diff please

[marchiafava]

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A 40 y/o woman with no sig PMH presents to her PC Doc with Left hand swelling which is associated with some mild discomfort off and on for the last couple months. Recently the swelling became much worse. She denies any parasthesias, muscle weakness, or joint pains.

No sig PSH, FH, ALL
Meds- none

can't give labs because this is a patient my buddy briefly presented to me. What is in your diff for unilateral hand swelling without severe pain or neurological deficit. Thanks

 

[punjabiMD]

since I haven't started in the wards yet, please don't kill me if my reasoning is incorrect.
the first thing that comes to my mind is a possible thoracic outlet syndrome (although I would consider this to be second to TRAUMA... sometimes you have to specifically name certain events/injuries to the patient to get a positive history). The only thing is that this would almost always have some kind of neuro sx (paresthesias and pain), but a more specific venous occlusion (usually cephalic vein) can sometimes appear without any sx but intermittent hand edema.
What does this woman do for a living; does she have any kind of activity involving repetitive activity? Do you have any more info for HPI (alleviating, aggravating, temporal factors)?

Another possibility could be lymphadenitis, check for enlarged supratrochlear or infraclavicular nodes.

Additional HPI and PE info would be the most helpful. Any varices or telangiectasias? Is she left-handed?! Maybe she's occluding something when she sits in the recliner all day watching TV all day w/ a remote in her hand (since she just lost her job two months ago).

 

[punjabiMD]

someone in the residency forum said "DVT until proven otherwise."