A 31 yo previously healthy man noticed some mild swelling in his left forearm following his daily workout, which involved doing pushups and lifting weights. Two weeks later he developed left shoulder pain and some bluish discoloration of the arm. A Doppler ultrasound showed a DVT in the left subclavian and proximal internal jugular veins. He was treated with low molecular weight heparin and transitioned to warfarin. There has been some improvement in his arm swelling and discomfort. He otherwise feels well. He is referred for evaluation and recommendations for management.
Medication: Warfarin 4 mg/day.
No smoking, consumes alcohol in moderation.
Married, no children, works as a paramedic.
No family history of venous thromboembolism. Father diabetic, coronary disease. Mother hypertensive, DJD, achalasia, history of unspecified cardiac arrhythmia. Brother with hypercholesterolemia and GERD. Sister with hx of melanoma and multiple sclerosis.
ROS: Occasional irregular heartbeat, otherwise negative.
Examination: Healthy looking man, appears generally well, normal vital signs. Left arm swollen and slightly dusky, prominent superficial veins over L shoulder and upper chest. Liver edge palpable just below costal margin, smooth and nontender. Exam otherwise normal.
TEST MENU
CBC and differential
Retic count
INR
aPTT
Bone marrow biopsy
Iron/TIBC
Ferritin
B-12
Folate
ESR
Hemoglobin electrophoresis
Hemoglobin A2
Haptoglobin
Osmotic fragility
G6PD
EPO
Thrombin time
Platelet function screen
Platelet aggregometry
Bleeding time
Fibrinogen
D-dimer
Fibrin monomer
Factor II, X, V, VII, IX, VIII, XI, XII, XIII
Protein C
Protein S
Antithrombin
Activated protein C resistance
Factor V Leiden
Prothrombin gene mutation
Inhibitor screen
SPEP
Serum immunofixation
UPEP
Urine immunofixation
Quantitative immunoglobulins
Serum viscosity
Lytes, glucose, creat, BUN
AST, ALT
Alk phos, GGT, bili
LDH
CRP
Uric acid
Albumin, total protein
Urinalysis
Urine hemosiderin
Chest xray
Skeletal survey
BodyCT
V/Q scan
Helical chest CT
Other radiology
Other pathology (biopsy)