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Test yourself on some causes of a swollen and painful leg!

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Approach to the patient with a swollen painful leg

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Question 1

Stem 1, question 1 of 3

Shoshanna, a 65 year old female, presents with a swollen and painful right leg to her local urgent treatment centre.

Which of the disease process is being described: "Thrombus formation in a superficial vein and inflammation in the surrounding tissue of that vein"?
A
Cellulitis
B
Erysipelas
C
Deep vein thrombosis
D
Trauma
E
Thrombophlebitis
Question 1 Explanation: 
This is a simple match the definition with the term. Both cellulitis and erysipelas are infections of the skin. Trauma can result in thrombus formation as a secondary result. Deep vein thrombosis is also incorrect as the definition in the question clearly states superficial.
Question 2

Stem 1, question 2 of 4

When asked about past medical history Shoshanna explains she is currently being treated with trastuzumab and had a lumpectomy 2 months ago. Given these risk factors, what is the most likely diagnosis for Shoshanna's swollen and painful leg?
A
Cellulitis
B
Compartment syndrome
C
Deep vein thrombosis
D
Thrombophlebitis
E
Ruptured Popliteal Cyst
Question 2 Explanation: 
This question tests your understanding of risk factors for deep vein thrombosis (DVT). The stem gives a number of risk factors for deep vein thrombosis, but requires application to know this. Trastuzumab is a monoclonal antibody used to treat breast cancers with an over expression of HER-2, remember that active cancer is a major risk factor for DVT. Another risk factor for DVT includes surgery in the last 3 months, Shoshanna had a lumpectomy 2 months ago. Thus, given the information in the stem the most likely diagnosis is a deep vein thrombosis
Question 3

Stem 1, question 3 of 4

Which of the following is not an examination finding in a deep vein thrombosis?
A
Localised pain along deep venous system
B
Prominent superficial veins
C
Phlegmasia cerulea dolens
D
Unilateral calf swelling
E
Symmetrical oedema
Question 3 Explanation: 
Symmetrical oedema is not usually an examination finding in DVT, usually oedema will be asymmetrical. Phlegmasia cerulea dolens can occur when a DVT is large enough to obstruct both venous and arterial inflow which causes ischaemia, the affected limb will appear blue and painful.
Question 4

Stem 1, question 4 of 4

Shoshanna is started on Dabigatran to treat her deep vein thrombosis. What is the mechanism of dabigatran?
A
Inhibition of Vitamin K epoxide reductase
B
Inhibition of factor Xa
C
Inhibition of thrombin and factor Xa by complexing antithrombin III
D
Inhibition of thromboxane synthesis
E
Inhibition of thrombin
Question 4 Explanation: 
Dabigatran is a direct thrombin inhibitor. The other answers are the mechanism of warfarin, apixaban/rivaroxaban/edoxaban, heparin and anti platelet drugs respectively.
Question 5

Stem 2, question 1 of 3

Sven, a 28 year old man, had a motorbike accident and was found to have broken his right tibia and fibula, causing a swollen and painful leg.

The next day Sven complains of increasing pain in his right leg and notices it appears cold and pale. What is the most likely diagnosis?
A
Deep vein thrombosis
B
Haematoma
C
Ruptured popliteal cyst
D
Compartment syndrome
E
Haemarthroses
Question 5 Explanation: 
This is when the 5 P's comes in very helpful. Say it with me now "Pain, pulselessness, paraesthesia, pallor and perishingly cold!". Given the recent history of a fracture with the increasing pain, pallor and (perishingly) cold presentation of the limb, compartment syndrome is the only answer choice that fits.
Question 6

Stem 2, question 2 of 3

What is the definition of compartment syndrome?
A
A pathological condition characterised by elevated interstitial pressure in a closed muscular compartment that results in macrovascular compromise
B
A pathological condition characterised by reduced extracellular pressure in a closed osteofascial compartment that results in microvascular compromise
C
A pathological condition characterised by elevated interstitial pressure in a closed osteofascial compartment that results in macrovascular compromise
D
A pathological condition characterised by elevated interstitial pressure in a closed osteofascial compartment that results in microvascular compromise
E
A pathological condition characterised by reduced interstitial pressure in a closed osteofascial compartment that results in microvascular compromise
Question 6 Explanation: 
This question is a relatively simple direct recall of a definition but all five answer options are worded very similarly to try to stop you from guessing it. Compartment syndrome occurs due to increased interstitial pressure due to intra-compartmental bleeding in a closed space and so results in small vessel compromise.
Question 7

Stem 2, question 3 of 3

Sven undergoes an emergency fasciotomy to relieve the pressure in the anterior compartment of the leg. What is the function of the anterior compartment of the leg?
A
Dorsiflexion of the foot and ankle
B
Eversion of the foot
C
Plantarflexion of the foot
D
Plantarflexion and inversion of the foot
E
Plantarflexion and eversion of the foot.
Question 7 Explanation: 
The function of the anterior compartment of the dorsiflexion of the foot and ankle as this requires a smaller group of muscles than the posterior compartment that provides plantarflexion movement.
Question 8

Stem 3, question 1 of 3

Elsabeth, an 84 year old female, presents to her GP with a hot, swollen and painful left leg that appears to be spreading. It is red and raised, there is a sharp border between the uninvolved skin. Elsabeth also  has lymphoedema, venous insufficiency and healing leg ulcer.

What is the most likely diagnosis?
A
Deep vein thrombosis
B
Thrombophlebitis
C
A ruptured popliteal cyst
D
Cellulitis
E
Erysipelas
Question 8 Explanation: 
Elsabeth is presenting with signs of cellulitis but more speficically erysipelas. This is a distinct form of cellulitis with notable lymphatic involvement and is raised with a sharp demarcation from uninvolved skin. The question stem also highlights risk factors for cellulitis: lymphoma, venous insufficiency and leg ulcers.
Question 9

Stem 3, question 2 of 3

Elsabeth is diagnosed with erysipelas, which of the following is a common causative organism of this?  
A
Streptococcus aureus
B
Haemophilus influenzae
C
Cryptococcus neoformans
D
Beta-haemolytic streptococci
E
Toxoplasma gondii
Question 9 Explanation: 
Beta-haemolytic streptococci and Staphylococcus aureus are the common causative agents of cellulitis and erysipelas. Cryptococcus neoformans is a yeast, toxoplasma gondii is a protozoan. Streptococcus aureus does not exist. Unfortunately with this question it's one that you either know, or you don't!
Question 10

Stem 3, question 3 of 3

Which of the following is most appropriate to start to treat Elsabeth?
A
Ethambutol
B
Aciclovir
C
Maraviroc
D
Fluconazole
E
Flucloxacillin
Question 10 Explanation: 
Flucloxacillin is the first line for cellulitis infections as these provide cover for methicillin resistance Staphylococcus aureus *remember to consult local antibiotic guidelines for your area*. Ethambutol is used to treat tuberculosis, aciclovir and maraviroc are anti-virals for herpes simplex and HIV respectively. Fluconazole is an anti-fungal agent.
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