internal medicine final 23-24.pdf

هاريسون&دايفدسون تم بعون الله???

Davidson MCQs
Harrison MCQs

التوضيح?

Diuretics are contraindicated in patients with lymphedema and may
cause depletion of intravascular volume and metabolic abnormalities. Patients should be encouraged to
participate in physical activity; frequent leg elevation can reduce the amount of edema. Psychosocial
support is indicated to assist patients cope with anxiety or depression related to body image, self-esteem,
functional disability, and fear of limb loss. Physical therapy, including massage to facilitate lymphatic
drainage, may be helpful. The type of massage used in decongestive physiotherapy for lymphedema
involves mild compression of the skin of the affected extremity to dilate the lymphatic channels and
enhance lymphatic motility. Multilayered, compressive bandages are applied after each massage session to reduce recurrent edema. After optimal reduction in limb volume by decongestive physiotherapy, patients can be fitted with graduated compression hose. Occasionally, intermittent pneumatic compression devices can be applied at home to facilitate reduction of the edema. Liposuction in conjunction with decongestive physiotherapy may be considered to treat lymphedema, particularly postmastectomy lymphedema. Other surgical interventions are rarely used and are often not successful in ameliorating lymphedema. Microsurgical lymphaticovenous anastomotic procedures have been performed to rechannel lymph flow from obstructed lymphatic vessels into the venous system. Limb reduction procedures to resect subcutaneous tissue and excessive skin are performed occasionally in
severe cases of lymphedema to improve mobility

1. You are taking care of a patient who suffers from chronic lymphedema due to recurrent streptococcal lymphangitis as a child. She finds her leg swelling unsightly and asks about therapeutic options. All of the following are reasonable therapeutic options…

1. You are taking care of a patient who suffers from chronic lymphedema due to recurrent
   streptococcal lymphangitis as a child. She finds her leg swelling unsightly and asks about therapeutic
   options. All of the following are reasonable therapeutic options for chronic lymphedema EXCEPT:

التوضيح?

Secondary lymphedema is an acquired condition that results from
damage to or obstruction of previously normal lymphatic channels. Recurrent episodes of bacterial
lymphangitis, usually caused by streptococci, are a very common cause of lymphedema. The most
common cause of secondary lymphedema worldwide is lymphatic filariasis, affecting approximately 129
million children and adults worldwide and causing lymphedema and elephantiasis in 14 million of these
affected individuals. Other infectious causes include lymphogranuloma venereum and tuberculosis. In
developed countries, the most common secondary cause of lymphedema is surgical excision or
irradiation of axillary and inguinal lymph nodes for treatment of cancers, such as breast, cervical,
endometrial, and prostate cancer, sarcomas, and malignant melanoma. Lymphedema of the arm occurs in
13% of breast cancer patients after axillary node dissection and in 22% after both surgery and
radiotherapy. Lymphedema of the leg affects approximately 15% of patients with cancer after inguinal
lymph node dissection. Tumors, such as prostate cancer and lymphoma, also can infiltrate and obstruct lymphatic vessels. Less common causes include contact dermatitis, rheumatoid arthritis, pregnancy, and self-induced or factitious lymphedema after application of tourniquets.

التوضيح?

This is a classic clinical picture for a chronic venous insufficiency with an
active venous ulcer. Symptoms in patients with varicose veins or venous insufficiency, when they occur,
include a dull ache, throbbing or heaviness, or pressure sensation in the legs typically after prolonged
standing; these symptoms usually are relieved with leg elevation. Additional symptoms may include
cramping, burning, pruritus, leg swelling, and skin ulceration. Edema, stasis dermatitis, and skin
ulceration near the ankle may be present if there is superficial venous insufficiency and venous
hypertension. Findings of deep venous insufficiency include increased leg circumference, venous
varicosities, edema, and skin changes. The edema, which is usually pitting, may be confined to the
ankles, extend above the ankles to the knees, or involve the thighs in severe cases. Over time, the edema
may become less pitting and more indurated. Dermatologic findings associated with venous stasis include
hyperpigmentation, erythema, eczema, lipodermatosclerosis, atrophie blanche, and a phlebectasia
corona. Lipodermatosclerosis is the combination of induration, hemosiderin deposition, and
inflammation, and typically occurs in the lower part of the leg just above the ankle. Atrophie blanche is a
white patch of scar tissue, often with focal telangiectasias and a hyperpigmented border; it usually
develops near the medial malleolus. A phlebectasia corona is a fan-shaped pattern of intradermal veins
near the ankle or on the foot. Skin ulceration may occur near the medial and lateral malleoli. A venous
ulcer is often shallow and characterized by an irregular border, a base of granulation tissue, and the
presence of exudate. Ulcers due to arterial insufficiency are typically at the terminal end of a digit, since
that is where flow is most limited. Diabetic ulcers are typically at pressure points such as the sides of the
toes or the ball or heel of the foot. The patient’s report of months of leg discomfort make Bacillus
anthracis infection (cutaneous anthrax) and arachnid envenomation unlikely