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Question 1
Incorrect
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You evaluate a 45-year-old woman with a swollen and red left calf and thigh. Her D-dimer level is elevated, and you schedule an ultrasound examination, which shows a proximal vein clot (DVT). She has no significant medical history and no known drug allergies.
According to the current NICE guidelines, which anticoagulant is recommended as the initial treatment for DVT?Your Answer: Unfractionated heparin
Correct Answer: Rivaroxaban
Explanation:The current guidelines from NICE recommend that the first-line treatment for confirmed deep-vein thrombosis (DVT) or pulmonary embolism (PE) should be either apixaban or rivaroxaban, which are direct oral anticoagulants.
If neither of these options is suitable, the following alternatives should be considered:
1. LMWH (low molecular weight heparin) should be administered for at least 5 days, followed by dabigatran or edoxaban.
2. LMWH should be combined with a vitamin K antagonist (VKA), such as warfarin, for at least 5 days or until the international normalized ratio (INR) reaches at least 2.0 on 2 consecutive readings. Afterward, the VKA can be continued alone.
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This question is part of the following fields:
- Vascular
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Question 2
Incorrect
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A 65-year-old woman with a significant smoking history and a confirmed diagnosis of peripheral vascular disease comes in with suspected acute limb ischemia.
What test should be ordered if there is uncertainty about the diagnosis?Your Answer: Hand-held Doppler ultrasound scan
Correct Answer: Arteriography
Explanation:Acute limb ischaemia refers to a sudden decrease in blood flow to a limb, which puts the limb at risk of tissue death. This condition is most commonly caused by either a sudden blockage of a partially blocked artery or an embolus from another part of the body. It is considered a surgical emergency, as without surgical intervention, the limb can experience extensive tissue necrosis within six hours.
The typical signs of acute limb ischaemia are often described using the 6 Ps: constant and persistent pain, absence of pulses in the ankle, paleness or cyanosis of the limb, loss of power or paralysis, reduced sensation or numbness, and a sensation of coldness. The leading cause of acute limb ischaemia is a sudden blockage of a previously narrowed artery (60% of cases). The second most common cause is an embolism (30%), which can originate from sources such as a blood clot in the heart or a prosthetic heart valve. It is important to differentiate between these two causes, as the treatment and prognosis differ.
Other potential causes of acute limb ischaemia include trauma, Raynaud’s syndrome, iatrogenic injury, popliteal aneurysm, aortic dissection, and compartment syndrome. If acute limb ischaemia is suspected, it is crucial to seek immediate assessment by a vascular surgeon. Patients with suspected peripheral arterial disease should undergo an ankle brachial pressure index (ABPI) measurement. If there is uncertainty in the diagnosis, urgent arteriography may be necessary.
The management of acute limb ischaemia in secondary care depends on factors such as the type and location of the blockage, duration of ischaemia, presence of other medical conditions, type of conduit (artery or graft), risks associated with treatment, and viability of the limb. Possible interventions include percutaneous catheter-directed thrombolytic therapy, surgical embolectomy, and endovascular revascularisation if the limb is still viable. If the limb is at immediate or marginal risk, the choice between surgical or endovascular techniques will depend on factors such as time to revascularisation and the severity of sensory and motor deficits. In cases where the limb is unsalvageable, amputation may be necessary to prevent further complications and potential multi organ damage.
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This question is part of the following fields:
- Vascular
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Question 3
Incorrect
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A 68-year-old woman is seen in an outpatient clinic for her abdominal aortic aneurysm (AAA).
What is considered an indication for elective surgery for an AAA in UK clinical practice?Your Answer: Any aneurysm that is 5 cm in diameter
Correct Answer: An aneurysm of 4.5 cm in diameter that has increased in size 1 cm in the past 6 months
Explanation:An abdominal aortic aneurysm (AAA) is a condition where the abdominal aorta becomes enlarged, either in a specific area or throughout its length, reaching 1.5 times its normal size. Most AAAs are found between the diaphragm and the point where the aorta splits into two branches. They can be classified into three types based on their location: suprarenal, pararenal, and infrarenal. Suprarenal AAAs involve the origin of one or more visceral arteries, pararenal AAAs involve the origins of the renal arteries, and infrarenal AAAs start below the renal arteries. The majority of AAAs (approximately 85%) are infrarenal. In individuals over 50 years old, a normal infrarenal aortic diameter is 1.7 cm in men and 1.5 cm in women. An infrarenal aorta with a diameter greater than 3 cm is considered to be an aneurysm. While most AAAs do not cause symptoms, an expanding aneurysm can sometimes lead to abdominal pain or pulsatile sensations. Symptomatic AAAs have a high risk of rupture. In the UK, elective surgery for AAAs is typically recommended if the aneurysm is larger than 5.5 cm in diameter or if it is larger than 4.5 cm in diameter and has increased in size by more than 0.5 cm in the past six months.
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This question is part of the following fields:
- Vascular
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Question 4
Incorrect
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A 40-year-old woman presents with a painful, swollen right ankle following a recent hike in the mountains. You assess her for a possible sprained ankle, and as part of your assessment, you measure her ankle circumference.
What is the THRESHOLD level suggested by NICE as indicating a higher likelihood of a sprained ankle?Your Answer:
Correct Answer: More than 3 cm between the extremities
Explanation:The NICE guidelines for suspected deep vein thrombosis (DVT) suggest considering the possibility of DVT if typical symptoms and signs are present, particularly if the person has risk factors like previous venous thromboembolism and immobility.
Typical signs and symptoms of DVT include unilateral localized pain (often throbbing) that occurs during walking or bearing weight, as well as calf swelling (or, less commonly, swelling of the entire leg). Other signs to look out for are tenderness, skin changes such as edema, redness, and warmth, and vein distension.
To rule out other potential causes for the symptoms and signs, it is important to conduct a physical examination and review the person’s general medical history.
When assessing leg and thigh swelling, it is recommended to measure the circumference of the leg 10 cm below the tibial tuberosity and compare it with the unaffected leg. A difference of more than 3 cm between the two legs increases the likelihood of DVT.
Additionally, it is important to check for edema and dilated collateral superficial veins on the affected side.
To assess the likelihood of DVT and guide further management, the two-level DVT Wells score can be used.
For more information, you can refer to the NICE Clinical Knowledge Summary on deep vein thrombosis.
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This question is part of the following fields:
- Vascular
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Question 5
Incorrect
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A 45-year-old woman presents with a painful, swollen right calf following a recent flight from New York. You assess her for a possible deep vein thrombosis (DVT).
Which scoring system does NICE recommend for assessing the likelihood of DVT?Your Answer:
Correct Answer: Two-level Wells score
Explanation:The NICE guidelines for suspected deep vein thrombosis (DVT) suggest considering the possibility of DVT if typical symptoms and signs are present, particularly if the person has risk factors like previous venous thromboembolism and immobility.
Typical signs and symptoms of DVT include unilateral localized pain (often throbbing) that occurs during walking or bearing weight, as well as calf swelling (or, less commonly, swelling of the entire leg). Other signs to look out for are tenderness, skin changes such as edema, redness, and warmth, and vein distension.
To rule out other potential causes for the symptoms and signs, it is important to conduct a physical examination and review the person’s general medical history.
When assessing leg and thigh swelling, it is recommended to measure the circumference of the leg 10 cm below the tibial tuberosity and compare it with the unaffected leg. A difference of more than 3 cm between the two legs increases the likelihood of DVT.
Additionally, it is important to check for edema and dilated collateral superficial veins on the affected side.
To assess the likelihood of DVT and guide further management, the two-level DVT Wells score can be used.
For more information, you can refer to the NICE Clinical Knowledge Summary on deep vein thrombosis.
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This question is part of the following fields:
- Vascular
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Question 6
Incorrect
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A 65-year-old woman with a history of smoking and a confirmed diagnosis of peripheral vascular disease presents with symptoms suggestive of acute limb ischemia. After conducting a series of tests, the medical team suspects that an embolus is the likely cause.
Which of the following investigations would be the most beneficial in determining the origin of the embolus?Your Answer:
Correct Answer: Popliteal ultrasound
Explanation:Acute limb ischaemia refers to a sudden decrease in blood flow to a limb, which puts the limb at risk of tissue damage. This condition is most commonly caused by either a sudden blockage of a partially blocked artery due to a blood clot or by an embolus that travels from another part of the body. It is considered a surgical emergency, as without prompt surgical intervention, the affected limb may suffer extensive tissue death within six hours.
The leading cause of acute limb ischaemia is the sudden blockage of a previously narrowed artery segment, accounting for 60% of cases. The second most common cause is an embolus, which makes up 30% of cases. Emboli can originate from sources such as a blood clot in the left atrium of the heart in patients with atrial fibrillation (which accounts for 80% of peripheral emboli), a clot formed on the heart wall after a heart attack, or from prosthetic heart valves. It is crucial to differentiate between these two causes, as the treatment and prognosis differ.
To properly diagnose acute limb ischaemia, several important investigations should be arranged. These include a hand-held Doppler ultrasound scan, which can help determine if there is any remaining blood flow in the arteries. Blood tests such as a full blood count, erythrocyte sedimentation rate, blood glucose level, and thrombophilia screen should also be conducted. If there is uncertainty in the diagnosis, urgent arteriography may be necessary.
In cases where an embolus is suspected as the cause, additional investigations are needed to identify its source. These investigations may include an electrocardiogram to detect atrial fibrillation, an echocardiogram to assess the heart’s structure and function, an ultrasound of the aorta, and ultrasounds of the popliteal and femoral arteries.
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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 woman with a history of heavy smoking and a confirmed diagnosis of peripheral vascular disease comes in with symptoms suggestive of acute limb ischemia. After conducting a series of tests, the medical team suspects an embolus as the likely cause.
Which of the following investigations would be the LEAST useful in determining the origin of the embolus?Your Answer:
Correct Answer: Thrombophilia screen
Explanation:Acute limb ischaemia refers to a sudden reduction in blood flow to a limb, which puts the limb’s viability at risk. This condition is most commonly caused by either a sudden blockage of a previously partially blocked artery due to a blood clot or by an embolus that travels from a distant site. It is considered a surgical emergency, as without prompt surgical intervention, complete acute ischaemia can lead to extensive tissue death within six hours.
The leading cause of acute limb ischaemia is the sudden blockage of a narrowed arterial segment due to a blood clot, accounting for 60% of cases. The second most common cause is an embolism, which makes up 30% of cases. Emboli can originate from various sources, such as a blood clot in the left atrium of patients with atrial fibrillation (which accounts for 80% of peripheral emboli), a clot formed on the heart’s wall following a heart attack, or from prosthetic heart valves. It is crucial to differentiate between these two conditions, as their treatment and prognosis differ.
To properly investigate acute limb ischaemia, several important tests should be arranged. These include a hand-held Doppler ultrasound scan, which can help determine if there is any remaining arterial flow. Blood tests, such as a full blood count, erythrocyte sedimentation rate, blood glucose level, and thrombophilia screen, are also necessary. If there is uncertainty regarding the diagnosis, urgent arteriography should be performed.
In cases where an embolus is suspected as the cause, additional investigations are needed to identify its source. These may include an electrocardiogram to detect atrial fibrillation, an echocardiogram to assess the heart’s function, an ultrasound of the aorta, and ultrasounds of the popliteal and femoral arteries.
By rewriting the explanation and using paragraph spacing, the information is presented in a clearer and more organized manner.
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This question is part of the following fields:
- Vascular
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Question 8
Incorrect
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A 65-year-old woman with a history of smoking and a confirmed diagnosis of peripheral vascular disease comes in with suspected acute limb ischemia.
What is the primary cause of acute limb ischemia?Your Answer:
Correct Answer: Thrombotic occlusion
Explanation:Acute limb ischaemia refers to a sudden decrease in blood flow to a limb, which puts the limb at risk of tissue death. This condition is most commonly caused by either a sudden blockage of a partially blocked artery or an embolus that travels from another part of the body. It is considered a surgical emergency, as without prompt surgical intervention, the limb may suffer extensive tissue damage within six hours.
The typical signs of acute limb ischaemia are often described using the 6 Ps: constant and persistent pain, absence of pulses in the ankle, paleness or discoloration of the limb, loss of power or paralysis, reduced sensation or numbness, and a sensation of coldness. The leading cause of acute limb ischaemia is a sudden blockage of a previously narrowed artery (60% of cases). The second most common cause is an embolism, such as from a blood clot in the heart or following a heart attack. It is important to differentiate between these two causes, as the treatment and prognosis differ.
Other potential causes of acute limb ischaemia include trauma, Raynaud’s syndrome, iatrogenic injury (caused by medical procedures), popliteal aneurysm, aortic dissection, and compartment syndrome. If acute limb ischaemia is suspected, it is crucial to seek immediate assessment by a vascular surgeon.
The management of acute limb ischaemia in a hospital setting depends on factors such as the type and location of the blockage, duration of ischaemia, presence of other medical conditions, type of blood vessel affected, and the viability of the limb. Treatment options may include percutaneous catheter-directed thrombolytic therapy, surgical embolectomy, or endovascular revascularisation if the limb can still be saved. The choice between surgical and endovascular techniques will depend on various factors, including the urgency of revascularisation and the severity of sensory and motor deficits.
In cases where the limb is beyond salvage, amputation may be necessary. This is because attempting to revascularise a limb with irreversible ischaemia and extensive muscle death can lead to a condition called reperfusion syndrome, which can cause inflammation and damage to multiple organs, potentially resulting in death.
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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 65-year-old woman is brought in by ambulance to the resuscitation area of your Emergency Department. She developed sudden onset chest pain and then collapsed while exercising at home. On examination, she is pale and sweaty, and you can palpate a pulsatile mass in her abdomen. You suspect that she has a ruptured abdominal aortic aneurysm (AAA).
What is the most suitable initial imaging technique for evaluating this patient?Your Answer:
Correct Answer: Bedside ultrasound scan
Explanation:An abdominal aortic aneurysm (AAA) is a localized or diffuse enlargement of the abdominal aorta, reaching 1.5 times its normal diameter. The majority of AAAs are found between the diaphragm and the aortic bifurcation. They can be classified as suprarenal, pararenal, or infrarenal, depending on which arteries are involved. About 85% of AAAs are infrarenal, with a normal diameter of 1.7 cm in men and 1.5 cm in women over 50 years old. An infrarenal aorta larger than 3 cm is considered an aneurysm. Risk factors for AAA development include age (most common in those over 65), male gender, smoking, hypertension, history of peripheral vascular disease, positive family history, and connective tissue disorders.
Most AAAs are asymptomatic, but an expanding aneurysm can cause pain or pulsatile sensations in the abdomen. Symptomatic aneurysms have a high risk of rupture. In the UK, elective surgery for AAAs is recommended if the aneurysm is larger than 5.5 cm or larger than 4.5 cm with a growth of more than 0.5 cm in the past six months.
Imaging modalities used to assess AAAs include ultrasound (best for unstable patients), CT scan with contrast (best for uncertain diagnosis), and MRI scan (suitable for stable patients in an elective setting). The most significant complication of AAA is rupture, which can result in sudden death. Only around 50% of patients with a ruptured AAA survive long enough to receive treatment. Common clinical features of a ruptured AAA include acute severe abdominal pain, flank pain (with pararenal AAAs), back pain (with more distal AAAs), unexplained syncope, and a pulsatile abdominal mass. Other less common complications include aortic branch involvement causing ischemia, distal embolization, rhabdomyolysis, and bacterial infection.
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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 65-year-old woman with a history of smoking and a confirmed diagnosis of peripheral vascular disease comes in with symptoms suggestive of acute limb ischemia. After conducting a series of tests, there is suspicion that an embolus is the underlying cause.
Which of the following characteristics is MOST INDICATIVE of an embolus as the underlying cause rather than a thrombus?Your Answer:
Correct Answer: Visible skin changes of the feet
Explanation:Acute limb ischaemia refers to a sudden reduction in blood flow to a limb, which puts the limb at risk of tissue death. This condition is most commonly caused by either a sudden blockage of a previously partially blocked artery by a blood clot or by an embolus that travels from another part of the body. Acute limb ischaemia is considered a medical emergency, and if not promptly treated with surgery to restore blood flow, it can lead to extensive tissue damage within six hours.
The classic signs of acute limb ischaemia are often described using the 6 Ps:
– Pain that is constant and persistent
– Absence of pulses in the ankle
– Pallor, cyanosis, or mottling of the skin
– Loss of power or paralysis in the affected limb
– Paraesthesia or reduced sensation, leading to numbness
– Feeling cold in the affected limbIt is important to be able to distinguish between ischaemia caused by a blood clot and ischaemia caused by an embolus. The following highlights the main differences:
Embolus Thrombus
– Onset is sudden, occurring within seconds to minutes – Onset is gradual, taking hours to days
– Ischaemia is usually severe due to the lack of collateral circulation – Ischaemia is less severe due to the presence of collateral circulation
– There is typically no history of claudication, and pulses may still be present in the other leg – There is often a history of claudication, and pulses may also be absent in the other leg
– Skin changes, such as marbling, may be visible in the feet. This can appear as a fine reticular blanching or mottling in the early stages, progressing to coarse, fixed mottling
– Skin changes are usually absent in cases of thrombus-induced ischaemia. -
This question is part of the following fields:
- Vascular
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