Fibromyalgia and shoulder pain...

Middle aged female presented to the ED Physio clinic 3/52 following onset of left shoulder pain and bruising.

History of Presenting complaint
Initial onset of Left upper chest wall atraumatic bruising. At the same time she reported intermittent pain, pins and needles and sensation of pressure, radiating to the hand.
A week after the onset of symptoms she noticed a prominence of the veins in over her left upper chest and into her left breast.

She presented to the receptionist as ‘Injury to arm/shoulder/tingling sensation’.
The RATs Doctor said "?Shoulder dislocation and reduction 2/52 ago. Today left arm pain increased.  Vascularly equal upper limbs and x-ray NAD" and referred to the Physio clinic for ‘post reduction pain’.

PMH  Fibromyalgia, Anxiety.
DH Pregabalin, Bisoprolol, Propanolol, Amitriptyline.

O/E; 
Venous engorgement left upper anterior chest wall into left breast.
Mild to moderate Supra and infra clavicular swelling left side. Swelling into pectoral border of Left Axilla.Slight increase in left biceps region swelling noted.
Pain medial to scapular from C7 to T4 paraspinally.
Neuro NAD, Vascular normal.
C-spine. Pain in left upper traps on left Rotation and Left Side flexion. No arm symptoms propagated on sustained neck movement.


WHAT IS GOING ON?  WHAT'S YOUR DIFFERENTIAL?

1)    Vascular(obstructive)
2)    Neurogenic (C-spine referred pain)

Doppler:  Occlusive Thrombus – distal subclavian, axillary and 2 upper brachial veins.

Learning points:
1)    Patients with fibromyalgia and chronic pain are a complex group whose acute symptoms may be difficult to interpret.
2)    Undress the patient.
3)    Patients do presume injury because of symptoms, despite absence of ?trauma. 
4)    Accurate history taking remains our greatest diagnostic tool

Further reading on upper limb DVTs.


Thanks Greg!