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  • Question 1 - A 68-year-old man is brought to Accident and Emergency by ambulance, complaining of...

    Correct

    • 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: 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.

    • This question is part of the following fields:

      • Vascular
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  • Question 2 - 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
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  • Question 3 - 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 4 - An 84-year-old woman presents with intermittent claudication.
    Which investigation will be most useful in...

    Correct

    • 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: 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
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  • Question 5 - 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: Monitoring of the aneurysm with ultrasounds at 3-monthly intervals

      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 6 - A 48-year-old man presents with constant abdominal pain that radiates to the back....

    Correct

    • 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.

    • This question is part of the following fields:

      • Vascular
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  • Question 7 - 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: Cold 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 8 - A 65-year-old man comes to the vascular clinic with a complaint of leg...

    Correct

    • 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: 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
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  • Question 9 - A 45-year-old man, who is a heavy smoker, was seen in the Surgical...

    Correct

    • 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: 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
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  • Question 10 - 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
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SESSION STATS - PERFORMANCE PER SPECIALTY

Vascular (7/10) 70%
Passmed