🤔 MEDIUM

Here is the first of two questions on oedema.  A bit like that scene in the Harry Potter book where the muggle expands and floats off (hence the balloons).  There are two to choose from and here is one of them … good luck!

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oedema

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Question 1
A 12 year old “popped a pimple” just inferior to the left nares. It is now red and inflamed, hot to the touch with a diffuse, hard-to-spot border about the size of a 2 pence piece.

What is the best management of this patient?
A
Analgesia
B
Intravenous antibiotics
C
Oral antibiotics
D
Topical antibiotics
E
Watchful waiting
Question 1 Explanation: 
Erysipelas or cellulitis of the triangle of danger to the face risks cavernous sinus thrombosis and meningoencephalitis in the worst case. The patient should be considered serious and started on co-amoxiclav and seek expert microbiological advice. Cochrane review (2020) shows little high-quality evidence for route of administration in cellulitis, so PO is standard with no further symptoms. This is usually given for ~7/7.
Question 2

Stem 1 of 2

A 24 year old female presents after a traumatic fall playing rugby 30 minutes earlier. Her left leg is notably swollen, painful and cold to the touch. She describes pins and needles, cannot weight bear and her leg appears to be in an unnatural position. Her distal ankle pulses are faint and thready.

State all of the following pulses that would be useful to ascertain in this patient
A
Anterior tibial artery
B
Dorsalis pedis
C
Femoral artery
D
Popliteal artery
E
Posterior tibial artery
Question 3

Stem 2 of 2

A provisional diagnosis of compartment syndrome is made and the vascular team paged. The patient is able to voluntarily contract the anterior, lateral and posterior leg compartments with pain. What is the immediate management of this patient?
A
Below-knee amputation
B
Langer line fasciotomy
C
Morphine sulphate I.V.
D
Surgical debridement
E
Ultrasound-guided centesis
Question 3 Explanation: 
The first-line management in a viable limb (notably muscle group power persisting usually in the first 6-8hr) is urgent surgical review with morphine sulphate IV, adequate maintaining fluids and fasciotomy.
Question 4
A patient presents with swelling of the left lower limb from the groin distally. He is struggling to walk and is deeply concerned. Medical history is notable for prostate CA, for which he received surgical resection and pelvic radiotherapy last month.

Which is the best-matched differential?
A
Localised trauma of the pelvis
B
Lymphoedema reaction
C
Osteomyelitis of the pelvis and femur
D
Recurrence of prostate cancer
E
Retention of urine to fascia lata of the thigh
Question 5

Stem 1 of 6

A 35 year old primigravida patient presents after returning from holiday abroad. She is acutely breathless and has been coughing. The patient is haemodynamically stable.

What is the most likely finding from sputum analysis?
A
Blood-streaked sputum
B
Clear sputum
C
Green sputum
D
Pink, frothy sputum
E
Yellow sputum
Question 5 Explanation: 
Haemoptysis is a rare, non-specific finding often overstated in haemoptysis. It is far likely the patient would exhibit a dry cough, or no cough, with the best matched differential.
Question 6

Stem 2 of 6

Given the best provisional differential, which is the least specific finding below?
A
Acute dyspnoea
B
Cough
C
Distended leg vein
D
Pleuritic chest pain
E
Temperature >37.8ºC
Question 6 Explanation: 
Fever is a more uncommon finding of PE than the other sx listed above.
Question 7

Stem 3 of 6

After history, what is the next best step in this patient?
A
Perform a CTPA
B
Perform a CXR
C
Perform a D-Dimer test
D
Perform a VQ scan
E
Perform a Well’s score
Question 7 Explanation: 
In a non-pregnant patient you would calculate a Well's score and use that to determine whether you should first get a D-dimer or move straight to imaging. However, this patient is pregnant so probability assessments and D-dimers are not indicated. You would move straight to a CXR to rule out other possible causes. An ECG should also be performed. See RCOG's 2015 Green-top guideline 37b (pp 7-11).
Question 8

Stem 4 of 6

The investigations discussed above are inconclusive. What is the next step?
A
Discharge for watchful waiting
B
Perform a CTPA
C
Perform a D-Dimer test
D
Perform an emergent TOE
E
Pulmonary Embolism Rule Out Criteria Screen
Question 8 Explanation: 
A CTPA or a VQ scan can be used to rule a PE in or out. RCOG guidelines (pp 7-11) say both are acceptable and, where possible, women should be involved in the decision, although local guidelines and availability will vary. Note that if the CXR was abnormal, a CTPA is preferred.

A VQ scan causes very slightly more radiation to the fetus than CTPA, but CTPA carries more radiation to maternal breast tissue. CTPA is cautioned against in younger patients, those who've had previous CT scans, and those with a personal or family history of breast cancer.

As discussed in the previous explanation, D-dimers are not indicated in pregnancy; patients are in a hypercoagulative state so results will be misleading.

Question 9

Stem 5 of 6

There is a delay in arranging the scan and the patient is started on medication by the medical team. Which type of drug is the most likely to be administered?
A
Anti-fibrinolytic
B
Complexing antithrombin-III
C
Direct thrombin inhibitor
D
Factor ten, nine, seven and two inhibitor
E
Factor ten inhibitor
Question 9 Explanation: 
While DOACs may be indicated in a non-pregnant patient, in pregnancy the patient should be started on LMWH (see RCOG 2015 guidelines (pp 7-11)). LMWH binds to antithrombin-III, activating it, which in turn inhibits factor X.

Antifibrinolytics include TXA. Direct thrombin inhibitors are the decreasingly used dabigatran, factors II, VII, IX and X are the Vit K dependent clotting factors and are thus reduced by warfarin. Factor X inhibitors directly include DOACs such as apixaban and rivaroxaban.

Question 10
The patient's SBP drops to 85mmHg, she is tachycardic and tachypnoeic. Her spO2 has fallen to 87% on simple face mask O2 therapy. She is started on 15L high flow oxygen via non-rebreather. What other steps could now be acutely considered for this patient?
A
Alteplase
B
Inferior vena caval filters
C
IV dobutamine
D
IV noradrenaline
E
Low molecular weight heparin
Question 10 Explanation: 
The haemodynamically unstable patient as a first line requires high flow oxygen, anticoagulation, thrombolysis, cautious non-overloading fluid resuscitation and consideration of inotrope therapy.
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