Age: 52.0
Sex: M
Vaccine: COVID19
Symptoms: Joint range of motion decreased, Mean cell volume increased, Metabolic function test, Muscle spasms, Neutrophil percentage increased
Clinical narrative: In March I had a pain in my left calf muscle that I could not identify with getting hit or injuring it in any way. I called Urgent care because i read and heard about problem with the J&J vaccine that it was giving people blood clots. Urgent care said there was no need to come in that there was very little reason to believe that it was a blood clot. Then in June I woke up to very severe pain in my left leg from my foot all the way to my thigh. It was hot, swollen and I could barely bend my knee. I went to Urgent Care and they sent me across the street to the Hospital for an ultra sound on my leg. Here are the result from the ultra sound.  Real time color Doppler imaging and spectral analysis were performed during ultrasound evaluation of the left lower extremity is performed. There is persistent occlusive deep venous thrombosis within the mid to distal superficial femoral vein extending nonocclusive bleed to involve the popliteal vein and exclusively within the proximal popliteal and peroneal veins of the calf. The doctor put me on 3 week of taking a blood thinner twice a day and then will go down to taking one blood thinner once a day for 6 months. I also saw MD. Here are his notes from my Drs appt. Patient is seen today, 6/14/2021, to discuss management of left leg DVT.   Patient presented to urgent care on 5/20/2021.  He had noticed soreness in his left leg for a couple of days and then he awoke that day and the leg was swollen.  The duplex scan showed that he had occlusive clot involving left superficial femoral vein extending through popliteal vein down to peroneal vein in the left calf.  He was started on rivaroxaban 15 mg twice daily.   He transitions to 20 mg rivaroxaban daily tomorrow.   The leg soreness has eased slightly but the swelling has not improved.  He did have a repeat duplex scan on 6/7/2021 which was unchanged.  Thrombus persisted but was not worse.   He has not had chest pain or breathing issues or dyspnea.  He does recall that about 4 weeks earlier he had a muscle spasm sensation in the left calf.  He had received a Johnson & Johnson Covid immunization in late February, 2021.  He was aware of the public information about venous clotting in women who had received the J&J vaccine and was also aware that it involved cerebral veins.  He called his provider and was asked questions about the leg and otherwise the answers were negative.  So imaging was not obtained.  The muscle spasm sensation did not recur.   His family history is negative for clots in his personal history for clots is otherwise negative.  He is a maintenance manager.  He has not had lengthy travel recently.  He also denies any trauma to the legs.   He has a history of GERD from which she had developed iron deficiency anemia in June 2020.  He had undergone EGD has a result.  He also had a colonoscopy when he turned 50 years of age and had polyps removed and then had repeat colonoscopy 6 months later.  This evaluation occurred with Dr. of gastroenterology. His colonoscopy was on 12/20/2018.  One of the polyps was a hyperplastic polyp.  The second was a tubulovillous adenoma with high-grade dysplasia/intramucosal adenocarcinoma, 2 cm size.  Polyps were excised.  Had repeat endoscopy on 7/10/2019 he had a hyperplastic polyp in his rectum.   Also he had a PSA checked in summer 2020.  It was 0.5.   He is a smoker only of very infrequent cigars, perhaps every 6 to 8 months.   PAST  MEDICAL HISTORY:   GERD Sigmoid colon polyps, resected December 2018 and June 2019 Left leg DVT, May 2021 Sleep apnea Iron deficiency anemia related to gastritis.  Diagnosed June 2020, treated with oral iron ADHD History of depression   MEDICATIONS: has a current medication list which includes the following prescription(s): amlodipine, escitalopram, esomeprazole, multivit-iron-fa-calcium-mins, prednisone, rivaroxaban, unknown home medication, and tadalafil.     ALLERGIES:  Patient has no known allergies.   PAST SURGICAL HISTORY:   Vasectomy 2 colonoscopies, first in December 2018 and second in July 2019 EGD on 2 occasions, first in March 2019 and second in June 2020   FAMILY HISTORY:   Father died age 66.  He had a pacemaker and was on blood thinners Mother died of a throat cancer.  She was a heavy smoker.  Died at age 60 1 brother and 1 sister are healthy     SOCIAL HISTORY:   Smokes cigars, perhaps twice a year.  Never smoked cigarettes Alcohol use maybe 4 beers on the weekend Previously married and divorced 3 children, 2 daughters and 1 son ranging in age from 17 through 21    REVIEW OF SYSTEMS:   Significant for persistent soreness in his left leg albeit easing over the last 3 days and persistent swelling in his left leg including dorsum of his foot General:  Denies weight loss, no issues with energy, denies night sweats HEENT:  No mouth or throat soreness, no issues with hearing, no tinnitus, no issues with taste  No epistaxis Resp:  Denies cough, exertional dyspnea, sputum production.   Heart:  No palpitations, no exertional chest pain, no lightheadeness or dizziness when standing Gi:  No dysphagia.  No heartburn,  Denies nausea or vomitting.  Bowels are regular, no diarrhea or constipation.  Denies melena or hematochezia GU  Denies hematuria.  No dysuria.  No incontinuence.   Skin:  No rash, no petechiae, no dryness.  No itching or burning. Musculoskeletal:  No bone pains, no joint pains or swelling.  No localized weakness Neurologic:  Denies headaches, no double vision, no weakness, no change in sensation Psychiatric:  Good spirits, sleeping well, no anxiety, normal mood Endocrine:  Denies heat or cold intolerance. Heme:  No easy bruising       PHYSICAL EXAMINATION:   BP (!) 142/99  | Pulse 95  | Temp 97.6 °F (36.4 °C)  | Resp 18  | Ht 6' 3" (1.905 m)  | Wt 295 lb (133.8 kg)  | SpO2 96%  | BMI 36.87 kg/m²  Appears alert, oriented, not in distress.  Well developed   Psychiatric: Patient is alert oriented ×4, good spirits, interacts appropriately He has swelling in his left leg   DATA:   CBC: .5/20/2021: WBC 7.49 X10^3/uL; Hemoglobin 14.8 g/dL; Hematocrit (calc.) 43.4 %; Neutrophil (%) 75.4 %; MCV 98.4 fL; Platelet 141 X10^3/uL*   CMP: 4/22/2021: Bicarbonate (TCO2) 25 mmol/L; BUN/Creatinine 16; Calcium, total 9.0 mg/dL; AST (SGOT) 41 IU/L*; ALT (SGPT) 38 IU/L; Alkaline Phosphatase 62 IU/L; Bilirubin, Total 0.4 mg/dL; Protein, total 6.9 g/dL; Albumin 4.3 g/dL; Albumin / Globulin 1.7 5/20/2021: Sodium 142 mEq/L; Potassium 4.6 mEq/L; Chloride 103 mEq/L; BUN 13 mg/dL; Creatinine 1.2 mg/dL; Glucose 110 mg/dL*; Calcium, Ionized 1.17 mmol/L     ASSESSMENT:   1.  Left lower extremity DVT.  Etiology unclear.  No definite provocation.  He did receive a Johnson & Johnson Covid vaccine in late February, 2021.  He first noticed a muscle spasm sensation in left calf in mid April, 2021 and then had onset of soreness 2 days before his visit with swelling onset the day of his urgent care visit, 5/20/2021.   Currently on rivaroxaban.  Transitioning now to the 20 mg daily dose.   Family history negative for DVT as is his personal history.  PSA was unremarkable and summer 2020.  Has had prior colonoscopy in December 2018 and June 2019.  Did have finding of sigmoid colon polyps with atypia in 1 and possible noninvasive adenocarcinoma.  Repeat scope showed hyperplastic polyp but no additional polyps.  Has also had EGDs in March 2019 and June 2020 because of GERD and iron lack anemia.  Non-smoker.   I discussed with patient that we would usually treat him for 6 months with anticoagulation and then reassess to determine whether it is safe to discontinue therapy.  But if he has ongoing swelling and soreness in his leg it would be difficult to stop treatment because we would lose one of our early indicators of recurrence of DVT.  I also suggested that we should do a lab panel to assure that he does not have any underlying inherited or acquired abnormality that predispose to this clot, since we do not have any clear-cut causative etiology.  (We discussed that the Covid immunization may have been his predisposition, but that existing data suggest that this is a risk factor in females and that most of the episodes were central nervous system venous clots.)     PLAN:   1.  So we will draw lab panel assessing acquired and inherited predispositions for hypercoagulability.  And we will plan to see him back in a couple of months to reassess his status.