A 30-year-old man comes to the office due to 2 days of right arm pain, swelling, and heaviness. The symptoms are worse with activity or arm elevation above the head and improve with rest. The patient is an avid weight lifter and plays recreational baseball. Several hours prior to the onset of symptoms, he pitched 6 innings in a baseball game. He has no prior medical conditions and takes no medications. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Examination shows swelling and redness of the right arm from the elbow to the shoulder. Capillary refill is normal. What is the most likely cause of this patient's current symptoms?

Question

A 30-year-old man comes to the office due to 2 days of right arm pain, swelling, and heaviness.  The symptoms are worse with activity or arm elevation above the head and improve with rest.  The patient is an avid weight lifter and plays recreational baseball.  Several hours prior to the onset of symptoms, he pitched 6 innings in a baseball game.  He has no prior medical conditions and takes no medications.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Examination shows swelling and redness of the right arm from the elbow to the shoulder.  Capillary refill is normal.  What is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d434_802d_bc81_a359017b9ad1_MD0003_00 This young patient with acute right arm pain, swelling, and heaviness likely has upper extremity deep venous thrombosis (DVT). Although the vast majority of upper extremity DVTs arise in the setting of central catheters (eg, peripherally inserted central catheter), otherwise healthy patients can occasionally develop spontaneous DVT due to thoracic outlet abnormalities that compress or injure the axillosubclavian vein. Young, athletic men are at greatest risk because most cases are linked to hypertrophy of the scalene/subclavius muscles from weight lifting or damage to the vein from repetitive overhead arm motions (eg, baseball throwing, rowing). Congenital abnormalities of the thorax (eg, cervical rib) can also occasionally lead to spontaneous DVT. cervical rib Manifestations tend to arise in the dominant arm within hours of strenuous activity (eg, pitching a baseball game). Patients usually have acute upper extremity swelling, heaviness, and pain. The pain often improves with rest and arm elevation to the level of the heart; arm elevation above the head typically worsens symptoms (as in this patient). Diagnosis is generally made with Doppler or duplex ultrasonography. Thrombolysis and/or 3 months of anticoagulation are generally required; surgical thoracic outlet decompression may also be necessary. (Choice B) Hypertrophic cardiomyopathy is a genetic disorder associated with mutations to sarcomere genes. Most patients are asymptomatic but risk of sudden cardiac death, heart failure, and stroke are increased. Although low ejection fraction hypertrophic cardiomyopathy can cause edema, most patients have lower extremity edema and other signs of cardiac congestion (eg, dyspnea). (Choice C) Upper extremity lymphedema causes unilateral arm swelling, but most cases arise following surgical resection of axillary lymph nodes (eg, lymph node dissection for breast cancer). Lymphedema is usually chronic, not acute. (Choice D) Medial epicondylitis ("golfers elbow") can sometimes occur in pitchers. Although it often results in arm pain, the pain is localized to the medial elbow; it would not cause arm edema and erythema from the elbow to the shoulder. (Choice E) Superficial thrombophlebitis is generally marked by localized pain and swelling along the path of the vein. This patient with arm edema, heaviness, and pain that is worse with exertion more likely has DVT. Educational objective: Spontaneous upper extremity deep venous thrombosis most often occurs in young, athletic men who lift weights or engage in activities that have repetitive overhead arm motions (eg, pitching a baseball game). It is marked by acute arm swelling, heaviness, and pain. Treatment generally requires thrombolysis and/or 3 months of anticoagulation.

A 30-Year-Old Man Comes to the Office Due to 2