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Question 1
Incorrect
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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: Aortic dissection
Correct 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.
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This question is part of the following fields:
- Vascular
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Question 2
Correct
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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: 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.
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This question is part of the following fields:
- Vascular
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Question 3
Correct
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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: 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.
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This question is part of the following fields:
- Vascular
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Question 4
Incorrect
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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.
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This question is part of the following fields:
- Vascular
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Question 5
Correct
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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: 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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This question is part of the following fields:
- Vascular
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Question 6
Correct
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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: 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.
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This question is part of the following fields:
- Vascular
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Question 7
Incorrect
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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: Referral to a specialist surgeon within two weeks for further assessment
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
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This question is part of the following fields:
- Vascular
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Question 8
Correct
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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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This question is part of the following fields:
- Vascular
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Question 9
Incorrect
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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: Buerger’s disease
Correct 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.
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This question is part of the following fields:
- Vascular
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Question 10
Incorrect
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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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This question is part of the following fields:
- Vascular
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