Age: 59.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Deep vein thrombosis, Dyspnoea, Exercise tolerance decreased, Muscle spasms, Pain in extremity
Clinical narrative: FROM Admission H&P 8/21/2021: He reports increase in shortness of breath with exertion and some calf pain. He says the increase in shortness of breath started in May but he attributed it to possible allergies and so he started taking Zyrtec and Flonase. He saw some resolution through June and July and did not experience the increased shortness of breath; however, 1 week ago he noticed increased shortness of breath with hiking. Later that day he went swimming and when swimming he experienced left calf cramping. He has noticed most of this shortness of breath with exertion. He is a very active person and exercises almost every day through biking or other cardio activities. Today the patient was walking up a hill after a 3-hour meeting at the camp he is working at and he had to use the bathroom and felt dizzy and lightheaded. Once he got to the building he was staying in, he climbed the stairs to get to the bathroom, he called for his son because he was not feeling well and wanted him to evaluate him. Of note, his son is a 3rd-year medical student and a pharmacist. He sat down before urinating and felt like he might have lost consciousness. His son reported an irregularly irregular right radial pulse and had him do a vagal maneuver which he said got him into a regular pulse. From there he went to the bathroom but started feeling lightheaded again. His son supported him to laying down on the bed, rechecked his pulse and found it to be irregularly irregular again and repeated a vagal maneuver. His son held his legs up until EMS arrived. EMS reported that his color was gray and his oxygen saturation was in the low 80s on arrival. He was incontinent of urine in the bed. Of note his wife also reported left foot swelling a few days prior to this event. Hematology consultation 8/23/2021- He presented to our emergency department on Saturday 08/21/2021 with increasing symptoms of shortness of breath, particularly with exertion, as well as some left lower calf pain. The patient reports initially noting symptoms of shortness of breath with exercise beginning in May 2021. He attributed this to possible seasonal allergies and initiated Zyrtec and Flonase. He did have some improvement in his symptoms through June and July 2021, however, would have intermittent symptoms of shortness of breath particularly with exercise. He reports going for a hike approximately 1 week ago and noted some increasing shortness of breath during his hike. Later that day he went swimming and had cramping in his left calf. He notes he was at a meeting on Saturday morning. After the meeting he jogged uphill and noted some worsening shortness of breath, he felt dizzy and lightheaded, and was also noted to have an irregular pulse by his son. He was taken to the emergency department for further evaluation via EMS. Upon evaluation by EMS his oxygen saturations were in the low 80s. Laboratory studies revealed a troponin of 846.5, D-dimer elevated at 17.15. Doppler studies of lower extremities and CTA of the chest were performed noting evidence of pulmonary embolism with large clot burden and some evidence of right heart strain, along with acute DVT of the left lower extremity. Patient was appropriately initiated on a heparin drip. He has been since transitioned to Eliquis. He does not report any symptoms of chest pain. No worsening respiratory symptoms. No signs or symptoms of bleeding. No fevers or chills. No nausea, vomiting, diarrhea or constipation. He denies any previous history of blood clots, no recent travel, surgery, or trauma. He does report receiving his COVID-19 vaccine, the 2nd dose of Pfizer in April 2021. Otherwise no further concerns at this time. Per hematology consultation 8/23/2021: We have discussed with the patient today he will likely require lifelong anticoagulation in the setting of unprovoked clot. I have asked Dr to please ask pharmacy to report possibility of pulmonary embolism and deep venous thrombosis (DVT) following COVID-19 vaccination to our pharmacy.