor V Leiden mutations was negative.   COMMENT: The thrombophilia screening panel shows Free Protein S antigen, Protein C activity, and antithrombin within normal limits. There is no evidence of diagnostic criteria for antiphospholipid antibodies per Guidelines .   While there is no definitive current evidence of a lupus anticoagulant/inhibitor (LLI), false negative results may occur secondary to improper handling of the specimen, some reactive states, as well as administration of hydroxychloroquine (Plaquenil).    This thrombophilia screen is based on expert recommendation to detect a strong thrombophilia that may have an impact on recurrence and/or length of therapy OR may influence management of family members for the primary prevention of thrombosis. However, this profile is not exhaustive and, if clinical concern persists, additional testing may be of interest.   The undersigned staff pathologist has independently reviewed the?results pertinent to the above interpretation and (if performed) agrees?with the medical student, resident, or fellow evaluation.     MD.  Pathologist  Electronically signed 6/22/2023 11:58:23 PM   Case interpreted at: Reference Laboratory  Technical services performed at: Reference Laboratory  Group Detail Date Value w/Units Flags Normal Range Normal Reference Text Comment Ind Hypercoagulable Anti-thrombin III 06/08/2023 10:52:00 102 %         Hypercoagulable Protein C ACT 06/08/2023 10:52:00 89 %       Y Hypercoagulable Factor 5 Leiden 06/08/2023 10:52:00 (NOTE): ( DUPLICATE - Results previously reported as NORMAL from sample collected on 01/03/2022 under accession number. If duplicate testing is required, please contact the laboratory. Charges for this order have been credited.)          Hypercoagulable Protein S Free Antigen 06/08/2023 10:52:00 111 %       Y Hypercoagulable CHP Interpretation 06/08/2023 10:52:00 See Pathology Report          Hypercoagulable Lupus Anticoag Sensitive PTT 06/08/2023 10:52:00 See interpretation for LLI or APAS          Hypercoagulable RVV Patient 06/08/2023 10:52:00 See interpretation for LLI or APAS          Hypercoagulable APA Interpretation 06/08/2023 10:52:00 See Pathology Report          Hypercoagulable Anticardiolipin AB, IGM 06/08/2023 10:52:00 <1.5 MPL-U/mL   0.0-25.9   Y Hypercoagulable Anticardiolipin AB, IGG 06/08/2023 10:52:00 <1.6 GPL-U/mL   0.0-9.9     Hypercoagulable Anticardiolipin AB, IGA 06/08/2023 10:52:00 <2.0 APL-U/mL   0.0-9.9     Hypercoagulable Beta 2 Glycoprotein IGM 06/08/2023 10:52:00 <1.5 Unit/ML   0.0-19.9   Y Hypercoagulable Beta 2 Glycoprotein IGG 06/08/2023 10:52:00 <1.4 Unit/ML   0.0-5.9     Hypercoagulable Beta 2 Glycoprotein IGA 06/08/2023 10:52:00 <2.0 Unit/ML   0.0-10.9     Hypercoagulable LLI Interpretation 06/08/2023 10:52:00 Negative          Hypercoagulable Factor II 20210 Mutation 06/08/2023 10:52:00 (NOTE): ( DUPLICATE - Results previously reported as NORMAL from sample collected on 01/03/2022 under accession number Y929095. If duplicate testing is required, please contact the laboratory. Charges for this order have been credited.)          Anticoagulant Assays Rx anticoagulant 06/08/2023 10:52:00 Xarelto (rivaroxaban)          Anticoagulant Assays Rx anticoagulant 2 06/08/2023 10:52:00 Unknown          Anticoagulant Assays Rx anticoagulant 3 06/08/2023 10:52:00 UNK          Vision Screen  Hearing Screen