Age: 66.0
Sex: M
Vaccine: COVID19
Symptoms: Fatigue, Fibrin D dimer increased, Gene mutation identification test negative, Hyperlipidaemia, Hypertension
Clinical narrative: Patient received Moderna vaccine dose #1 on 3/3/21 at approximately 0900.  In the afternoon of 3/4/21, patient had sudden onset shortness of breath while at home, as well as fatigue and low energy. Patient knew that a potential side effect of vaccine was fatigue, so he assumed this was just a normal side effect to be expected. States that his difficulty breathing and fatigue continued for about a week. After continued urging from wife to seek medical care, patient visited urgent care center on 3/15/21. The urgent care did a D-Dimer lab, and an x-ray of chest. X-ray "showed something abnormal" so they did a CT scan as well, which showed a "huge pulmonary embolism." D-Dimer lab was elevated. Patient was transported to hospital by ambulance and had immediate surgery to remove blood clot from lungs at approximately 2100 on 3/15/21. Per patient, the surgeon said the clot was about the size of his palm. Surgeon reported that there was "100% blockage to left lung from the aortic artery and 90% blockage to right lung from aortic artery."  A DVT in popliteal vein was identified, and the surgeon assumes the clot started in the popliteal vein and broke off and traveled to lungs. Patient was admitted and hospitalized until he was discharged home on 3/18/21. During course of hospitalization, genetic testing was done and it was determined that the "genetic marker for clots was negative, so they think the clot is from a one-time event--patient's family does not need to be concerned that they have clotting issues." Patient states that he was started on heparin in the hospital, and was discharged home on Eliquis blood thinner, which is being tapered. Patient states that the doctors think he will be on Eliquis for about 6 months and will not need to be on it for life. Doctors say the DVT in leg will dissolve on its own. During hospitalization, an echogram and cardiac cath was performed, which showed "an old heart attack on the left side, but that collateral vessels have built up already." Right side of heart was weaker from having to work so hard due to blood clots in lung, but prior to discharge from hospital, the right side of heart was already showing improvement. A heart cath was done to check vessels and it was determined no stents were needed, although there was a small clot in left anterior descending artery. Patient was also newly diagnosed during course of hospitalization with Type II Diabetes in a non-obese person, HTN (which patient had never had before), Coronary Artery Disease, Hyperlipidemia, 1st degree AV block. Was discharged home with metformin, losartan, chlorthalidone, atorvastatin, and Aspirin. The chlorthalidone was discontinued, due to "blood pressure dropping too low--they think his high blood pressure was situational" per wife of patient. Medical doctors advised against receiving the 2nd dose of Moderna vaccine. Patient being followed by Internist at hospital.  Patient's shortness of breath resolved "immediately after clot was removed" but is continuing to be followed while on new medications and blood thinner dosing.  The above information was provided during telephone interview of patient and his wife.