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  • Question 1 - A 50-year-old woman had a traditional high tie, strip and avulsion procedure for...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Vascular
      23.6
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  • Question 2 - 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.

    • This question is part of the following fields:

      • Vascular
      21.4
      Seconds
  • Question 3 - An 88-year-old man presents to the Emergency Department with severe pain in his...

    Incorrect

    • 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: Thrombolysis

      Correct 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
      30.5
      Seconds
  • Question 4 - 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.

    • This question is part of the following fields:

      • Vascular
      40
      Seconds
  • Question 5 - 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 venogram 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.

    • This question is part of the following fields:

      • Vascular
      18.2
      Seconds
  • Question 6 - 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: Transposition of the great arteries

      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.

    • This question is part of the following fields:

      • Vascular
      18.2
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  • Question 7 - 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: Urea and electrolytes

      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
      16.6
      Seconds
  • Question 8 - 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
      45.9
      Seconds
  • Question 9 - 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 femoral artery pulsation is best felt over the distal femur on the medial aspect of the thigh

      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
      22
      Seconds
  • Question 10 - 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:

      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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SESSION STATS - PERFORMANCE PER SPECIALTY

Vascular (5/9) 56%
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