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deep vein thrombosis

Practice targeted AMC-style multiple-choice questions on deep vein thrombosis.

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A 45-year-old woman presents to the clinic with a 2-week history of a painful, swollen right calf. She recently returned from a long-haul flight from Europe. On examination, her right calf is warm, erythematous, and tender to touch. A D-dimer test is positive. What is the most appropriate next step in management?

A. Order a CT pulmonary angiogram
B. Advise bed rest and elevation of the leg
C. Start anticoagulation therapy immediately
D. Perform a Doppler ultrasound of the right leg
E. Prescribe compression stockings
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 65-year-old patient recently started on warfarin for deep vein thrombosis presents with a painful, expanding skin lesion on their leg. They report the lesion appeared suddenly and has worsened over the past 24 hours. INR is 2.8. Considering the clinical presentation and the appearance of the lesion, what is the most appropriate immediate management step?

A. Apply topical corticosteroids and compression bandaging.
B. Administer broad-spectrum antibiotics and debride the lesion.
C. Obtain a tissue biopsy for histopathology and culture.
D. Stop warfarin and initiate heparin and vitamin K.
E. Increase the warfarin dose and monitor INR closely.
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 78-year-old female on warfarin for chronic atrial fibrillation presents to the emergency department with a 24-hour history of increasing pain and discolouration in her right lower leg. She denies trauma or recent falls. Her INR this morning was 2.5 (target 2.0-3.0). Vital signs are stable: BP 130/80, HR 75, RR 16, Temp 36.8°C. Examination reveals the findings shown in the image. Considering the patient's history, current medication, and the clinical appearance depicted, what is the most appropriate immediate management?

A. Discontinue warfarin, administer Vitamin K, and initiate heparin or LMWH.
B. Arrange urgent surgical debridement of the affected area.
C. Increase the dose of warfarin and monitor INR closely.
D. Initiate broad-spectrum intravenous antibiotics.
E. Perform a Doppler ultrasound of the leg veins.
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A 72-year-old woman presents with sudden onset shortness of breath and pleuritic chest pain. She had knee surgery 10 days ago. She has a history of hypertension. On examination, she is anxious, respiratory rate is 24, heart rate 105, BP 130/80, SpO2 92% on room air. Lungs are clear. ECG shows sinus tachycardia. There is mild swelling in the operated leg. Considering the likely diagnosis, which initial investigation is most appropriate?

A. D-dimer
B. Chest X-ray
C. CT pulmonary angiography
D. Ventilation-perfusion scan
E. Lower limb ultrasound
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A 65-year-old patient with a history of DVT presents with sudden onset dyspnoea and pleuritic chest pain. Examination is unremarkable except for mild tachypnoea. Wells score is 4. Which initial investigation is most appropriate in the diagnostic pathway?

A. D-dimer
B. Lower limb ultrasound
C. V/Q scan
D. CT Pulmonary Angiogram (CTPA)
E. Chest X-ray
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 68-year-old patient on warfarin for a recent DVT presents with a painful, rapidly expanding skin lesion on their leg that started 48 hours ago. Their INR is 2.9. Given the clinical context and the appearance of the lesion, what is the most appropriate immediate management step?

A. Increase the warfarin dose and monitor INR closely.
B. Switch warfarin to a direct oral anticoagulant (DOAC).
C. Obtain a skin biopsy and continue current management.
D. Apply topical antibiotics and continue warfarin.
E. Stop warfarin, administer Vitamin K, and initiate heparin.
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A 62-year-old woman presents to the emergency department with acute onset of chest pain and shortness of breath. She describes the pain as sharp and worse with inspiration. She has a history of deep vein thrombosis and is currently on warfarin. On examination, her blood pressure is 110/70 mmHg, heart rate is 110 bpm, respiratory rate is 24 breaths per minute, and oxygen saturation is 88% on room air. Her jugular venous pressure is elevated, and she has clear lung fields on auscultation. An ECG shows sinus tachycardia with right axis deviation. Which of the following is the most likely diagnosis?

A. Acute myocardial infarction
B. Pulmonary embolism
C. Pericarditis
D. Pneumothorax
E. Aortic dissection
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 75-year-old woman on warfarin for chronic atrial fibrillation presents to the emergency department with a 24-hour history of rapidly worsening pain and discolouration in her right lower leg. She denies trauma. Her INR is 2.8. Physical examination reveals the findings shown in the image. Peripheral pulses are palpable. What is the most appropriate immediate management step?

A. Perform urgent surgical debridement of the affected area
B. Order a Doppler ultrasound of the leg to rule out deep vein thrombosis
C. Stop warfarin and administer Vitamin K and heparin
D. Increase the dose of warfarin to achieve a higher INR
E. Administer broad-spectrum intravenous antibiotics for suspected cellulitis
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