leg pain

Practice targeted AMC-style multiple-choice questions on leg pain.

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 reports the pain is severe and worsening rapidly. 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 therapeutic intervention?

A. Discontinue warfarin and administer Vitamin K.

B. Arrange urgent surgical debridement of the affected area.

C. Initiate broad-spectrum intravenous antibiotics.

D. Increase warfarin dose to achieve an INR of 3.0-4.0.

E. Prescribe oral analgesia and arrange outpatient follow-up.

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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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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 female presents with right leg pain and skin changes after starting warfarin for atrial fibrillation 5 days ago. Her INR is currently 3.5. Examination reveals the findings in the image. What is the MOST appropriate next step in management?

A. Apply compression bandages and elevate the leg

B. Start heparin and continue warfarin at the same dose

C. Reduce warfarin dose and monitor INR daily

D. Stop warfarin and administer vitamin K and fresh frozen plasma

E. Continue warfarin at the same dose and apply topical corticosteroids

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A 31-year-old man presents with gradual onset lateral knee pain that worsens with running and has no history of trauma. The pain is localized above the joint line, and there is no swelling. What is the likely diagnosis?

A. Patellofemoral pain syndrome

B. Quadriceps tendon tear

C. Lateral collateral ligament sprain

D. Iliotibial band syndrome

E. Lateral meniscus tear

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 72-year-old female on warfarin for chronic atrial fibrillation presents with a 2-day history of increasing pain and a developing lesion on her right lower leg. She denies trauma. Her INR is therapeutic at 2.5. Vitals are stable. Considering the clinical presentation and the image provided, what is the most appropriate immediate management?

A. Continue warfarin at a reduced dose and monitor the lesion closely.

B. Switch anticoagulation to a direct oral anticoagulant (DOAC).

C. Discontinue warfarin, administer vitamin K, and initiate heparin.

D. Initiate broad-spectrum antibiotics and arrange surgical debridement.

E. Apply topical corticosteroids and compression bandaging.

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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 reports the pain is severe and worsening rapidly. 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, the underlying mechanism involves a transient deficiency of which of the following?

A. Plasminogen

B. Antithrombin III

C. Protein C

D. Factor VIII

E. Vitamin K

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A patient on warfarin presents with leg pain. INR is 3.5. Given the image, what is the MOST appropriate next step?

A. Stop warfarin and administer vitamin K

B. Elevate the leg and apply warm compresses

C. Continue warfarin at the same dose

D. Apply topical corticosteroids

E. Start heparin and continue warfarin

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A 31-year-old man presents with gradual onset lateral knee pain that worsens with running. There is no history of trauma. The pain is localized above the joint line, and there is no swelling. What is the likely diagnosis?

A. Lateral meniscus tear

B. Iliotibial band syndrome

C. Patellofemoral pain syndrome

D. LCL sprain

E. Quadriceps tendon tear

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A patient on warfarin presents with leg pain. INR is 3.5. Given the image, what is the MOST likely underlying cause?

A. Antithrombin III deficiency

B. Factor V Leiden mutation

C. Protein C deficiency

D. Protein S deficiency

E. Prothrombin G20210A mutation

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A 70-year-old man with a history of atrial fibrillation presents with sudden onset of severe pain, pallor, and coldness in his left leg, extending below the knee. On examination, the leg is cool to touch, pale, and distal pulses (popliteal, dorsalis pedis, posterior tibial) are absent. Sensation is diminished below the ankle, but he can still move his toes slightly. Capillary refill is delayed. Which of the following is the most appropriate initial diagnostic investigation?

A. Arterial duplex ultrasound of the affected limb

B. Venous duplex ultrasound of the affected limb

C. CT angiography of the affected limb

D. Plain film X-ray of the affected limb

E. ECG and cardiac enzymes

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A 72-year-old woman presents with increasing pain in her right leg. She has been on warfarin for atrial fibrillation for the past 5 days. Her INR is currently 3.5. Examination reveals the findings shown. What is the MOST appropriate next step in management?

A. Prescribe oral antibiotics

B. Apply topical corticosteroids

C. Stop warfarin and administer vitamin K

D. Continue warfarin at the same dose

E. Start intravenous heparin

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A patient on warfarin presents with leg pain. INR is 3.5. Given the image, what is the MOST appropriate initial pharmacological intervention?

A. Vitamin K and four-factor prothrombin complex concentrate (PCC)

B. Topical corticosteroids

C. Low molecular weight heparin (LMWH)

D. Intravenous antibiotics

E. Continue warfarin at the same dose

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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 woman on warfarin for chronic atrial fibrillation presents with increasing pain in her right leg over the past 48 hours. Her INR is 4.0. Examination reveals the findings in the image. What is the MOST likely underlying cause?

A. Protein S deficiency

B. Prothrombin gene mutation

C. Antithrombin III deficiency

D. Factor V Leiden mutation

E. Protein C deficiency

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Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T — CC BY 4.0 · Source

A. Increase the dose of warfarin to achieve a higher INR

B. Start intravenous heparin and continue warfarin

C. Apply compression bandages and elevate the leg

D. Continue warfarin at the same dose and apply topical corticosteroids

E. Stop warfarin, administer vitamin K and start a direct oral anticoagulant

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leg pain

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