From the Guidelines
The differential diagnosis for right upper extremity pain should prioritize vascular issues, such as deep vein thrombosis (DVT), given the potential for significant morbidity and mortality, and a comprehensive workup should include imaging studies like duplex ultrasound, as recommended by the American College of Radiology 1. The differential diagnosis for right upper extremity pain is broad and includes musculoskeletal conditions (rotator cuff tendinopathy, adhesive capsulitis, cervical radiculopathy, lateral epicondylitis, osteoarthritis), neurological disorders (carpal tunnel syndrome, thoracic outlet syndrome, brachial plexopathy), vascular issues (deep vein thrombosis, arterial insufficiency), and systemic conditions (rheumatoid arthritis, fibromyalgia). Key considerations in the diagnosis of upper extremity DVT include:
- Soft-tissue swelling due to altered capillary hemodynamics, which can be caused by increased plasma volume, increased capillary hydrostatic pressure, decreased capillary oncotic pressure, or increased capillary permeability 1
- Risk factors for UEDVT, such as indwelling venous devices, advanced age, previous thrombophlebitis, postoperative state, hypercoagulability, heart failure, cancer, and extrinsic compression 1
- Symptoms of UEDVT, including ipsilateral upper-extremity edema, pain, paresthesia, and functional impairment 1 A comprehensive workup should begin with a detailed history and physical examination, focusing on pain characteristics, functional limitations, and neurological assessment. Initial orders should include:
- Basic laboratory tests, such as complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and C-reactive protein to evaluate for inflammation or infection
- Imaging studies, starting with plain radiographs of the affected area, potentially followed by MRI for soft tissue evaluation or CT for bone detail
- Electromyography and nerve conduction studies if neurological symptoms are present
- Vascular studies like duplex ultrasound, which is recommended by the American College of Radiology for the diagnosis of suspected upper extremity DVT 1 Initial management should prioritize the prevention of further vascular complications, and may include anticoagulation therapy, in addition to rest, ice, compression, and elevation (RICE), and non-steroidal anti-inflammatory drugs such as ibuprofen 400-800mg three times daily or naproxen 500mg twice daily for 1-2 weeks. Physical therapy should be considered early to maintain function and prevent stiffness. The specific treatment plan will ultimately depend on the underlying diagnosis, with specialist referral to orthopedics, neurology, or rheumatology as appropriate based on initial findings.
From the Research
Differential Diagnosis of Right Upper Extremity Pain
The differential diagnosis of right upper extremity pain can be complex and requires a comprehensive approach. Some possible causes of right upper extremity pain include:
- Peripheral neuropathy 2
- Musculoskeletal disorders
- Vascular disorders
- Referred pain from other areas, such as the neck or chest
Orders to be Placed
To evaluate right upper extremity pain, the following orders may be placed:
- Complete blood count (CBC) to rule out underlying infections or inflammatory conditions 3, 2
- Liver function tests (LFTs) to evaluate for hepatobiliary disease 4, 5
- Electrodiagnostic studies, such as electromyography (EMG) or nerve conduction studies (NCS), to evaluate for peripheral neuropathy 2
- Imaging studies, such as X-rays, CT scans, or MRI scans, to evaluate for musculoskeletal or vascular disorders
Complete Workup
A complete workup for right upper extremity pain may include:
- Comprehensive history and physical examination to identify potential underlying causes
- Laboratory tests, such as CBC, LFTs, and fasting blood glucose, to evaluate for underlying conditions 3, 2
- Imaging studies, such as X-rays, CT scans, or MRI scans, to evaluate for musculoskeletal or vascular disorders
- Electrodiagnostic studies, such as EMG or NCS, to evaluate for peripheral neuropathy 2
- Referral to a specialist, such as a neurologist or orthopedic surgeon, for further evaluation and management if necessary 2