A 59-year-old woman presents to her primary care provider with a 6-month history of progressive left-arm swelling. Two years ago she had a partial mastectomy and axillary lymph node dissection for left breast cancer. She was also treated with radiotherapy at the time. Upon further questioning, she denies fever, pain, or skin changes, but reports difficulty with daily tasks because her hand feels heavy and weak. She is bothered by the appearance of her enlarged extremity and has stopped playing tennis. On physical examination, nonpitting edema of the left arm is noted with hyperkeratosis, papillomatosis, and induration of the skin. Limb elevation, exercise, and static compression bandaging are started. If the patient has no improvement, which of the following will be the best next step?

Vascularized lymph node transfer

A patient presents to the emergency department with arm pain. The patient recently experienced an open fracture of his radius when he fell from a ladder while cleaning his house. Surgical reduction took place and the patient's forearm was put in a cast. Since then, the patient has experienced worsening pain in his arm. The patient has a past medical history of hypertension and asthma. His current medications include albuterol, fluticasone, loratadine, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 150/95 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient's cast is removed. On physical exam, the patient's left arm is tender to palpation. Passive motion of the patient's wrist and fingers elicits severe pain. The patient's left radial and ulnar pulse are both palpable and regular. The forearm is soft and does not demonstrate any bruising but is tender to palpation. Which of the following is the next best step in management?

Measurement of compartment pressure

A 24-year-old woman presents to her primary care physician for unilateral breast pain. The patient states that she has been breastfeeding her son but has been experiencing worsening pain recently. Her pain is severe enough that she is now struggling to breastfeed her son with her left breast. The patient's past medical history is notable for gestational diabetes which was controlled with diet and exercise. Her temperature is 101°F (38.3°C), blood pressure is 137/69 mmHg, pulse is 100/min, respirations are 13/min, and oxygen saturation is 97% on room air. Physical exam reveals an erythematous breast with a 3-cm tender and fluctuant mass of the left breast. Which of the following is the best next step in management?

Ultrasound and fine needle aspiration

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 25-year-old man presents with pain and a limited range of motion in his right shoulder. He is a collegiate baseball player and says he has not been playing for approx. 1 week because his shoulder hurts when he throws. He also noticed trouble raising his arm over his head. He describes the pain as moderate, dull, and aching in character and worse when he moves his arm above his shoulder or when he lays in bed on his side. He denies any recent acute trauma to the shoulder or other joint pain. The medical history is significant for asthma, which is managed medically. The current medications include albuterol inhaled and fluticasone. He reports a 5-year history of chewing tobacco but denies smoking, alcohol, or drug use. The temperature is 37.0°C (98.6°F); blood pressure is 110/85 mm Hg; pulse is 97/min; respiratory rate is 15/min, and oxygen saturation is 99% on room air. The physical examination is significant for tenderness to palpation on the anterolateral aspect of the right shoulder. The active range of motion on abduction of the right shoulder is decreased. The passive range of motion is intact. No swelling, warmth, or erythema is noted. The sensation is intact. The deep tendon reflexes are 2+ bilaterally. The peripheral pulses are 2+. The laboratory results are all within normal limits. A plain radiograph of the right shoulder shows no evidence of fracture or bone deformities. An MRI of the right shoulder shows increased T1 and T2 signals in the rotator cuff tendon. Which of the following is the best initial course of treatment for this patient?

NSAIDs and conservative measures

Intra-articular corticosteroid injection

Conservative measures (rest and ice)

Post-mastectomy complications for USMLE Step 2 CK: High-Yield Surgery Lessons

🩹 Clinical Manifestations - The Immediate Aftermath

Hematoma:
- Occurs within 24 hours post-op.
- Presents with pain, swelling, ecchymosis, and ↑ drain output.
- ⚠️ May require urgent surgical evacuation to prevent flap necrosis.
Seroma:
- Most common complication; collection of serous fluid under skin flaps.
- Typically develops 1-2 weeks post-op.
- Management: observation, aspiration for large/symptomatic collections.
Infection:
- Presents with erythema, warmth, tenderness, fever.
- Common pathogens: Staphylococcus aureus, Streptococcus pyogenes.
Skin Flap Necrosis:
- Dusky, violaceous discoloration of the skin edge, may lead to eschar.
Nerve Injury:
- Long Thoracic n.: "Winged scapula" (Serratus Anterior palsy).
- Thoracodorsal n.: Weak arm adduction/internal rotation (Latissimus Dorsi palsy).

Winged Scapula: Anatomy and Appearance

⭐ Injury to the intercostobrachial nerve is the most frequent nerve injury during axillary dissection, causing numbness or paresthesia of the inner upper arm.

⏳ Complications - The Long Haul

Lymphedema:
- Chronic, progressive swelling of the ipsilateral arm.
- Cause: Disruption of axillary lymphatics, especially after Axillary Lymph Node Dissection (ALND).
- Presentation: Pitting edema, heaviness, ↑ risk of cellulitis/lymphangitis.
- Mgmt: Compression garments, manual lymphatic drainage, physical therapy.
- ⚠️ Avoid BP cuffs, IVs, and phlebotomy on the affected arm.
Post-Mastectomy Pain Syndrome (PMPS):
- Chronic neuropathic pain (>3 months) in the axilla, medial arm, or chest wall.
- Cause: Injury to the intercostobrachial nerve during axillary dissection.
Shoulder/Arm Dysfunction:
- ↓ Range of motion, weakness, "winged scapula."
- Cause: Injury to long thoracic n. (serratus anterior) or thoracodorsal n. (latissimus dorsi).

⭐ The risk of lymphedema is significantly lower with sentinel lymph node biopsy (SLNB) (~~5%) compared to axillary lymph node dissection (ALND) (~~20-40%).

Psychosocial: Body image issues, depression, anxiety.
Phantom Breast Syndrome: Non-painful or painful sensations in the absent breast.

🗺️ Anatomy - Nerve Injury Map

Nerve injury is a key risk during axillary lymph node dissection.

Nerve	Muscle(s) Innervated	Clinical Deficit & High-Yield Points
Long Thoracic n.	Serratus Anterior	Winging of the scapula on pushing against a wall. Difficulty with arm abduction > 90°.
Thoracodorsal n.	Latissimus Dorsi	Weakness in arm adduction, extension, & internal rotation (e.g., pulling up). Often sacrificed if involved by tumor.
Intercostobrachial n.	(Sensory only)	Numbness/paresthesia of medial upper arm & axilla.
Medial Pectoral n.	Pectoralis Major & Minor	Weakness in arm adduction & internal rotation; atrophy of pectoral muscles.

⭐ Most common injury: The intercostobrachial nerve is a sensory nerve most frequently damaged during axillary dissection, leading to posteromedial arm numbness.

🛠️ Management - Tackling Troubles

Seroma/Hematoma:
- Small: Observe for self-resolution.
- Symptomatic/Large: Sterile needle aspiration.
- Recurrent: Consider drain placement or sclerotherapy.
Surgical Site Infection (SSI):
- Cellulitis: Antibiotics (cover Staph/Strep).
- Abscess: Incision & Drainage (I&D) + antibiotics.
Skin Flap Necrosis:
- Limited: Conservative wound care.
- Extensive: Surgical debridement ± grafting.
Chronic Pain/Neuropathy:
- Gabapentin, pregabalin, TCAs; physical therapy.

⭐ Lymphedema management focuses on control, not cure. Complete Decongestive Therapy (CDT) is the gold standard. ⚠️ Crucially, avoid BP cuffs, IVs, and phlebotomy on the affected arm.

⚡ High-Yield Points - Biggest Takeaways

Lymphedema: Chronic high-protein swelling from axillary lymph node dissection (ALND). Biggest risk factor for angiosarcoma (Stewart-Treves syndrome).

Nerve Injury: Long thoracic → winged scapula (serratus anterior). Thoracodorsal → weak arm adduction (latissimus dorsi). Intercostobrachial → upper inner arm numbness.

Seroma: Most common early complication; a collection of serous fluid under the skin flaps.

Phantom Breast Syndrome: Sensation in the amputated breast; treat with TCAs or gabapentin.

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