Late one evening, the last patient of the day came in complaining with a nonproductive cough of one month duration. A nonsmoker, nondrinker, nonrecreational drug user, this 19 year old male had been healthy all of his life with no chronic illness, no known allergies and denied fever or other symptoms. He even said, “I’m never sick.”

The family history was noncontributing with both parents and both sets of grandparents and his only sibling alive and well without chronic illness or genetic diseases. Exam was essentially normal with the exception of left upper lobe diminished breath sounds. He had a husky build and was in no obvious distress. Vital signs were within normal limits, there was no fever, tachypnea or tachycardia.

The patient had on a short sleeve shirt and his left upper arm was markedly larger than his right. He stated that he was right hand dominate. Measurement of both upper arms revealed the left arm was 1 1/2 inches larger than the left. On closer examination there was a very faint area of cyanosis on the inner aspect of the arm down to the middle of the deltoid.

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He denied pain in his arm, but did admit that his left shoulder had been hurting really bad for about a week, and the only relief he got was when he held his arm up above his head. Differential diagnoses, which included venous thrombosis and pulmonary embolism, were discussed with the patient.

The patient was referred to an ED forty miles away with copies of his electronic health record. We called his family to provide transport to another facility since all local outpatient diagnostic departments were closed. The next morning, after we were unable to reach the patient or his family via telephone, we called the hospital where he was sent.

The patient was admitted and did indeed have a left arm venous thrombosis and multiple small pulmonary emboli. He was started on a heparin drip. The chest x-ray had also revealed there was no pneumonia, but there was an 8 cm mass of the left upper lobe. An oncologist and pulmonologist had been consulted and they both felt that he had some type of lymphoma that had been found with the diagnostic testing.

On day three, the patient was transferred to M.D. Anderson hospital in Houston, Texas for further evaluation, testing, diagnosis and treatment. Consulting physicians sent reports that revealed the patient had aggressive Hodgkin’s lymphoma and was entered into a clinical trial with multiple chemotherapy modalities.

Six months later a PET scan revealed total remission of the initial mass and there were no metastases identified. Follow up at one month, two months, three months, six months and finally every year revealed no recurrence of the Hodgkin’s lymphoma.

The patient is now once again enjoying good health and is productively employed as a welder. He is three years post treatment and has had no lasting side effects from his chemotherapy. We see him occasionally for preventative health practices, such as influenza immunizations. He says he feels really fortunate that we had his “cough” checked out.

Billie Napier, RN, MSN, FNP-CS, practices in San Augustine, Texas.

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