Course 8, question 60
Case 2
Kas 8-2E: Patient with edema of the arm
MUDr. Martin Havrda
Female, 60 years, retired.
Reason for examination: Increasing edema of the arm with dull ache and heaviness.
Family history: Father was a smoker, he passed away at the age of 65 due to myocardial infarction.
Mother was obese, she died at 60 due to cancer of the bowel. Sister is healthy. No children.
Gynecologic history: Period started at 11, menopause at 53. She has never been pregnant.
Past diseases: Common child diseases. She has never been ill until the age of 53 when she noticed a
small lump in her right breast. She postponed medical examination until the time when the lump
incrased in size and when retraction of the skin above the lump became evident. She underwent
sonography of the breast, mammography and biopsy of the lesion and breast cancer was recognized.
Then mastectomy was performed together with removal of axillary lymph nodes. She had radiotherapy
of the right axilla and chemotherapy. She is under regular follow-up at the oncology department and
she is disease-free according to the last medical report. Three months after the surgery she
developed mild intermittent swelling of the right hand.
Current complaints: Three weeks ago she had power distribution redone in her house. She had to
clean the whole house – she was carrying heavy containers with rubble, she was cleaning the floors
and windows, she was moving furniture with her husband. Following this heavy work she developed
edema of the right hand and arm, which became heavy with dull ache and feeling of pressure. She
thought that the edema was only a temporary reaction of her arm to the work, but it got worse over
time despite her self-treatment with rest and cold dressings. She can feel touches at the extremity, she
can move it, but movements are limited due to edema and overall rigidity of the extremity. She has no
fever, she can breathe well.
Examination: BP 120/80 mmHg, PR 75/min regular, BT 36,5°C.
Obese, normal skin turgor, no cyanosis, no icterus. Jugular veins filling normal. Thyroid gland not
palpable. Lymph nodes on the neck not palpable. Right-sided scar on the chest followin mastectomy
and surgery of the axilla. Hyperpigmentations of the skin in the involved area. No abnormal mass can
be detected on the chest or within the axilla. Regions with hyperesthesia or hypesthesia near to the
scar. Left breast normal, lymph nodes in the left axilla not palpable. Percussion of the chest normal,
lower border symmetrical, normal vesicular breathing.Heart sounds regular, no murmurs. Abdomen
soft, not tender, liver not enlarged. Legs without edema. Left hand and arm without edema.
Edema and induration of the whole right upper extremity. Heavy sensations and dull ache during
palpation, no localized pain. Normal colour of the skin. Subcutaneous veins are not dilated. Pulsations
at the radial and ulnar arteries are well palpable. Joints are without localited swelling or erythema, non
tender, active and passive motility is well preserved, not painful. Skin sensitivity well maintained.
Laboratory analysis: Normal values of common laboratory tests (blood count, Na, K, Cl, urea,
creatinine, glucose, ALT, AST, ALP, gamma-GMT, bilirubin, cholesterol, triglycerides, uric acid,
albumin, urinanalysis).
Questions:
1) What is probably the principal mechanism of edema formation in this patient?
2) We should suspect another possible mechanism responsible for worsening of edema. Why?
3) Discuss the arguments supporting the role of other known mechanisms of edema formation or
making them unlikely.
4) Which test can confirm your diagnosis?
5) What are the treatment options for this patient? What is the role of diuretics in her treatment?
Patophysiology: How does the edema cause injury to the patient´s tissue?
Pathology: Tumors of the breast.