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)