Lymph/Venous

A 38-year-old woman reports aching and fatigue in both legs after long shifts standing, beginning after her pregnancies. Examination shows visible, palpable, tortuous vessels over the calves and thighs without ulceration or skin fibrosis. What is the most likely diagnosis?

Varicose veins. Dilated, tortuous superficial vessels with aching worsened by prolonged standing are characteristic; pregnancy and elevated venous pressure are contributing factors.

A 46-year-old warehouse worker reports leg heaviness after prolonged standing and heavy lifting. Examination shows dilated, tortuous superficial vessels, and imaging demonstrates blood flowing back toward the foot when valve leaflets fail to close. What is the underlying mechanism of this condition?

Venous valve incompetence causing reflux and progressive venous hypertension. Venous distention prevents leaflet coaptation, and rising pressure promotes failure of subsequent valves.

A 51-year-old woman has prominent tortuous vessels over both calves but only mild discomfort, while her sister has fewer visible vessels and substantial aching. Neither has ulcers or acute inflammation. Which examination feature reliably predicts symptom severity in this condition?

Neither the number nor the size of the varicosities predicts symptom severity. The lecture explicitly states that symptom severity does not correlate with these visible findings.

A 43-year-old woman reports leg heaviness after standing and itching above the ankle. Examination reveals palpable, tortuous superficial vessels with localized tenderness but no fever or linear induration. What is the most likely explanation for her itching?

Venous eczema associated with varicose veins. Itching may occur above the ankle or over a large varicosity.

A 49-year-old woman seeks treatment for painful, tortuous vessels over the calf and thigh. The clinician needs to identify the source of abnormal backward flow before choosing an intervention. What is the gold-standard diagnostic imaging modality for this condition?

Duplex ultrasonography. It evaluates vessel structure and blood flow to identify the reflux source feeding the symptomatic vessels.

A 40-year-old teacher reports aching legs after standing throughout the day. Examination shows tortuous superficial vessels without ulcers, and duplex imaging identifies reflux. What is the most appropriate initial conservative intervention?

Elastic graduated compression stockings providing 20–30 mm Hg pressure. Compression reduces venous pressure and may prevent progression.

A 44-year-old woman receives conservative treatment for aching legs and visible, tortuous calf vessels. She asks when to wear the prescribed stockings and how to position her legs overnight. What instructions are most appropriate?

Wear compression stockings daily during waking hours and elevate the legs at night. These measures reduce the effects of elevated venous pressure.

A 57-year-old woman requests treatment of small, symptomatic superficial vessels despite conservative measures. The planned procedure directly injects an agent that permanently closes the targeted vessels. Which intervention is being performed?

Sclerotherapy. The injected agent produces permanent fibrosis and obliteration of the target veins.

A 48-year-old woman undergoes procedural treatment for small superficial vessels that cause discomfort and cosmetic concerns. Examination shows small-caliber vessels without ulceration or infection. Which injected agents are taught for these small vessels?

Chemical irritants such as glycerin or hypertonic saline. The lecture lists these agents for sclerotherapy of small veins.

A 53-year-old woman has symptomatic reflux involving a superficial vessel measuring 5 mm in diameter. A nonsurgical injection procedure is selected after duplex evaluation. Which agents are taught for vessels of this size?

Foam or cyanoacrylate glue. The lecture uses these agents for vessels greater than 4 mm and for the great saphenous vein.

A 55-year-old woman develops recurrent visible calf vessels after treatment limited to small tributaries. Duplex imaging shows that the larger superficial reflux source was never treated. Which intervention is most important to reduce further recurrence?

Address the larger saphenous reflux source. The lecture reports recurrence greater than 50% when the larger saphenous veins are not addressed.

A 50-year-old woman continues to have painful, tortuous superficial vessels despite conservative treatment. Duplex imaging identifies a reflux source suitable for a definitive procedure. Which procedural options are taught for this condition?

Surgical vein stripping, laser ablation, or radiofrequency ablation. The lecture describes excellent results with surgical measures and a five-year success rate of 85–90%.

An 80-year-old woman develops bleeding from a prominent superficial calf vessel after lightly striking her leg against furniture. She has longstanding visible, tortuous vessels and no major penetrating injury. What complication best explains this presentation?

Bleeding from a superficial varicosity after minor trauma. The lecture identifies this complication particularly in older patients.

A 62-year-old hospitalized man develops a red, painful, indurated line at the site of a recent peripheral IV. Examination reveals a tender palpable cord with little surrounding edema and no fever. What is the most likely diagnosis?

Superficial venous thrombophlebitis. Localized redness, tenderness, and cordlike induration after IV catheterization are characteristic, while edema is uncommon.

A 35-year-old pregnant woman develops focal pain and redness over a previously prominent superficial calf vessel. Examination reveals a tender linear cord without substantial limb swelling or systemic symptoms. What is the most likely diagnosis?

Superficial venous thrombophlebitis. Pregnancy and varicose veins are lecture-listed risk factors, and a localized tender cord supports this diagnosis.

A 67-year-old man with a long-term arm catheter develops localized redness, tenderness, and palpable cordlike induration. The clinician is concerned about an additional occult clot beyond the visible abnormality. What is the most appropriate diagnostic test?

Duplex ultrasound. It establishes the extent of superficial thrombophlebitis and detects associated DVT.

A 59-year-old woman develops painful linear induration around an arm catheter. She has little edema and no systemic symptoms, but the clinician orders imaging because this catheter-associated presentation carries a substantial risk of an occult deeper clot. What associated complication should be assessed?

Concomitant DVT. The lecture reports occult DVT in approximately 20% of upper-extremity PICC-related thrombophlebitis cases.

A 45-year-old man has a small, tender, erythematous cord at the site of a peripheral IV removed yesterday. He is afebrile, has no chills, and has no spreading limb swelling. What is the most appropriate initial management?

Local heat, NSAIDs, and elevation of the extremity. An uncomplicated localized presentation generally follows a benign, brief course and receives supportive care.

A 61-year-old woman develops tenderness, redness, and cordlike induration around a peripheral IV that remains in place. She has no fever or chills. What is the most appropriate catheter-related intervention?

Remove the IV catheter and avoid further IV access in the affected extremity. Removing the provoking catheter is part of the lecture’s general treatment.

A 54-year-old woman has a painful, palpable cord above the knee. Duplex imaging shows a 6-cm thrombus in the major superficial vessel along the medial leg, ending 4 cm from its junction with the deep system. What is the most appropriate pharmacologic management?

Prophylactic-dose fondaparinux or rivaroxaban. The lecture recommends this for great saphenous thrombophlebitis that is at least 5 cm long, above the knee, and more than 3 cm from the saphenofemoral junction.

A 60-year-old man has painful linear induration above the knee, and ultrasound shows a superficial thrombus measuring 7 cm that ends 5 cm from the deep-system junction. Anticoagulation is started according to the lecture’s criteria. What is the typical treatment duration?

Six weeks. This is the lecture’s typical anticoagulation duration for superficial venous thrombophlebitis.

A 58-year-old woman develops a rapidly lengthening area of painful linear induration in the leg. Duplex imaging raises concern that the clot is extending toward the deep venous system. What treatment escalation is appropriate?

Full anticoagulation. The lecture allows full anticoagulation for rapidly progressing symptoms or concern for extension into the deep system.

A 66-year-old man receiving treatment for active malignancy develops a tender, erythematous superficial cord in the leg. Duplex imaging defines the clot extent and excludes a concurrent deeper clot. Which pharmacologic intervention is indicated because of his risk profile?

Anticoagulation. Active malignancy is an independent lecture-listed indication for anticoagulation in superficial venous thrombophlebitis.

A 42-year-old woman with a known thrombophilia develops localized painful linear induration in the calf. Duplex imaging confirms a superficial clot without a concurrent deeper clot. What is the most appropriate pharmacologic intervention?

Anticoagulation. Known thrombophilia is a lecture-listed indication, as is a history of venous thromboembolism.

A 70-year-old hospitalized man develops a painful, indurated cord around an IV site followed by high fever and shaking chills. The catheter remains in place, and the affected area is increasingly tender. What is the most likely diagnosis?

Septic superficial thrombophlebitis. High fever and chills accompanying catheter-associated venous inflammation suggest an intravascular infection.

A 64-year-old woman develops high fever, chills, and painful linear induration around an IV catheter. The catheter is removed and blood cultures are obtained. Which organism is the most common pathogen in this presentation according to the lecture?

Staphylococcus aureus. It is the most common pathogen in thrombotic or septic catheter-associated complications described in the lecture.

A 73-year-old man has high fever, chills, and a painful indurated cord at an IV site. The catheter is removed, cultures are drawn, and IV antibiotics are being arranged. Which urgent anticoagulant is taught to limit further thrombus formation?

Heparin. The lecture calls for urgent heparin treatment in septic superficial thrombophlebitis to limit additional thrombus formation.

A 68-year-old woman develops high fever and chills with a red, painful cord at a catheter site. The catheter is removed and blood cultures are collected. Which empiric antibiotic regimen is taught for this condition?

IV vancomycin plus IV ceftriaxone for 4–6 weeks. The lecture treats septic superficial thrombophlebitis as an intravascular infection requiring prolonged antibiotics.

A 71-year-old man has persistent intravascular infection involving a painful, indurated superficial vessel despite catheter removal and medical treatment. The involved segment remains a concern as an infectious focus. Which additional intervention may be required?

Surgical removal of the involved vein. The lecture lists excision as a possible requirement in septic superficial thrombophlebitis.

A 65-year-old woman with a remote history of a leg clot develops chronic lower-leg edema, hyperpigmentation, and skin fibrosis. A painful ulcer lies just above the medial ankle. What is the most likely diagnosis?

Chronic venous insufficiency. Chronic edema with fibrotic, hyperpigmented skin and a medial ankle ulcer reflects longstanding venous hypertension.

A 63-year-old man develops progressive lower-leg edema, hyperpigmentation, and recurrent ulceration years after treatment of a leg clot. He has no recent injury or operation. What is the most common underlying etiology of this condition?

Prior DVT. The lecture identifies previous DVT as the most common cause of chronic venous insufficiency.

A 69-year-old woman has chronic lower-leg edema with skin fibrosis and hyperpigmentation. Imaging shows thickened valve leaflets that fail to meet during closure. What mechanism produces her tissue changes?

Venous hypertension transmitting increased hydrostatic pressure to the subcutaneous tissues. Persistent edema subsequently causes fibrosis, hyperpigmentation, and late ulceration.

A 72-year-old man has a painful wound just above the ankle on the anterior-medial lower leg. The surrounding skin is chronically swollen, fibrotic, and hyperpigmented. What is the most likely type of ulcer?

Venous stasis ulcer. The lecture places these painful ulcers just above the ankle on the medial or anterior leg.

A 67-year-old woman has recurrent breakdown of a previously healed wound above the medial ankle. Examination shows a thin scar over a fibrotic base with chronic edema and hyperpigmentation. Why is the healed site susceptible to recurrent ulceration?

The thin scar over a fibrotic base breaks down easily with trauma. This is the healing pattern described for venous stasis ulceration.

A 60-year-old man has longstanding lower-leg edema, skin fibrosis, and hyperpigmentation with a painful ankle-region ulcer. The clinician wants to determine whether abnormal backward blood flow is present. What is the most appropriate diagnostic test?

Duplex ultrasonography. The lecture recommends duplex imaging to assess for venous reflux in chronic venous insufficiency.

A 74-year-old woman has chronic lower-leg edema and a painful ulcer above the medial ankle. Compression treatment is being considered, but coexisting impaired arterial supply has not been assessed. What is the most appropriate next diagnostic step?

Measure the ankle-brachial index. The lecture recommends checking for arterial insufficiency with ABIs when ulcers are present.

A 76-year-old man has chronic lower-leg edema, hyperpigmentation, and a painful ankle-region ulcer. His ankle-brachial index is 0.60. Which proposed treatment should be withheld according to the lecture?

Compression stockings. The lecture states that compression stockings cannot be used when the ABI is below 0.7.

A 62-year-old woman has chronic lower-leg edema and hyperpigmentation without evidence of significant arterial insufficiency. She spends most of the day seated with her feet on the floor. What is the most appropriate conservative management?

Fitted graduated compression stockings, avoidance of prolonged sitting or standing, and intermittent leg elevation. The lecture also recommends sleeping with the legs above heart level.

A 70-year-old woman has a painful ulcer above the medial ankle with marked chronic edema, and arterial assessment permits compression. The wound has persisted despite simple dressings. What is the most important initial treatment principle?

Treat the underlying edema with compression. The lecture emphasizes edema control as the first step in treating venous ulcers.

A 68-year-old man has a painful ankle-region ulcer with chronic edema and hyperpigmentation. Arterial assessment permits compression, and the clinician selects a semirigid dressing containing zinc oxide and calamine paste. Which intervention is being used?

An Unna boot. The lecture describes this compression bandage as gauze evenly saturated with zinc oxide and calamine paste.

A 66-year-old woman has a persistent painful ulcer above the medial ankle despite appropriate edema management. The clinician considers an oral adjunct to accelerate healing. Which medication is taught for this purpose?

Pentoxifylline. The lecture identifies it as beneficial for accelerating venous ulcer healing.

A 71-year-old man has an ankle-region ulcer with chronic edema and hyperpigmentation but no expanding warmth or erythema. He asks whether an antibiotic cream will improve healing. Which proposed treatment lacks supporting evidence in the lecture?

Topical antibiotics. The lecture states that evidence does not support their use for venous ulcer healing.

A 69-year-old woman begins compression-based care for a painful ulcer above the medial ankle. She has chronic edema and fibrosis, and no evidence of cellulitis. What healing timeframe should she expect according to the lecture?

Four to six months. The lecture emphasizes that venous ulcer healing can take several months.

A 73-year-old man with chronic lower-leg hyperpigmentation and an ankle-region ulcer develops expanding warmth and blanching erythema around the wound. The redness extends beyond his usual skin changes. What is the most appropriate additional treatment?

Oral antibiotics for cellulitis. Expanding warmth and erythema around an ulcer suggest superimposed infection despite the baseline hyperpigmentation.

A 57-year-old woman develops gradual arm enlargement after regional lymph node resection and radiation. Examination shows markedly thickened, fibrotic skin and subcutaneous tissue with reduced range of motion. What is the most likely diagnosis?

Secondary lymphedema. Node resection and radiation can obstruct lymphatic drainage, producing progressive fluid and fibroadipose tissue accumulation.

A 22-year-old man has longstanding progressive limb enlargement attributable to congenital abnormalities of the drainage vessels. There is no history of surgery, radiation, trauma, or malignancy. What is the most likely diagnosis?

Primary lymphedema. The lecture attributes the primary form to congenital abnormalities of proximal or distal lymphatics.

A 64-year-old woman develops progressive limb enlargement as malignancy extensively involves regional nodes. Examination shows thickened skin and increasingly firm subcutaneous tissue. What is the underlying mechanism of her swelling?

Mechanical obstruction of lymphatic drainage causing secondary lymphedema. Extensive malignant involvement of regional nodes is a lecture-listed cause.

A 59-year-old woman develops gradual limb swelling after regional radiation therapy. The swelling initially pits with pressure but becomes progressively firmer as the skin and subcutaneous tissue thicken. How should the initial pitting affect the suspected diagnosis?

Initial pitting is compatible with lymphedema. The lecture states that edema may pit early and becomes less pitting as fibrosis progresses.

A 55-year-old man has slowly progressive limb enlargement with thickened fibrotic skin and decreased range of motion after regional node surgery. The cause is evident from his history and examination. What is the most appropriate initial diagnostic approach?

Clinical diagnosis. The lecture states that lymphedema is usually diagnosed clinically, with imaging reserved for investigating an unknown underlying cause.

A 48-year-old woman has insidious limb enlargement with marked skin and subcutaneous fibrosis. She has no known precipitating surgery, radiation, trauma, or established malignancy. What is the principal role of imaging in this presentation?

Determine the underlying cause. Imaging is reserved for investigating an unknown etiology rather than routinely establishing the clinical diagnosis of lymphedema.

A 61-year-old woman has persistent limb enlargement, skin thickening, and limited movement after regional node resection. She asks about measures to control the swelling and preserve function. What is the most appropriate management?

Specialty lymphedema care with elevation, compression stockings or wraps, lymphatic massage or pneumatic compression, and physical therapy. These lecture-taught measures can control swelling and support normal function.

A 56-year-old man has chronic limb enlargement with thickened fibrotic skin following radiation treatment. His swelling is being managed with compression and physical therapy. Which preventive intervention is particularly important?

Meticulous skin care to avoid secondary infection. The lecture specifically emphasizes skin care as part of lymphedema management.

A 36-year-old woman develops throbbing pain around an infected hand wound followed within hours by fever, chills, and a red streak extending toward the axilla. Regional nodes are enlarged and tender. What is the most likely diagnosis?

Acute lymphangitis with regional lymphadenitis. A proximal red streak from an infected wound with tender regional nodes and rapidly developing systemic symptoms is characteristic.

A 45-year-old man develops a red streak extending proximally from a leg abscess, tender regional nodes, and high fever. His white blood cell count is elevated with a left shift. Which organisms should empiric treatment cover?

Hemolytic streptococci and Staphylococcus aureus. The lecture identifies either or both as typical causes of lymphangitis and lymphadenitis.

A 52-year-old woman presents with an infected foot wound, proximal red streaking, tender regional nodes, tachycardia, and rapidly developing chills. Her leukocyte count is elevated with a left shift. What is the most appropriate next step?

Hospital admission for IV antibiotics and close observation. The lecture emphasizes that this infection can progress within hours to sepsis and death.

A 33-year-old man has high fever, tender regional nodes, and a red streak extending proximally from an infected finger wound. He is admitted for treatment. What empiric antibiotic coverage is most appropriate according to the lecture?

Antibiotics covering staphylococci and streptococci, commonly a cephalosporin. These are the lecture’s typical bacterial targets.

A 41-year-old woman has fever, tender regional nodes, and proximal red streaking from a skin wound. The treating clinician suspects MRSA involvement. Which antibiotic is specifically listed in the lecture for this situation?

Trimethoprim-sulfamethoxazole. The lecture lists this antibiotic when MRSA is suspected.

A 47-year-old man has an infected hand wound, a proximal red streak, tender nodes, and fever. Antibiotic therapy has begun. Which additional local interventions are appropriate?

Heat, elevation if possible, immobilization, analgesia, and treatment of the source wound. The lecture includes these supportive measures alongside prompt antibiotic therapy.

A 58-year-old woman has persistent fever and proximal red streaking from an infected wound despite initial treatment. Her leukocyte count remains elevated with a left shift. Which source-directed diagnostic study may help guide treatment?

Wound culture and sensitivity testing. The lecture recommends considering it in severe or refractory infections while recognizing possible contamination by skin organisms.

A 29-year-old man presents after a cat scratch with enlarged regional nodes that are relatively nontender. He lacks the rapidly developing high fever and markedly tender nodes expected with an invasive infection spreading from a wound. What is the most likely alternative diagnosis?

Cat-scratch disease caused by Bartonella henselae. A cat-scratch history with relatively nontender regional nodes is the lecture’s distinguishing pattern.

A 63-year-old man has an infected leg wound, severe systemic illness, and palpable subcutaneous crepitus. His condition appears more severe than a superficial infection with proximal red streaking. Which alternative diagnosis should be considered?

Gangrene or necrotizing fasciitis. The lecture identifies deeper tissue infection, greater illness severity, and possible subcutaneous crepitus as distinguishing findings.

A 40-year-old woman has fever and tender regional nodes after an infected hand wound, but the proximal red streak is faint on examination of her darker skin. She also has tachycardia and a leukocyte count elevated with a left shift. How should the faint skin finding affect clinical suspicion?

A faint red streak does not exclude lymphangitis. The lecture warns that proximal streaking may be subtle and easily missed in persons of color.