Chief Complaint: Right arm pain and swelling, chest pain, dyspnea, and headache 

History: A 19-year-old female with a history of migraines presented with 2 weeks of progressive right upper extremity pain and swelling, associated with headache, chest pain, and dyspnea. 

Two weeks earlier, she had been seen at an UC for a migraine, where an IV was placed in the right antecubital fossa.  After the IV was removed, she developed progressive pain along the medial upper arm with mild swelling and tenderness. She had difficulty fully extending the arm or raising it above her shoulder. She also had a Nexplanon implant in the affected arm, placed over one year earlier. 

Over the last two weeks, she subsequently developed substernal chest pain and dyspnea at rest and with exertion, with associated nausea. She denied fever, URI symptoms, or vomiting. 

She had no known history of DVT/PE, recent surgery or trauma, tobacco or substance use. She denied estrogen-containing contraceptive use.

Vital Signs 

• T 37.3°C 

• HR 82 

• BP 133/87 

• RR 18 

• SpO₂ 99% on room air 

Pertinent Exam 

• General: Alert, well appearing 

• CV: Regular rate and rhythm; equal radial pulses 

• Resp: Clear bilaterally; normal work of breathing 

• Chest: Right chest wall tenderness 

• RUE: Tenderness along the medial upper arm with limited elbow extension and shoulder elevation; no focal erythema or fluctuance or edema, only presence of slight induration proximal to the antecubital fossa, neurovascularly intact distally 

• Neuro: No focal deficits 

Her migraine was treated orally because she preferred to avoid another IV. Given her unilateral upper-extremity symptoms with chest pain and dyspnea, the differential included superficial or deep venous thrombosis, thrombophlebitis, and pulmonary embolism. 

Initial Workup 

ECG showed normal sinus rhythm with sinus arrhythmia. Right upper-extremity ultrasound demonstrated a partially occlusive thrombus involving the right basilic and cephalic veins. Her headache improved somewhat with oral therapy, but she continued to report chest pain and dyspnea.  Hematology was consulted and laboratory evaluation was obtained. CBC, chemistry, coagulation studies, and fibrinogen were reassuring. A D-dimer was not obtained.