Extremity Swelling Research Articles

Unilateral Lower Extremity Swelling as an Unusual Presentation of Non-hodgkin’s B-cell Lymphoma

Non-Hodgkin’s B-cell lymphoma is a hematological condition with different types based on clinical presentation, pathological features, and therapeutic response, like Diffuse Large B-cell Lymphoma (DLBCL), follicular lymphoma, and Chronic Lymphocytic Leukemia (CLL). We report A 33-year-old male presented with a complaint of unilateral leg swelling, firstly supposed to be a Deep Vein Thrombosis (DVT); however, in multiple Doppler ultrasonography, DVT was ruled out. The patient’s precise history revealed a swollen mass in the left knee region for two months that slowly enlarged and was confirmed with a physical examination. Doppler ultrasonography of the lower extremities conducted in our center presented no sign of deep vein thrombosis; however, it demonstrated some complex conglomerate lymph nodes in the left inguinal compressing the ipsilateral femoral and iliac vein. It also revealed bulky adenopathy, with a 95×65 mm left knee mass. The performed biopsy reported the existence of malignant lymphoma, suggesting the existence of DLBCL. Consequently, he was referred to a hematology/oncology department for appropriate treatment. This unusual presentation of DLBCL and the importance of noticing an accurate history taking and physical examination, instead of conducting unnecessary paraclinical tests (several Doppler ultrasonography in this case), have led us to report this case.

Diagnosis and management of secondary lymphedema

Secondary lymphedema, more common than its primary variant is essentially a clinical diagnosis. Evaluation should include measurement of limb circumference and volume and appropriate staging protocols to determine the severity of the condition. Imaging studies such as magnetic resonance imaging and lymphoscintigraphy are invaluable in ruling out other causes of extremity swelling and for planning surgical treatment. Conservative measures such as combined decongestive therapy are of prime importance in reducing the limb volume and should be continued to maintain the results of surgical treatment. Pharmacotherapy does not have much role in lymphedema. Surgical options which were initially restricted to debulking procedures in chronic late stages are now gaining more relevance with the advent of physiological techniques to prevent further progression of the condition. Detailed counseling regarding the chronic nature of the disease and the need for regular follow-up along with rehabilitation programs will further improve the management of lymphedema.

Diagnosis and management of secondary lymphedema

Secondary lymphedema, more common than its primary variant is essentially a clinical diagnosis. Evaluation should include measurement of limb circumference and volume and appropriate staging protocols to determine the severity of the condition. Imaging studies such as magnetic resonance imaging and lymphoscintigraphy are invaluable in ruling out other causes of extremity swelling and for planning surgical treatment. Conservative measures such as combined decongestive therapy are of prime importance in reducing the limb volume and should be continued to maintain the results of surgical treatment. Pharmacotherapy does not have much role in lymphedema. Surgical options which were initially restricted to debulking procedures in chronic late stages are now gaining more relevance with the advent of physiological techniques to prevent further progression of the condition. Detailed counseling regarding the chronic nature of the disease and the need for regular follow-up along with rehabilitation programs will further improve the management of lymphedema.

What Are We Missing in Our Search for MIS-C?

A previously healthy 3-year-old boy presented with 6 days of fever and fatigue. Three days before, he saw his pediatrician and had negative rapid strep antigen and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction test results. Given persistent fever up to 40°C with decreased appetite and urine output, the patient presented to the emergency department. There was no reported rash, skin peeling, eye redness, redness of the oral mucosa, congestion, rhinorrhea, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, or diarrhea. The patient had recently started preschool but had no known exposure to the coronavirus disease 2019 (COVID-19). On arrival, the patient was febrile to 39.2°C, mildly tachycardic, and normotensive. On examination, he had clear conjunctivae, a normal oropharynx, and moist mucous membranes. No rash, extremity swelling, or lymphadenopathy was appreciated. He was breathing comfortably, and his lungs were clear to auscultation bilaterally. His abdomen was soft and nontender with mild left-sided flank tenderness. Given the patient’s prolonged fever, multisystem inflammatory syndrome in children (MIS-C) was considered and an extensive laboratory evaluation was initiated, including all the laboratories suggested as potentially useful in the evaluation of MIS-C (Table 1). Laboratory results were notable for normal white blood cell and platelet counts and a metabolic panel with normal sodium and albumin. Inflammatory markers were elevated with a C-reactive protein (CRP) level of 14 mg/dL, an erythrocyte sedimentation rate (ESR) of 110 mm/hour, and mild elevations of ferritin, D-dimer, and fibrinogen levels. The patient’s troponin level was within normal limits, and his B-type natriuretic peptide (BNP) level was mildly elevated. A urinalysis was notable for small protein, negative nitrite results, small leukocyte esterase, …

Role of ultrasound in the diagnosis of paediatric acute osteomyelitis.

AimThe aims of our study were to evaluate cases of extremity pain or swelling in paediatric patients using USG to diagnose acute osteomyelitis, and correlate USG findings with MRI findings.Material and methods18 paediatric patients with extremity pain or swelling were evaluated. After the clinical and laboratory work-up, imaging was done using radiographic examination, USG and MRI of the affected limb.Results5 patients (27.8%) out of 18 were diagnosed with acute osteomyelitis based on USG findings, confirmed by MRI and surgical drainage. The mean age of the patients with acute osteomyelitis was 8.2 years. Male children were more commonly affected as compared to female. The distal metaphysis of the femur was the most common site involved (80%). The right lower limb was more commonly affected. The most frequent presentation was pain at the affected site. On USG, deep soft tissue fluid collection around the bone was present in all cases (100%). Periosteal thickening or elevation with subperiosteal fluid collection was seen in 4 cases (80%). Increased vascularity within or around the periosteum on colour Doppler was seen in 4 cases (80%).ConclusionsAcute osteomyelitis is a common entity in the paediatric population, presenting with acute limb pain and swelling. Early diagnosis and management of acute osteomyelitis are essential to prevent serious complications. USG can play an important role in the early diagnosis of paediatric acute osteomyelitis, and should be incorporated into the treatment protocols followed in cases of suspected acute osteomyelitis. MRI should be reserved as problem-solving tool.

Erythromelalgia: A Child With V400M Mutation in the SCN9A Gene.

Erythromelalgia is a rare pain syndrome caused by gain-of-function mutations of the SCN9A gene. The gene encodes Nav1.7 channels, preferentially located in the sympathetic ganglia and nociceptive sensory neurons of the dorsal root ganglia (DRG),1 that play a key role in pain modulation.2 DRG hyperexcitability leads to decreased pain threshold and increased firing frequency of pain signaling neurons.3 Clinically, this presents as recurrent, severe burning pain, redness, warmth, and often swelling of the distal extremities. Exposure to cold may provide relief but can lead to skin ulcerations.4 There is anecdotal evidence of partial relief from NSAIDS, antihistamines, and sodium channel blockers.5,6 Carbamazepine and oxcarbazepine inactivate sodium channels but have been ineffective in most patients. Only 1 family with erythromelalgia and V400M mutation in the SCN9A gene that responded to carbamazepine was reported so far.3

Clinical Presentation and Evaluation of Pelvic Venous Disorders in Women

The term pelvic venous disorders (PeVD) describes a group of related clinical entities with overlapping clinical presentations that were previously characterized by separate imprecise syndromic terminology. The clinical manifestations of PeVD may variously include chronic pelvic pain; pelvic origin extrapelvic lower extremity and genital varices; lower extremity pain and swelling; and left flank pain and hematuria. This manuscript focuses on the primary manifestations of PeVD in women - chronic pelvic pain and pelvic origin lower extremity and vulvar varices - and will review the underlying pathophysiology and related complicating factors (such as maladaptive pain responses) to explain the variety of clinical presentations.

Identifying Social Determinants of Health Leads to the Diagnoses of Scurvy in the Developed World. Case Report.

Identifying social determinants of health can help diagnose certain nutritional deficiencies. By overcoming these barriers, we can prevent future hospitalizations and better public health. We present a unique case where a 46-year-old man presents with bilateral lower extremity swelling secondary to vitamin C deficiency. Throughout history taking, his social determinants of health were identified and he was diagnosed with scurvy from the suspected poor nutritional intake. His poor nutritional intake could have resulted from a lack of financial stability and a harsh home environment. This case is evidence that social determinants of health can directly impact a patient’s well-being, and as physicians, we need to identify them to provide the most resources we can to help improve patient care. This in turn can decrease unnecessary emergency room visits and hospitalizations.

Expanding the Horizon: Single-port Robotic Vascularized Omentum Lymphatic Transplant.

Summary:Vascularized omentum lymphatic transplant is frequently used for the treatment of lymphedema due to demonstrated efficacy, a reduced complication profile, and, in particular, negligible risk of donor site lymphedema. Historically harvested by open laparotomy, more recent techniques involve laparoscopic omental harvest. Although effective and reproducible, laparoscopy may be limited by reduced visualization, minimal tactile feedback, multiple port sites, and imprecise instrumentation. Therefore, we employed the da Vinci Single-Port (SP) surgical robot system for vascularized omentum lymphatic transplant. A 52-year-old man with a 3-year history of progressive left lower extremity swelling and lymphoscintigraphy and magnetic resonance lymphangiogram consistent with lymphedema of unknown etiology underwent vascularized omentum lymphatic transplant to the left groin. A 2.5-cm infraumbilical incision was used for placement of the primary trocar, through which the camera and operating instruments were passed. Following robotic harvest, the omental lymph node flap was transferred to the left groin for microsurgical anastomosis. The procedure was uneventful, and the patient was discharged on postoperative day 1. At 6 weeks, there were no complications. Here, we show for the first time the safety and feasibility of robotic omental lymph node flap harvest for extremity lymphedema using the da Vinci Single-Port robotic system. The benefits of this technology include a minimally-invasive approach that allows for flap dissection and removal through a single 2.5-cm incision. Further investigation is necessary to characterize the indications and limitations of this technique in plastic surgery.

Seasonal Variation in Swelling of Lower Extremities in Patients With Chronic Venous Insufficiency

Seasonal Variation in Swelling of Lower Extremities in Patients With Chronic Venous Insufficiency

A Murine Tail Lymphedema Model.

Lymphedema is extremity swelling caused by lymphatic dysfunction. The affected limb enlarges because of accumulation of fluid, adipose, and fibrosis. There is no cure for this disease. A mouse tail model that uses a focal full thickness skin excision near the base of the tail, resulting in tail swelling, has been used to study lymphedema. However, this model may result in vascular comprise and consequent tail necrosis and early tail swelling resolution, limiting its clinical translatability. The chronic murine tail lymphedema model induces sustained lymphedema over 15 weeks and a reliable perfusion to the tail. Enhancements of the traditional murine tail lymphedema model include 1) precise full thickness excision and lymphatic clipping using a surgical microscope, 2) confirmation of post-operative arterial and venous perfusion using high resolution laser speckle, and 3) functional assessment using indocyanine green near infrared laser lymphangiography. We also use tissue nanotransfection technology (TNT) for novel non-viral, transcutaneous, focal delivery of genetic cargo to the mouse tail vasculature.

A Case of Upper Limb Venous Thrombosis in Paget-Schroetter Syndrome

Deep venous thrombosis (DVT) of the upper extremities is usually secondary to inflammatory processes, malignancy, immobility from trauma, and inherited or acquired thrombophilias. This is a case of a young man who presented to our facility complaining of upper extremity pain and swelling. Imaging results showed thrombosis in the deep venous system of the left upper extremity, consistent with Paget-Schroetter syndrome.

Characteristics of patients with C1 esterase inhibitor deficiency: a single center study.

Hereditary angioedema (HAE) is a primary complement factor deficiency, characterized by recurrent submucosal/subcutaneous swelling episodes. SERPING1 gene defects encoding C1 esterase inhibitor (C1INH) are responsible from the disease. Fifteen patients with HAE are retrospectively evaluated in this study. All patients (n = 15) had HAE type I, 13 were from the same family, other two from two different families. Median age at onset of symptoms was 7 years (2-20); median age on diagnosis, 12 (0,5-41) and median delay in diagnosis, 3 years (0-33). Clinical symptoms were extremity edema(92,3%), facial edema(46%), abdominal pain (46%), genital edema (46%), and laryngeal edema (23%). Some patients suffered from recurrent abdominal pain, had been empirically given colchicine with familial mediterranean fever (FMF) when they admitted. One presented with bullous skin eruption, soon after developed extremity edema. Both resolved spontaneously after C1INH concentrate therapy. Two females suffered from recurrent genital edema after sexual activity. One patient experienced compartment syndrome-like swelling of extremity after playing football. One patient diagnosed with panic attack due to fear of death by asphyxiation, and was diagnosed with HAE disease. A nonsense mutation in exon 8, a missense mutation in exon 2 in SERPING1 gene was present in Family 1 and another patient (P14) from the other family, respectively. Sporadic/autosomal dominant inheritance ratio was 2/3 in the families present in our series. Patients with HAE presents with a large spectrum of symptoms. In mediterranean countries, patients with abdominal attacks may be misdiagnosed with FMF. Thus, health-care professionals should be alert, and put HAE in the first line of differential diagnoses when the disease symptoms are present. Consequently, morbidity/mortality will decrease with effective treatment options.

Case 290.

History A 26-year-old man presented with a 1-month history of chest pain, a palpable and painful right inguinal mass, and edema in the right lower extremity. One month earlier, he started to experience left chest pain with no cough. Pulmonary CT angiography (CTA) revealed a left lower lobe segmental pulmonary embolus. The local hospital made a diagnosis of pulmonary embolism (PE). He received anticoagulants, and his chest pain was gradually relieved. At the time of current presentation, the patient was experiencing right lower extremity swelling and pain. Physical examination revealed a 4 × 3 cm palpable right inguinal mass with no redness. His medical history and family history were negative. The results of laboratory work-up were normal, with a D-dimer level of 0.16 mg/L fibrinogen equivalent units (reference range, <0.46 mg/L) and an international normalized ratio of 2.45 (therapeutic range, 2.0-3.0 for a patient taking warfarin), except the prothrombin time was 28.2 seconds (reference range, 9.6-12.8 seconds) and the activated partial thromboplastin time was 52.2 seconds (reference range, 24.8-33.8 seconds). Echocardiography, chest radiography, chest CT, and contrast-enhanced CT revealed no abnormalities. The patient underwent right lower extremity vascular conventional US (Philips IU22; Philips) with an L9-3 probe (3-9 MHz, venous condition) and contrast-enhanced US (1.5-2.0 mL, SonoVue; Bracco) with an intravenous bolus injection at the initial evaluation. Two days later, noncontrast and contrast-enhanced CT images of the lower abdomen (1.5 mL per kilogram of body weight, 300 mg/mL iomeprol, Iomeron; Bracco) were acquired for further evaluation (Figs 1-3).

Focal vasculitic myositis as a primary manifestation of Behçet's disease: a case series of 10 Korean patients in a locomotive medicine clinic.

Muscle involvement in Behçet's disease (BD) is rare, and several cases have been reported in the literature. Therefore, this study aimed to describe the clinical, laboratory and imaging findings in adult patients presenting with BD-associated myositis before the diagnosis of BD. We retrospectively screened patients who visited a locomotive medicine clinic presenting with myalgia, local swelling, or tenderness of extremities without an established diagnosis of BD. We enrolled patients whose pain in the extremities was proven to be suggestive of focal vasculitic myositis and who were eventually diagnosed as having BD at the initial visit or during follow-up. We thoroughly reviewed the clinical, histological and imaging findings and treatment outcomes in patients who presented with focal vasculitic myositis as the primary manifestation of BD. Ten adult patients with focal vasculitic myositis as the primary manifestation of BD were enrolled. The lower and upper extremities were affected in eight and two patients, respectively. The affected lower extremities were the calf (n = 6) and thigh muscles (n = 2). The common findings of MRI included high signal intensity of the affected muscles and intermuscular fascia on fat-suppressed images, suggestive of myofascitis and oedematous changes in the subcutaneous layer. The results of skin or muscle biopsy were suggestive of vasculitis. All the patients were pain-free at the short-term follow-up (1-3 weeks) after oral steroid therapy. Focal vasculitic myositis can be a primary manifestation of BD warranting medical attention. BD-associated myositis responds well to oral steroid therapy.

Gianturco Z-stent placement for the treatment of chronic central venous occlusive disease: implantation of 208 stents in 137 symptomatic patients.

To report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease. Overall, 137 patients, with mean age 48.6±16.1 years (range, 16-89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis. In total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement. Gianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.

Pre-operative predictors of lower extremity swelling following total knee arthroplasty in patients with venous insufficiency and osteoarthritis.

Post-operative swelling and oedema following total knee arthroplasty (TKA) are one of the most important causes of dissatisfaction. We aimed to assess the clinical variables associated with post-operative swelling and edema after TKA and to compare their performance in respect of predicting them pre-operatively. The study cohort comprised 116 patients who underwent TKA between January 2018 and May 2019 in our centre. The diameters and the grade of venous insufficiency (VI) in the lower extremity veins were measured with duplex ultrasonography preoperatively and at one and three months post-operatively. The study cohort was divided into the patients with leg swelling positive with a difference in leg circumference of > 2cm (n = 56, 48.2%) and leg swelling negative with a difference of ≤ 2cm (n = 60, 51.7%) fromthe pre-operative leg diameter. Independent predictors for lower extremity swelling were pre-operative great saphenous diameter (GSV) diameter > 5.5mm [odds ratio (OR) 2.51, 95% CI 0.24-0.91; p = 0.0012], GSV reflux > 1s [OR 3.28, 95% CI 1.16-12.1; p = 0.003], deep only VI [OR 1.32, 95% CI 0.74-1.87; p = 0.021], CEAP C4-6 [OR 1.62, 95% CI 0.36-0.91; p = 0.018], and hypothyroidism [OR 1.55, 95% CI 1.31-11.2; p = 0.031]. GSV diameter of > 5.38mm and GSV reflux duration > 1.23s had the best predictive value for lower extremity oedema following TKA.

The Clinical Efficacy of Maizhiling Combined with Low Molecular Weight Heparin in the Treatment of Deep Vein Thrombosis after Spinal Cord Injury

This research aims to discuss the clinical efficacy of Maizhiling combined with low molecular weight heparin calcium in the treatment of deep vein thrombosis after spinal cord injury, in the meantime to discuss the effects of the drug combination on coagulation function, hemodynamics and clinical safety. We chose 40 patients with deep vein thrombosis after spinal cord injury in our hospital as the study cohort divided them into control group (n=20) and observation group (n=20) randomly. The control group received low molecular weight heparin calcium subcutaneous injections while the observation group received low molecular weight heparin calcium intravenous infusion of low molecular weight heparin calcium and oral Maizhiling. Then make a contrast of the affected limbs detumescence time, lower limb circumference, coagulation parameters, overall response rate, incidence of complications and adverse drug reactions after treatment between both groups. After treatment, the observation group’s swelling time and the average difference of lower limb circumference were significantly reduced (p<0.01), prothrombin time, activated partial thromboplastin time and D-dimer both were significantly lower (p<0.01) and the clinical effective rate was higher (p<0.05). Both groups incidence of complications and adverse drug reactions have no significant difference (p>0.05). Low molecular weight heparin calcium combined with Maizhiling is effective on spinal cord injury deep vein thrombosis patients. The lower extremity swelling time is significantly shortened, the blood coagulation function and blood viscosity are improved, and the adverse drug incidence and complications are not increased. The combined use is used to treat patients with deep vein thrombosis. It is worth widely using in clinical practice.

Coronavirus disease 2019 combined with venous thromboembolism: Clinical features and prevention

Objective: To analyze the clinical characteristics and control methods of coronavirus disease 2019 (COVID-19) complicated with venous thromboembolism(VTE), and to provide scientific basis for disease prevention, diagnosis and treatment. Methods: We retrospectively studied the cases of COVID-19 complicated with VTE in Renmin Hospital of Wuhan University from January 30, 2020 to March 19, 2020, and their clinical features, results of exmaninations, treatment methods, complications, and prognosis were reviewed. Results: Among the 1 448 COVID-19 patients, 17(1.17%) were VTE positive, 60-69 years old patients were more common. The main clinical types were critical (64.7%) and severe (35.7%) types. The main clinical symptoms were lower extremity swelling (70.6%) and pain (35.7%);58.8% of the patients had a history of high risk factors related to VTE. Most VTE patients were peripheral (58.8%) and involved bilateral limbs (41.2%). The proportion of neutrophils, D-dimer and fibrin degradation products at the last examination were lower than those on admission to the hospital, while the total number and proportion of lymphocytes were higher. Of the 17 VTE cases, 64.7% received venous catheterization, 58.8% received endotracheal intubation or tracheotomy, and 2 patients received extracorporeal membrane oxygenation (ECMO). The rate of bleeding was as high as 53%, and the risk of cardiovascular and cerebrovascular accidents was very high;the prognosis of the patients was poor, and the mortality rate was 23.5%. The cure rate was 17.6%, and the improvement rate was 47.1%. Two patients were still in critically ill. Conclusion: Venous thromboembolism was common in elderly COVID-19 patients with severe types and critical types. Most patients were male and characterized by atypical symptoms, and the early active VTE risk assessment and prevention procedures should be adopted. The risk for bleeding and cardiovascular/cerebrovascular accidents was high, although most cases had good outcomes after active treatment. © 2021, Editorial Board of Medical Journal of Wuhan University. All right reserved.

The Impact of Lymphedema Therapy on Quality of Life: A Case Report

Background and Purpose: Lymphedema is a chronic inflammatory lymphostatic disease known as the buildup of lymph fluid in the fatty tissues that can cause swelling and discomfort in the arms, legs, face, neck, trunk, abdomen, and genitals [1]. Failure of the lymphatic system causes lymphedema [1]. Lymphedema may reduce the quality of life and may progress as well as cause other complications such as cellulitis if untreated [1]. Although there is no cure for lymphedema, there are interventions to reduce or manage the swelling and the discomfort [1]. The purpose of this study is to show that a patient with lymphedema can improve their quality of life significantly with adequate lymphedema therapy interventions using Complete Decongestive Therapy (CDT). Method and Procedures: A 47-year-old African American female patient presented to outpatient physical therapy with a report of experiencing bilateral lower extremity swelling for about ten years. To determine the effects of the treatments, the lymphedema therapist examined the patient using the following tests and measures and outcome measurement tools: Bilateral Girth Measurements, the Lymphedema Life Impact Scale Version 2 (v2), and the Global Rating of Change (GRoC) Scale. The patient attended physical therapy sessions 2 times per week for 3 weeks not including the date of initial evaluation. Thus, the patient attended five treatment sessions. The patient actively participated in the creation of the current goal: to decrease bilateral lower extremity swelling. Results: On discharge assessment (6th visit), the patient reported a reduction in pain to (3/10). The patient scored a 12/68 on the Lymphedema Life Impact Scale (v2) indicating that her quality of life had improved significantly within the past three weeks since receiving lymphedema therapy services. The patient made excellent progress, demonstrated marked improvements with involved extremities lymphatic circulation, and decreased swelling with girth measurements. The patient reported significant improvements with functional activities of daily living such as standing, sitting to standing, and walking. The patient also reported that her quality of life improved significantly.