🤔 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 8

Stem 4 of 6

The Well’s score is a 6. What is the next best 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 is the definitive step in a ?PE patient who has tested Well’s score of “PE likely”. A D-dimer is not useful in this patient as a negative finding is insufficiently specific or sensitive to rule-out definitive imaging. Despite the risk of pregnancy, a CTPA is still definitive first line testing in a likely PE patient. A VQ scan causes very slightly more radiation to the fetus than CTPA, but CTPA carries more radiation to maternal breast tissue. A VQ scan could be performed, at Radiologist and medical team discretion, but availability is dwindling and it is not considered first line (BMJ Best Practice, 2020).
Question 9

Stem 5 of 6

Before the results of the imaging study are returned, the patient is started by senior medical team on medication. Which is the most likely 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: 
It is routine practice (BMJ, 2020) to start the patient on unfractionated heparin in the likely PE patient before CTPA studies return. Antifibrinolytics include TXA, complexing antithrombin III is the role of heparin, direct thrombin inhibitors are the decreasingly used dabigatran, factor 10, 9, 7 and 2 inhibitors are coumarin (Warfarin) and factor ten inhibitors directly include DOACs such as apixaban and rivaroxaban.
Question 10
The patients 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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