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  • Question 1 - A 72-year-old woman presents to the General Practitioner complaining of ‘bulging blue veins’...

    Incorrect

    • A 72-year-old woman presents to the General Practitioner complaining of ‘bulging blue veins’ on her legs. While examining the patient’s legs, you note the presence of tortuous, dilated veins, accompanied by brown patches of pigmentation and dry, scaly plaques of skin. A diagnosis of varicose veins is made.
      Which vein is most likely to be affected?

      Your Answer: Short saphenous vein

      Correct Answer: Long saphenous vein

      Explanation:

      Understanding the Venous System and Varicose Veins

      Varicose veins are a common condition that affects the superficial venous system. The long saphenous vein, which ascends the medial side of the leg and passes anteriorly to the medial malleolus of the ankle, is the most common cause of varicose veins. However, insufficiencies in the deep venous system, such as the femoral vein and popliteal vein, can also contribute to chronic venous insufficiency.

      It is important to note that not all superficial veins are affected by varicose veins. The cephalic vein, for example, is an upper limb vein and is not likely to be affected. The short saphenous vein, which ascends the posterior side of the leg and passes posteriorly to the lateral malleolus of the ankle, can also cause varicose veins but is not the most common distribution.

      Understanding the different veins in the venous system and their potential for insufficiency can help in the diagnosis and treatment of varicose veins and other venous conditions. It is important to consult with a healthcare professional for proper evaluation and management.

    • This question is part of the following fields:

      • Vascular
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  • Question 2 - A 65-year-old postal worker underwent a routine screening appointment for abdominal aortic aneurysm...

    Incorrect

    • A 65-year-old postal worker underwent a routine screening appointment for abdominal aortic aneurysm (AAA) and was diagnosed with an AAA measuring 4.2 cm at its widest diameter. What would be the appropriate management for this patient?

      Your Answer: Immediate admission under a surgical team for surgical repair

      Correct Answer: Annual monitoring with ultrasound scanning

      Explanation:

      Management of Abdominal Aortic Aneurysm (AAA)

      Abdominal Aortic Aneurysm (AAA) is a condition that affects men aged 65 and over, putting them at risk of developing an enlarged aorta. To manage this condition, different approaches are taken depending on the size of the aneurysm.

      Annual Monitoring with Ultrasound Scanning
      Men aged 65 and over are offered screening via ultrasound scanning during the year they turn 65. Patients diagnosed with a small AAA (3.0-4.4 cm in diameter) are invited to return annually for monitoring. They are also given lifestyle advice, including smoking cessation, diet, and exercise.

      Discharge with Reassurance
      Patients with a normal result (measurement of <3 cm in diameter) are discharged and do not require further screening tests as the condition is unlikely to progress to a dangerous extent. Three-Monthly Monitoring with Ultrasound Scanning
      Patients with a medium-sized AAA (4.5-5.4 cm in diameter) are offered three-monthly ultrasound scanning.

      Referral to a Specialist Surgeon within Two Weeks for Further Assessment
      Patients with a large AAA (5.5 cm or more in diameter) are referred to a specialist surgeon to be seen within two weeks to discuss treatment options. Surgical repair is usually advised, as long as there are no contraindications to surgery.

      Immediate Admission under a Surgical Team for Surgical Repair
      Emergency repair is not indicated for an aneurysm measuring 4.2 cm. Emergency repair is usually only indicated if a patient has a leaking or ruptured aortic aneurysm.

      Managing Abdominal Aortic Aneurysm (AAA) According to Size

    • This question is part of the following fields:

      • Vascular
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  • Question 3 - A 48-year-old man presents with constant abdominal pain that radiates to the back....

    Incorrect

    • A 48-year-old man presents with constant abdominal pain that radiates to the back. The pain came on suddenly. Examination of the abdomen reveals a central mass. You note that he has become clinically shocked.
      He has a blood pressure of 76/45, heart rate 150, respiratory rate 28.
      Which of these is the most important step in the definitive management of this patient?

      Your Answer: Crossmatch blood

      Correct Answer: Arrange for surgery

      Explanation:

      Emergency Management of a Ruptured Aortic Aneurysm

      When a patient presents with symptoms of a ruptured aortic aneurysm, immediate action is necessary to save their life. The first step is to prepare the patient for surgery by informing the theatre, a vascular surgeon, and an anaesthetist. Without surgery, the mortality rate for a ruptured aneurysm is 100%. During surgery, a Dacron graft is inserted after clamping the aorta above the rupture.

      While waiting for surgery, a blood transfusion may be necessary to replace lost blood. However, surgery is the definitive treatment. It is also important to crossmatch blood and transfuse as needed.

      A computed tomography (CT) scan may be useful in diagnosing the condition, but it should not be performed until the patient is haemodynamically stable. In the meantime, obtaining an amylase level is necessary to rule out acute pancreatitis, although the presence of a mass suggests an aneurysm.

      In summary, emergency management of a ruptured aortic aneurysm requires prompt action to prepare the patient for surgery, administer blood transfusions, and obtain necessary diagnostic tests. Without immediate intervention, the patient’s life is at risk.

    • This question is part of the following fields:

      • Vascular
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  • Question 4 - A 68-year-old man presents to the surgical assessment unit with severe back pain...

    Incorrect

    • A 68-year-old man presents to the surgical assessment unit with severe back pain that has been ongoing for several hours. He is an ex-smoker with a medical history of hypertension and hyperlipidaemia, and has undergone multiple surgeries for Crohn's disease in the past. An urgent abdominal ultrasound is ordered, which reveals a 5.1 cm infrarenal abdominal aortic aneurysm (AAA). What would be the most suitable course of action?

      Your Answer: Elective open repair of the aneurysm

      Correct Answer: Elective endovascular repair of the aneurysm

      Explanation:

      Options for Treating an Unruptured Abdominal Aortic Aneurysm in a Symptomatic Patient

      When faced with an unruptured abdominal aortic aneurysm (AAA) in a symptomatic patient, there are several treatment options to consider. In this case, the aneurysm is located infra-renally and is not large enough to warrant surgical intervention based on size alone. However, the patient’s symptoms require action.

      Elective endovascular repair of the aneurysm is the best option in this scenario. The patient can be sent home with analgesia and scheduled for endovascular repair in approximately one week. This approach is particularly suitable for patients over 70 years old, who tend to have better outcomes with endovascular repair than with open surgery. Additionally, the patient’s history of Crohn’s surgery puts them at risk for abdominal adhesions, which could complicate open surgery.

      Emergency repair of the aneurysm, whether endovascular or open, is generally not recommended in this case since the aneurysm has not ruptured. Monitoring the aneurysm with ultrasound scans at 3-monthly intervals is a reasonable option for asymptomatic patients, but surgical intervention is necessary for symptomatic patients.

      Overall, elective endovascular repair is the most appropriate treatment option for this patient’s unruptured AAA.

    • This question is part of the following fields:

      • Vascular
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  • Question 5 - An 88-year-old man presents to the Emergency Department with severe pain in his...

    Correct

    • An 88-year-old man presents to the Emergency Department with severe pain in his left leg, below the knee. This pain came on suddenly an hour ago, after walking to his bathroom. He knows that he gets claudication on walking over 250 metres, and is unsure if this pain is the same. His medical history includes hypertension, controlled with amlodipine 5 mg od. On examination, his left leg below the knee is pale, cold and numb, with absent dorsalis pedis and posterior tibial pulses, but present pulses on his right leg.
      Given the likely diagnosis, what is the most appropriate management?

      Your Answer: Embolectomy

      Explanation:

      Treatment Options for Acute Limb Ischaemia: Embolectomy and Thrombolysis

      Acute limb ischaemia can be caused by either an embolus or a thrombosis. The diagnosis is clinical and can be remembered using the 6Ps: Pale, Pulseless, Paraesthesia, Pain, Paralysis, and Perishingly cold. In the case of an embolic cause, urgent embolectomy using a Fogarty catheter to retrieve the clot is the appropriate treatment. Post-embolectomy, patients should be anticoagulated with IV heparin and then switched over to warfarin.

      Thrombolysis is the appropriate treatment if the ischaemia is caused by a thrombosis. However, based on the clinical history, if the patient has an embolic cause, thrombolysis is not recommended. Thrombosis tends to present over hours to days, with a history of claudication and is less severe as collateral blood supply develops. Contralateral pulses tend to be absent.

      Amputation below the right knee is an effective treatment but should only be considered by experienced consultants as it will have serious long-term implications for patients. Because the man has presented relatively quickly, it is unlikely that amputation will be required.

      High dose warfarin is not a treatment for acute limb ischaemia. The clot needs to be removed.

      Angiography is not performed when complete occlusion is suggested by the clinical picture, as it introduces a delay in revascularisation. In an incomplete occlusion, angiography is used to place stents to open the vessels.

      In summary, the appropriate treatment for acute limb ischaemia caused by an embolus is embolectomy, while thrombolysis is the appropriate treatment for ischaemia caused by a thrombosis. Amputation should only be considered as a last resort, and high dose warfarin is not a treatment option. Angiography and stenting are only used in cases of incomplete occlusion.

    • This question is part of the following fields:

      • Vascular
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  • Question 6 - A 60-year-old man was brought into the Emergency Department with sudden onset of...

    Correct

    • A 60-year-old man was brought into the Emergency Department with sudden onset of severe back pain lasting 20 min. The pain was constant and not exacerbated by coughing or sneezing. On examination, the patient was in shock, with a palpable 8-cm mass deep in the epigastrium above the umbilicus. His past medical history includes a 6-cm abdominal aortic aneurysm diagnosed 2 years ago at the time of cholecystectomy. The patient is a non-smoker and drinks 2 pints of beer a week.
      Which is the most probable diagnosis?

      Your Answer: Rupturing abdominal aortic aneurysm

      Explanation:

      Possible Diagnoses for Sudden-Onset Severe Back Pain

      When a patient presents with sudden-onset severe back pain, it is important to consider various possible diagnoses. In the case of a male patient with increasing age and a known history of abdominal aortic aneurysm, a rupturing aneurysm should be suspected until proven otherwise. This is especially true if there is associated shock and a large palpable mass deep in the epigastrium. Blood initially leaks into the retroperitoneal space, causing severe back pain, before blowing out into the peritoneal cavity. Acute cholecystitis is unlikely if the patient has had a previous cholecystectomy. Acute pancreatitis may present with epigastric pain, but this patient does not have other symptoms consistent with the condition. Herniated lumbar disc pain is usually worsened by coughing or sneezing and radiates down the leg, which is not the case here. Aortic dissection could present similarly, but given the known history of a large aortic aneurysm, a rupture is more likely. Therefore, it is important to consider all possible diagnoses and take appropriate action to manage the patient’s condition.

    • This question is part of the following fields:

      • Vascular
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  • Question 7 - A 55-year-old man, with a known abdominal aortic aneurysm presents for his annual...

    Correct

    • A 55-year-old man, with a known abdominal aortic aneurysm presents for his annual review.
      What size abdominal aortic aneurysm (AAA) would indicate the need for urgent elective surgery of the aneurysm?

      Your Answer: An increase of >1 cm per year

      Explanation:

      Monitoring and Repair of Abdominal Aortic Aneurysms

      Abdominal aortic aneurysms (AAA) are a potentially life-threatening condition that require careful monitoring and, in some cases, elective repair. The current guidelines for monitoring and repair depend on the size of the aneurysm and its rate of growth.

      An increase of >1 cm per year indicates a need for elective repair, as does an AAA with a diameter greater than 5.5 cm. Symptomatic aneurysms or those causing complications also require repair. Endovascular repair is often preferred over open surgery.

      For AAAs between 3.0-5.4 cm, monitoring via ultrasound is required. AAAs between 4.5-5.4 cm require more frequent monitoring (every 3 months) than those between 3.0-4.4 cm (annual monitoring). An increase of 0.5-1 cm per year does not necessarily indicate a need for repair.

      Regular monitoring and timely repair can help prevent the potentially fatal complications of AAA.

    • This question is part of the following fields:

      • Vascular
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  • Question 8 - A patient with risk factors for atherosclerosis presents with pain (even when resting)...

    Incorrect

    • A patient with risk factors for atherosclerosis presents with pain (even when resting) in the leg.
      About which sign or symptom are you most concerned in an elderly patient?

      Your Answer: Pulseless limb

      Correct Answer: Paraesthesiae

      Explanation:

      Understanding the Six Ps of Limb Ischaemia

      Limb ischaemia is a serious condition that can lead to the loss of a limb if not treated promptly. To diagnose acute limb ischaemia, doctors look for the six Ps: pain, paraesthesiae, paralysis, pulselessness, pallor, and coldness. Of these, paraesthesiae and paralysis are the most concerning, as they indicate that the limb is at risk of being lost within 24 hours without intervention.

      It’s important to note that pulselessness, pain, pallor, and coldness are also symptoms of acute limb ischaemia, but they don’t necessarily indicate the severity of the condition. For example, a patient may have a pulseless limb but still have time to save the limb with proper treatment. Similarly, a patient may experience pain, pallor, or coldness, but these symptoms alone don’t necessarily mean that the limb is in immediate danger.

      In summary, understanding the six Ps of limb ischaemia is crucial for diagnosing and treating this serious condition. If you or someone you know is experiencing symptoms of acute limb ischaemia, seek medical attention immediately to prevent the loss of the limb.

    • This question is part of the following fields:

      • Vascular
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  • Question 9 - A 60-year-old woman without significant medical history experiences a paradoxical embolic stroke after...

    Incorrect

    • A 60-year-old woman without significant medical history experiences a paradoxical embolic stroke after developing a deep vein thrombosis.
      What embryological issue is the most probable cause of this?

      Your Answer: Tricuspid atresia

      Correct Answer: Patent foramen ovale

      Explanation:

      Common Congenital Heart Defects and Their Risks

      Congenital heart defects are abnormalities in the heart’s structure that are present at birth. These defects can cause serious health problems and even death if left untreated. Here are some common congenital heart defects and their associated risks:

      Patent Foramen Ovale: This defect occurs when the septum primum and secundum fail to fuse, resulting in a hole in the heart. This can lead to paradoxical emboli, where venous thrombosis enter the systemic circulation and cause serious health problems.

      Tetralogy of Fallot: This is a form of congenital cyanotic heart disease that can cause premature cardiac failure and death if not surgically corrected in childhood.

      Bicuspid Aortic Valve: This defect is a common cause of premature aortic stenosis, but it cannot cause a venous thrombosis to enter the systemic circulation.

      Transposition of the Great Arteries: This is another form of congenital cyanotic heart disease that can cause premature cardiorespiratory failure and death if not surgically corrected in childhood.

      Tricuspid Atresia: This defect results in a hypoplastic right ventricle and requires both an atrial and ventricular septal defect to allow pulmonary and systemic blood flow. It must be corrected in childhood to prevent death.

      It is important to diagnose and treat congenital heart defects early to prevent serious health problems and premature death.

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      • Vascular
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  • Question 10 - A 68-year-old man is brought to Accident and Emergency by ambulance, complaining of...

    Incorrect

    • A 68-year-old man is brought to Accident and Emergency by ambulance, complaining of abdominal pain. He says the pain is 8/10 in strength, radiates to the groin, iliac fossae and back and began suddenly half an hour ago. He cannot identify anything that prompted the pain and has not yet eaten today. He says he also feels dizzy and faint. The man has had two stents after a cardiac arrest in 2011. He has hypertension and hypercholesterolaemia. He smokes 35 cigarettes a day but does not consume alcohol. On examination, the patient looks grey. His blood pressure is 100/70 mmHg, heart rate 126 bpm, respiratory rate 28 breaths/minute and temperature 37.4 °C. He has widespread abdominal tenderness on light palpation. You cannot palpate any masses.
      What is the most likely diagnosis?

      Your Answer: Myocardial infarction

      Correct Answer: Ruptured abdominal aortic aneurysm

      Explanation:

      Differential Diagnosis for Abdominal Pain: Ruptured Abdominal Aortic Aneurysm, Pancreatitis, Pyelonephritis, Myocardial Infarction, and Acute Cholecystitis

      Abdominal pain can be caused by a variety of conditions, and it is important to consider the patient’s symptoms and medical history to make an accurate diagnosis. In this case, the patient has multiple risk factors for cardiovascular disease, including hypertension, smoking, age, and being male. The sudden onset of pain radiating to the groin, back, and iliac fossae is typical of a ruptured abdominal aortic aneurysm, which can cause shock and requires immediate surgical intervention.

      Pancreatitis is another possible cause of the patient’s pain, with pain radiating to the back and often accompanied by fever and jaundice. However, the patient has not eaten recently and does not drink alcohol, which are common triggers for gallstone-induced and alcohol-induced pancreatitis.

      Pyelonephritis, or a kidney infection, can also cause back pain and septic shock, but the sudden onset of pain is less typical. A patient with severe pyelonephritis would also be expected to have a fever.

      Although the patient has multiple cardiac risk factors, his pain is not typical of a myocardial infarction, or heart attack. Myocardial infarction can cause abdominal pain, but it is unlikely to radiate to the back and groin.

      Acute cholecystitis, or inflammation of the gallbladder, typically causes right upper quadrant pain, jaundice, and fever, which are not present in this patient.

      In summary, the patient’s symptoms and medical history suggest a ruptured abdominal aortic aneurysm as the most likely cause of his abdominal pain, but other conditions such as pancreatitis and pyelonephritis should also be considered. A thorough evaluation and prompt intervention are necessary to prevent further complications.

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      • Vascular
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  • Question 11 - A 75-year-old woman is admitted to the Coronary Care Unit after being diagnosed...

    Correct

    • A 75-year-old woman is admitted to the Coronary Care Unit after being diagnosed with an inferior myocardial infarction. On day 2, she complains of sudden onset of severe pain in her left leg that started 30 minutes ago and is increasing in intensity. She has never had this kind of pain before and, prior to this admission, claims to have been extraordinarily well for her age. On examination, the leg is cool and pale in comparison to the right leg. Femoral pulses are present and of good volume; however, the pulse rhythm is noted to be irregular. The pulses in her right leg are all palpable. There are no pulses felt below the groin on the left leg.
      Select the most appropriate diagnosis for this patient.

      Your Answer: Acute ischaemic limb due to an embolus from a proximal site

      Explanation:

      Causes of Acute Limb Ischaemia

      Acute limb ischaemia is a medical emergency that requires urgent intervention. There are several possible causes of this condition, including embolism from a proximal site, muscle haematoma due to anticoagulant therapy, chronic ischaemic limb, acute ischaemia due to thrombosis of an atherosclerotic plaque, and extensive deep vein thrombosis.

      The most common cause of acute limb ischaemia is embolism from a proximal site. This occurs when a clot forms in the heart or a blood vessel and travels down to block a smaller artery in the leg. The classical symptoms of acute limb ischaemia are known as the 6 Ps, which include sudden onset of severe pain, absence of pulses, paraesthesiae, paralysis, pain on passive movement, and a pale, cold limb. Urgent referral to vascular surgeons is required, and angiography should be performed to determine the site and extent of the obstruction. If the limb is threatened by severe ischaemia, urgent revascularisation within 4 hours is necessary.

      Muscle haematoma due to anticoagulant therapy is another possible cause of limb ischaemia, but it would not present with sudden-onset pain and absence of pulses. Chronic limb ischaemia would not present with sudden-onset severe pain either. Acute ischaemia due to thrombosis of an atherosclerotic plaque typically gives a more gradual onset of increasing pain and may be preceded by a history of intermittent claudication. Finally, extensive deep vein thrombosis would cause a warm, swollen limb with pulses present.

      In conclusion, acute limb ischaemia is a serious condition that requires prompt diagnosis and treatment. The underlying cause of the condition will determine the appropriate management, and urgent referral to vascular surgeons is necessary in most cases.

    • This question is part of the following fields:

      • Vascular
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  • Question 12 - A 68-year-old man comes to his General Practitioner complaining of painless, gradual, one-sided...

    Incorrect

    • A 68-year-old man comes to his General Practitioner complaining of painless, gradual, one-sided swelling in his right leg. He reports that this is more noticeable in the evenings. During clinical examination, the right leg is swollen, but there is no redness or excessive warmth upon touch. He is in good health otherwise. He had undergone surgery in the past to treat prostate cancer.

      What is the initial investigation that should be performed to confirm the diagnosis?

      Your Answer: Ultrasound

      Correct Answer: Lymphoscintigram

      Explanation:

      Diagnostic Tests for Lymphoedema: Choosing the Right One

      Lymphoedema is a condition characterized by swelling in the limbs due to the accumulation of lymphatic fluid. While clinical examination can often diagnose lymphoedema, further investigations may be necessary to confirm the diagnosis and rule out other possible causes. Here are some diagnostic tests that may be requested and their relevance in diagnosing lymphoedema:

      Lymphoscintigram: This is the first-line investigation to confirm lymphoedema. It involves injecting a radioactive tracer into the affected limb and then imaging the lymphatic system to assess the flow of lymphatic fluid.

      Blood smear: A blood smear may be requested if filariasis is suspected as a cause of lymphoedema. This test involves examining a blood sample under a microscope to look for the presence of microfilariae, which are the larvae of filarial worms.

      Computed tomography (CT) scan: CT scans are less useful in evaluating lymphoedema as they do not provide specific information about soft tissues.

      Genetic testing: Genetic testing is useful in diagnosing primary lymphoedema, which can be caused by genetic mutations. However, it is less likely to be relevant in cases of secondary lymphoedema, which is more commonly caused by surgery, infection, or trauma.

      Ultrasound: While not useful in diagnosing lymphoedema, ultrasound may be helpful in ruling out other possible causes of limb swelling, such as deep vein thrombosis.

      In summary, the choice of diagnostic test for lymphoedema depends on the suspected cause and the clinical presentation of the patient. A lymphoscintigram is the most useful test for confirming lymphoedema, while other tests may be requested to rule out other possible causes.

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      • Vascular
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  • Question 13 - A 20-year-old student comes to her doctor with worries about her hands. When...

    Correct

    • A 20-year-old student comes to her doctor with worries about her hands. When it's cold outside, her hands become extremely cold and slightly painful, and they change color. They start off very pale, then turn blue, and finally turn red. Upon examining her hands, there are no scars or signs of ulcers. She has no significant medical history.
      What is the most probable diagnosis?

      Your Answer: Primary Raynaud’s phenomenon

      Explanation:

      Common Causes of Hand Discoloration and Pain

      Hand discoloration and pain can be caused by various conditions. One of the most common causes is Raynaud’s phenomenon, also known as Raynaud’s disease. This condition is characterized by a color change in the hands from white to blue to red. Primary Raynaud’s phenomenon is benign and usually affects young women. Chemical hand warmers can be used for symptomatic relief. On the other hand, secondary Raynaud’s or Raynaud’s syndrome is caused by an underlying disease process or medication. It can cause pain, scarring, and ulceration of the fingertips.

      Thoracic outlet syndrome is another condition that can cause hand pain and paraesthesiae. It is characterized by unilateral symptoms and can affect various areas such as the neck, arm, and hand. Buerger’s disease, also known as thromboangiitis obliterans, is a rare disease that causes inflammation and thrombosis of small and medium arteries. This leads to symptoms similar to acute ischaemia such as pain, claudication, and absent pulses.

      Vibration white finger is a condition that can occur after prolonged use of power tools. It causes whiteness, numbness, and loss of dexterity in the fingers. Finally, blue finger syndrome is a rare condition that results from spontaneous thrombosis of one finger.

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      • Vascular
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  • Question 14 - A 68-year-old man presented to the clinic with occasional abdominal pain, for which...

    Correct

    • A 68-year-old man presented to the clinic with occasional abdominal pain, for which his general practitioner could find no reason. After your assessment, you organise an ultrasound scan of the abdomen to rule out any pathology and incidentally find out that the patient has an abdominal aortic aneurysm (AAA).
      Which statement best applies to an AAA?

      Your Answer: Surveillance is carried out with CT scanning or ultrasound

      Explanation:

      Understanding Abdominal Aortic Aneurysms: Diagnosis, Monitoring, and Treatment

      Abdominal aortic aneurysms (AAAs) are a serious medical condition that require careful monitoring and prompt treatment. Diagnosis is typically done through ultrasound screening, with men being invited for screening during their 65th year. Once an AAA is detected, monitoring is done through CT scanning or ultrasound, with the frequency of scans increasing as the aneurysm grows in size. If a leak is suspected, immediate surgical intervention is necessary, although a CT scan may be performed first to assess the extent of the leak. Surgery is typically done when the aneurysm reaches a diameter of 5.5 cm or greater, with repair options including open surgery with a synthetic graft or endovascular repair. Patients may present with central and upper abdominal pain radiating to their back, and misdiagnosis as renal colic can be fatal. Understanding the diagnosis, monitoring, and treatment of AAAs is crucial for ensuring the best possible outcomes for patients.

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  • Question 15 - A 50-year-old patient presents with acute pain in his right calf, from the...

    Incorrect

    • A 50-year-old patient presents with acute pain in his right calf, from the knee downwards, causing him great difficulty in walking. Of note, pulses are not palpable in the right limb below the knee. While standing, the right limb appears more erythematosus than the left, but this colour quickly fades on laying the patient flat.
      Which one of the following statements is correct?

      Your Answer: Lumbar sympathectomy is indicated in the above condition

      Correct Answer: Chronic arterial insufficiency is likely to be an underlying factor in the above presentation

      Explanation:

      Understanding Chronic Arterial Insufficiency and Acute Limb Ischaemia

      Chronic arterial insufficiency can be a contributing factor to acute limb ischaemia, a condition where blood flow to a limb is suddenly blocked. In patients with pre-existing stenotic vessels, an embolus or thrombus can easily occlude the vessel, leading to acute limb ischaemia. While patients with chronic arterial insufficiency may develop collaterals, these may not prevent the symptoms of acute limb ischaemia. Paraesthesiae, or altered sensation, is a common symptom of acute limb ischaemia. While ankle-brachial pressure index measurement can be useful, it is of limited use in diagnosing acute limb ischaemia. A Fogarty catheter can be used for surgical embolectomy, and lumbar sympathectomy may be performed in chronic arterial insufficiency to increase distal blood flow.

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  • Question 16 - A 50-year-old woman had a traditional high tie, strip and avulsion procedure for...

    Incorrect

    • A 50-year-old woman had a traditional high tie, strip and avulsion procedure for her varicose veins in the distribution of the long and short saphenous veins. She experienced difficulty walking after the surgery because she could not dorsiflex or evert her foot. The surgeon had warned her beforehand that nerve damage was a possibility.
      What nerve was affected during the patient's varicose vein surgery?

      Your Answer: Tibial nerve

      Correct Answer: Common peroneal nerve

      Explanation:

      Understanding Foot Drop: Common Peroneal Nerve Damage

      Foot drop, the inability to dorsiflex the foot, is often caused by damage to the common peroneal nerve. This nerve is commonly damaged during varicose vein surgery when the short saphenous vein is avulsed around the head and neck of the fibula. The nerve divides to innervate the anterior and lateral compartments of the leg, and paralysis of these compartments causes foot drop. Patients compensate for the loss of dorsiflexion by adopting a high-stepping gait, resulting in a loud slap with each step. Other nerves, such as the sciatic, medial plantar, lateral plantar, and tibial nerves, may cause different symptoms and pain locations. Understanding the specific nerve damage is crucial for proper diagnosis and treatment.

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      • Vascular
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  • Question 17 - A 65-year-old man comes to the vascular clinic with a complaint of leg...

    Incorrect

    • A 65-year-old man comes to the vascular clinic with a complaint of leg pain during exercise. He reports that the pain occurs in both calves, with the left side being slightly worse than the right. The pain starts after walking a few meters and subsides when he sits down. The patient has a medical history of type II diabetes mellitus, hypercholesterolemia, hypertension, and glaucoma. He has a 40 pack-year smoking history but quit smoking ten years ago when he was diagnosed with diabetes.
      You conduct an Ankle: Brachial Pressure Index (ABPI) test on the man and find that his left leg ABPI is 0.8, while his right leg ABPI is 0.9. What would be your initial approach to managing this patient?

      Your Answer: Conduct a duplex USS arteriogram of both legs

      Correct Answer: Optimise control of diabetes, ensure he is compliant with his statin, supervised exercise programme for 3 month and prescribe 75 mg of clopidogrel daily

      Explanation:

      Management of Intermittent Claudication in a Patient with Multiple Risk Factors

      Intermittent claudication is a common symptom of arterial disease and can be caused by multiple risk factors, including smoking, diabetes, and hypercholesterolaemia. In managing a patient with intermittent claudication, it is important to first assess their ankle-brachial pressure index (ABPI) measurement to determine the severity of their arterial disease.

      For patients with ABPI measurements between 0.6-0.9, first-line treatment involves managing risk factors and encouraging supervised exercise for three months. This patient should be optimally controlled for diabetes and compliant with their statin medication. Additionally, they should be prescribed 75 mg of clopidogrel daily to reduce the risk of blood clots.

      A duplex USS arteriogram of both legs should be conducted to assess the extent of arterial disease. If necessary, a contrast-enhanced MRI may be used to plan revascularisation. However, surgery is typically only considered as a third-line treatment option.

      It is important to note that analgesia is not the first-line treatment for intermittent claudication. Instead, addressing risk factors and enrolling in a supervised exercise programme for three months should be prioritised. Patients should be encouraged to exercise for two hours a week, to the maximum point of pain.

      In summary, managing intermittent claudication in a patient with multiple risk factors involves a comprehensive approach that addresses risk factors, encourages exercise, and may involve further diagnostic testing and medication.

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  • Question 18 - A 33-year-old woman, a smoker, presents to the Emergency Department at 28 weeks’...

    Incorrect

    • A 33-year-old woman, a smoker, presents to the Emergency Department at 28 weeks’ gestation with a swollen left lower leg. She reported experiencing some pain and swelling in both legs in the past week, but woke up this morning with the left leg being tender and red.
      Her medical history is unremarkable, but she is feeling short of breath and her vital signs are stable.
      Upon examination, there is bilateral lower limb swelling, with the left side being significantly more swollen and painful upon palpation. The skin is also warm to the touch. An electrocardiogram (ECG) shows no abnormalities.
      What is the initial step in managing this patient's likely diagnosis?

      Your Answer: Ultrasound Doppler of left lower leg

      Correct Answer: Commence low-molecular-weight heparin treatment

      Explanation:

      Management of Deep Vein Thrombosis in Pregnancy

      During pregnancy, a swollen, erythematosus, and painful leg is treated as a deep vein thrombosis (DVT) until proven otherwise. A risk assessment should be performed at the booking visit to identify factors that increase the likelihood of venous thromboembolism (VTE). If a pregnant patient presents with symptoms suspicious of a DVT, treatment-dose low-molecular-weight heparin should be administered immediately, provided there are no contraindications. Treatment should not be delayed until investigations are performed, but if a Doppler scan of the deep veins in the legs precludes the diagnosis of DVT, treatment can be discontinued.

      If investigations confirm DVT, treatment should continue throughout pregnancy and for 6 weeks postpartum, with a total of at least 3 months of treatment. Contraindications to low-molecular-weight heparin include heparin-induced thrombocytopenia, allergy, haemorrhagic disorders, recent cerebral haemorrhage, peptic ulceration, and active bleeding. A computed tomography pulmonary angiogram (CTPA) is the standard method for diagnosing a pulmonary embolus, but due to the risk of radiation to the fetus, a ventilation-perfusion scan is used as first-line in pregnancy. Warfarin is contraindicated in pregnancy, but may be considered as an alternative to heparin in cases where heparin is contraindicated and a VTE is diagnosed, following discussion with the haematology team.

      If a leg Doppler confirms a DVT, no further investigation is required, and the patient can continue on treatment-dose low-molecular-weight heparin. However, if a Doppler shows no evidence of DVT, a chest X-ray should be performed to rule out a cause of shortness of breath such as pneumonia. If the chest X-ray is negative, a ventilation-perfusion scan should be performed to rule out a pulmonary embolus. Ultrasound Doppler is the gold standard for diagnosing DVT and is essential in this case.

    • This question is part of the following fields:

      • Vascular
      6.4
      Seconds
  • Question 19 - A 32-year-old man is being evaluated in the Emergency Department after a car...

    Incorrect

    • A 32-year-old man is being evaluated in the Emergency Department after a car accident at high speed. He has several fractures in his lower limbs and a posterior dislocation of his right hip. The doctor examining him wants to determine if he has any vascular damage. He starts by checking the pulses in his limbs.
      What is accurate about arteries in the lower limbs?

      Your Answer: The dorsalis pedis artery is a terminal branch of the posterior tibial artery

      Correct Answer: The anterior tibial artery lies between the tibialis anterior and extensor hallucis longus in the anterior compartment of the leg

      Explanation:

      Understanding Lower Limb Pulse Points and Arteries

      The lower limb has several pulse points that are commonly examined. The femoral artery can be palpated at the mid-inguinal point, while the popliteal artery can be felt in the popliteal fossa with the knee in semi-flexion. The posterior tibial pulse is best appreciated below the medial malleolus, and the dorsalis pedis pulse is typically palpable between the tendons of the extensor hallucis longus medially and the extensor digitorum laterally on the dorsum of the foot.

      It’s important to note that the dorsalis pedis pulse is only palpable medial to the tendon of the extensor hallucis longus. Additionally, the anterior tibial artery lies on the tibia between the tibialis anterior and extensor hallucis longus in the lower anterior compartment of the leg, and the dorsalis pedis artery is a terminal branch of the anterior tibial artery.

      Lastly, the fibular (peroneal) artery is not a direct branch of the popliteal artery. Instead, it is a branch of the tibioperoneal trunk, which is a branch of the popliteal arch. Understanding these pulse points and arteries can aid in proper diagnosis and treatment of lower limb conditions.

    • This question is part of the following fields:

      • Vascular
      1.3
      Seconds
  • Question 20 - As an FY2 doctor in the Emergency Department, you are attending to a...

    Incorrect

    • As an FY2 doctor in the Emergency Department, you are attending to a patient who is experiencing severe abdominal pain. The patient is unable to localise the pain, and reports feeling faint. Upon examination, you observe a pulsatile expansile mass above their umbilicus, along with generalised abdominal tenderness. The patient's blood pressure is 95/51 mmHg, and their pulse is 114 bpm. While awaiting a surgical review, the patient is receiving fluid resuscitation for their low blood pressure. In this scenario, which of the following would provide the most useful information for planning the patient's management?

      Your Answer: Ultrasound

      Correct Answer: Computerised tomography (CT) scan

      Explanation:

      Imaging Options for Abdominal Aortic Aneurysm (AAA)

      Abdominal aortic aneurysm (AAA) is a serious condition that requires prompt diagnosis and treatment. Clinical diagnosis may be possible based on the presence of a pulsatile expansile mass and severe shock, but a computerised tomography (CT) scan is needed to assess the dimensions and anatomical relations of the aneurysm. This information is crucial in determining the most suitable type of surgical repair, such as endovascular aneurysm repair (EVAR).

      X-rays are not useful for visualising soft tissue structures, while intravenous arteriograms are completely inappropriate as the contrast can cause peritonitis and worsen the patient’s condition. Ultrasound scans are good for confirming suspected AAAs in stable patients, but they cannot provide accurate information for surgical planning.

      In summary, a CT scan is the most appropriate imaging option for diagnosing and planning treatment for AAA.

    • This question is part of the following fields:

      • Vascular
      1.7
      Seconds
  • Question 21 - A 43-year-old man presents with intermittent claudication. He has a body mass index...

    Correct

    • A 43-year-old man presents with intermittent claudication. He has a body mass index of 32 kg/m2 and smokes 40 cigarettes a day. He admits that he has an extremely unhealthy diet. There is no family history of cardiovascular disease but his father died of complications of diabetes. His blood pressure is 160/110 mmHg.
      What is the most likely cause of the claudication?

      Your Answer: Atherosclerosis

      Explanation:

      Atherosclerosis, a disease commonly associated with the elderly, is now being observed in younger patients. This patient exhibits all the risk factors for atherosclerosis, which is the leading cause of intermittent claudication. While diabetes is not a direct cause of limb ischaemia, it is a risk factor for atherosclerosis, which this patient may have. Buerger’s disease, an arthritis that affects young male smokers, is rare and unlikely in this patient who is obese, hypertensive, and has a family history of diabetes. Coarctation of the aorta, which is characterized by hypertension and radiofemoral delay, should be considered in young patients with intermittent claudication, but there are no other signs in this patient. Takayasu’s disease, a rare arthritis that causes claudication and neurological signs, is more common in women and often presents with pulseless upper limbs due to arterial occlusion caused by intimal fibrosis.

    • This question is part of the following fields:

      • Vascular
      11.1
      Seconds
  • Question 22 - A 56-year-old man presents to the Emergency Department with central abdominal pain. The...

    Incorrect

    • A 56-year-old man presents to the Emergency Department with central abdominal pain. The pain started very suddenly, is described as severe and radiates through to his back. He has a past medical history of hypertension. On examination, the patient looks unwell, with some bruising around his flanks.
      Investigation Result Normal value
      Heart rate (HR) 118 bpm 60–100 bpm
      Blood pressure (BP) 98/62 mmHg < 120/80 mmHg
      Respiratory rate (RR) 28 breaths/min 12–18 breaths/min
      Sats 95% on air 94–98%
      Temperature 36 °C 36.1–37.2 °C
      There is generalised tenderness upon palpation of the abdomen.
      Which of the following is the most likely diagnosis?

      Your Answer: Renal artery stenosis

      Correct Answer: Ruptured AAA

      Explanation:

      Possible Diagnoses for Abdominal Pain and Bruising

      When a patient presents with abdominal pain and bruising, it is important to consider a range of possible diagnoses. In this case, a ruptured abdominal aortic aneurysm (AAA) is the most likely explanation, given the patient’s history and examination findings. This is a serious condition with high mortality, and urgent surgical intervention is required if AAA is suspected. To avoid further complications, blood pressure should be maintained at less than 100 mmHg.

      Other potential diagnoses that should be ruled out include pancreatitis, renal artery stenosis, appendicitis, and aortic dissection. Pancreatitis can also cause abdominal pain and bruising, but the patient’s symptoms and signs suggest AAA as the primary concern. Renal artery stenosis typically presents differently and is less likely in this case. Appendicitis can cause central abdominal pain, but it is not the most likely explanation here. Aortic dissection can cause pain radiating to the back, but the location and severity of the pain in this patient do not fit with that diagnosis. Overall, prompt and accurate diagnosis is crucial for effective treatment and management of abdominal pain and bruising.

    • This question is part of the following fields:

      • Vascular
      247
      Seconds
  • Question 23 - A 45-year-old man, who is a heavy smoker, was seen in the Surgical...

    Incorrect

    • A 45-year-old man, who is a heavy smoker, was seen in the Surgical Outpatient Clinic, complaining of severe pain in both legs, even at rest. On examination, he had chronic ulceration of his toes.
      Which of the following conditions is he most likely to have?

      Your Answer: Granulomatosis with polyangiitis (GPA)

      Correct Answer: Buerger’s disease

      Explanation:

      The patient is suffering from Buerger’s disease, also known as thromboangiitis obliterans. This disease affects medium-sized and small arteries, particularly the tibial and radial arteries, and can extend to veins and nerves of the extremities. It is most commonly seen in heavy cigarette-smoking men, but there has been an increase in cases among women due to changing smoking trends. The disease typically begins before the age of 35 and causes severe pain, even at rest, due to neural involvement. Chronic ulcerations and gangrene can occur as later complications. Abstinence from smoking in the early stages can prevent further attacks. Other possible conditions, such as granulomatosis with polyangiitis, Kawasaki’s disease, polyarteritis nodosa, and Takayasu’s arthritis, have been ruled out based on the patient’s symptoms and medical history.

    • This question is part of the following fields:

      • Vascular
      8.6
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  • Question 24 - An 84-year-old woman presents with intermittent claudication.
    Which investigation will be most useful in...

    Incorrect

    • An 84-year-old woman presents with intermittent claudication.
      Which investigation will be most useful in determining whether she is a suitable candidate for bypass surgery?

      Your Answer: Ankle-brachial pressure index

      Correct Answer: Digital subtraction arteriography

      Explanation:

      Preoperative Investigations for Vascular Surgery

      Before undergoing vascular surgery, patients may need to undergo several preoperative investigations to assess their condition and determine the best course of treatment. These investigations include digital subtraction arteriography, urea and electrolyte testing, ankle-brachial pressure index measurement, and electrocardiogram (ECG) testing.

      Digital Subtraction Arteriography
      Digital subtraction arteriography is a type of angiography that uses an iodine-based dye to compare images before and after injection. This investigation is important to assess the patient’s run-off, or the adequacy of blood supply to distal arteries. Patients with poor run-off may not be good candidates for bypass surgery.

      Urea and Electrolytes
      Urea and electrolyte testing is particularly important for patients with hypertension, diabetes, and a history of renal disease. These tests can help assess the patient’s kidney function and electrolyte balance.

      Ankle-Brachial Pressure Index
      The ankle-brachial pressure index is a non-invasive test that measures the blood pressure in the ankle and compares it to the blood pressure in the arm. This test can provide an early indication of the severity of the patient’s ischaemia, or reduced blood flow. A value of 0.9-1.2 is considered normal, while values below 0.3 indicate critical ischaemia.

      Electrocardiogram (ECG)
      An ECG is a non-invasive test that measures the electrical activity of the heart. It is mandatory for all patients over 60 years of age undergoing surgery of any kind. This test can help identify any underlying heart conditions that may affect the patient’s ability to undergo surgery.

      Contrast Arteriography
      If digital subtraction arteriography is not available, contrast arteriography may be used to assess the patient’s blood vessels. This test involves injecting a contrast dye into the blood vessels and taking X-ray images to visualize the blood flow.

    • This question is part of the following fields:

      • Vascular
      8.9
      Seconds
  • Question 25 - A 56-year-old man comes to the Emergency Department complaining of sudden onset, searing...

    Incorrect

    • A 56-year-old man comes to the Emergency Department complaining of sudden onset, searing interscapular back pain that has been ongoing for 2 hours. He has a medical history of hypertension and takes ramipril and amlodipine. His vital signs are as follows: heart rate 110 beats per minute, blood pressure (BP) 140/91 mmHg, respiratory rate 22 per minute, oxygen saturation 95% on room air, temperature 37.1°C. Upon examination of the chest, there are no additional positive findings. The lungs expand symmetrically and have normal breath sounds. Heart sounds I and II are present without additional sounds. The initial electrocardiogram (ECG) was normal, and a portable chest X-ray showed a widened mediastinum as the only abnormality. What is the most useful investigation for diagnosing the patient's likely underlying condition?

      Your Answer: 24 hour ECG

      Correct Answer: CT thorax with intravenous (IV) contrast

      Explanation:

      The sudden onset of intense, searing pain between the shoulder blades is a common symptom of aortic dissection, a condition where the inner layer of the aortic wall separates from the middle layer, creating a false and true aortic lumen. This can cause tachycardia and elevated blood pressure due to increased sympathetic activity. A widened mediastinum on an erect chest X-ray is a classic sign of aortic dissection, but other conditions can also cause this appearance. To diagnose aortic dissection, a CT thorax with IV contrast is recommended for detailed and rapid visualization. Treatment options range from medical management of blood pressure to emergency cardiothoracic surgery, depending on the extent of the dissection. Other diagnostic tests, such as a coronary angiogram, 24-hour ECG, troponin test, and echocardiogram, may not be as effective in diagnosing aortic dissection. Aortic dissection is a serious and life-threatening cause of chest pain and can be classified based on the involvement of the ascending aorta and/or the descending aorta.

    • This question is part of the following fields:

      • Vascular
      12.8
      Seconds
  • Question 26 - A 35-year-old pregnant woman comes to the clinic with a complaint of a...

    Correct

    • A 35-year-old pregnant woman comes to the clinic with a complaint of a burning sensation in her legs. She reports that her legs are very sore and uncomfortable. Upon examination, there is a hard, tender, bulging of veins in both her thighs and the calf region, with hyperpigmentation and eczema of both the legs and an ulcer over the medial malleolus. What would prevent radiofrequency ablation from being performed as an initial treatment for this patient?

      Your Answer: Pregnancy

      Explanation:

      Interventional Treatment for Varicose Veins and Associated Complications

      According to the National Institute for Health and Care Excellence guidelines, interventional treatment for varicose veins during pregnancy is not recommended. However, compression hosiery can be used to alleviate leg swelling symptoms.

      Eczema of the lower limbs in varicose veins may indicate chronic venous insufficiency. In such cases, immediate radiofrequency ablation is necessary.

      Hard, painful veins are a sign of superficial venous thrombosis, a complication of varicose veins. Immediate intervention is required if there is evidence of this condition.

      Hyperpigmentation of the lower limbs in varicose veins also suggests chronic venous insufficiency. In such cases, radiofrequency ablation is indicated.

      An ulcer over the medial malleolus, particularly a chronic, non-healing ulcer in varicose veins, is a strong indication of chronic venous insufficiency. If eczema, non-healing leg ulcers, or hyperpigmentation are present, immediate radiofrequency ablation is necessary.

    • This question is part of the following fields:

      • Vascular
      20.7
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Vascular (8/26) 31%
Passmed