MEQ

Case 1
James Cheng, a 58 year old business man, presents to the Emergency Dept
the day after disembarking from a long haul international flight from
Europe. He has unilateral calf swelling.
Question 1.1
Draw a simple diagram of the major deep veins of the lower limb in relation to an
outline of the limb. Indicate in your diagram the points where the two major
superficial saphenous veins join the deep system.

Question 1.2
List 2 commonly used and widely available imaging investigations to determine the
cause of this patients lower limb swelling. Describe at least one advantage and one
disadvantage for each investigation.

The next day Mr Cheng becomes suddenly short of breath with a cough and
sharp chest pain.
Question 1.3
Give 4 clinical signs (not symptoms) which would support a diagnosis of pulmonary
embolism and in a few words only describe the physiological changes producing
them.

Question 1.4
Describe the physiological sequence of events which would lead to hypoxaemia in
this man immediately after pulmonary embolism.

It emerges that Mr Cheng has a brother who also had thrombosis in his
forties.

Question 1.5
Name 2 known genetic prothrombotic disorders and describe how they predispose to
thrombosis.

Case 2

Question 2.1

Question 2.2

Question 2.3

Case 3

Question 3.1

Question 3.2

Question 3.3

Question 3.4

Case 4

Question 4.1

Question 4.2

Question 4.3

Question 4.4

Question 4.5

Case 5
Ann Voight is a 48 year-old woman who complains of increasing pain and
swelling of her left leg over the previous 2 days following a long overseas
flight. She had painful varicose veins following a pregnancy 10 years ago.
Her other medical history is unremarkable apart from mild elevation in
serum cholesterol. She is slightly overweight, smokes 5-10 cigarettes per
day and is on no regular medications.
On clinical examination she has unilateral swelling of the whole left leg.
Venous duplex ultrasound scan of the leg shows an iliofemoral venous
thrombosis.
Question 5.1
Occasionally duplex venous ultrasound may not be diagnostic, due to obesity or
other reasons. Name one additional investigation available to determine the cause of
this patients lower limb swelling.

Mrs Voight is admitted to hospital and the following day complains of

shortness of breath and coughs up some blood-streaked sputum.
Question 5.2
What is the most likely cause of her shortness of breath and haemoptysis?

Investigations show that she has had a pulmonary embolism.

Question 5.3
List at least 2 consequences (pathological and/or physiological) of pulmonary
embolism.

Question 5.4
a) Name 2 drugs which are commonly used in the management of pulmonary
embolism (PE).
b) How are they monitored?

She is initially given heparin intravenously. After 2 days, you start Mrs
Voight on treatment with warfarin.
Question 5.5
Describe the mechanism by which warfarin exerts its anticoagulant effect.

Question 5.6
Describe briefly 1 mechanism whereby potentially dangerous drug interactions with
warfarin could occur. Give an example of a drug which could be involved in this
interaction.

Case 6
Silvia Bianchi is a 28 year old woman with a past history of rheumatic fever,
who is pregnant for the first time. During a routine review at 12 weeks
gestation, she reports that she has had difficulty climbing stairs for the last
week and gets winded with minimal exertion. She notes some mild
discomfort under the left breast when taking a deep breath or coughing. On
examination her chest is clear to auscultation.
Question 6.1
List at least 3 possible causes of dyspnoea in a pregnant woman.

After further questioning by her GP, she admits to tightness behind the
left knee for the last 2 weeks. Her left calf and thigh are marginally larger in
diameter than the right, with no pitting oedema.
Silvia is found to have an extensive left proximal deep vein thrombosis in
the left leg and two mismatched perfusion defects in the left lung (a high
probability scan for pulmonary embolism).
Question 6.2
Regarding the venous system of the lower limb:
a) Name the two major superficial veins of the lower limb and their usual points of
drainage into the deep system.
b) Describe at least one structure which acts to facilitate venous return in the deep
venous system and the mechanism by which it acts.

10

Question 6.3
Describe the changes in pregnancy which increase the risk of thrombosis.

Question 6.4
a) Which proven therapies for venous thrombosis are safe during pregnancy?
b) Which commonly-used anticoagulant is considered unsafe in pregnancy? What
problems are associated with this anticoagulant (nominate at least one problem)?

11

SBA
Case 1

Question 1.1

Question 1.2

Question 1.3

12

13

Case 2

Question 2.1

Question 2.2

14

Question 2.3

Question 2.4

Question 2.5

15

Case 3
Hayley Unwin is a 23 year old woman who presents 3 weeks post-partum
after her first pregnancy with pain and swelling of her left lower leg. A
proximal deep vein thrombosis extending to the ileofemoral vein is
confirmed by Doppler ultra-sound. The patient informs you that her elder
sister has a history of recurrent deep vein thrombosis in pregnancy
requiring heparin prophylaxis.
Question 3.1
With regard to venous thromboembolism (VTE) in pregnancy and the puerperium,
which one of the following statements is correct?
A) The lowest risk of pulmonary embolism from a deep vein thrombosis is in the
puerperium
B) Elevated D-Dimers are diagnostic for the presence of thrombosis
C) Pulmonary embolism occurs in a significant proportion of untreated deep vein
thromboses
D) Breast feeding after delivery is contraindicated as low-molecular weight heparin
and Coumarin are secreted in breast milk

Question 3.2
Which one of the following is correct regarding Factor V Leiden mutation?
A) It is not a risk factor for VTE in pregnancy
B) Co-inheritance with Prothrombin G20210A mutation confers a synergistically
higher risk of VTE during pregnancy
C) Its detection in Ms Unwin would alter management in future pregnancies
D) Its detection in Ms Unwin would not increase her risk of DVT after her pregnancy

Question 3.3
Which of the following statements regarding the veins of the lower limb is correct?
A) Superficial veins like the great saphenous vein are an essential component of
lower limb venous return
B) Only superficial veins have valves
C) Superficial veins travel with arteries with corresponding names
D) Most of the blood in the superficial veins drains into the system of deep veins

Question 3.4
The oral anticoagulant, warfarin, produces its effects by:
A) Inhibiting the synthesis of clotting factors II and VII
B) Activating thrombolysis
C) Inhibiting platelet aggregation

16

D) Activating anti-thrombin III

Question 3.5
Which one of the following is NOT a platelet function contributing to normal
haemostasis?
A) Adhesion to collagen following endothelial damage
B) Release of ADP, recruiting other platelets
C) Release of phospholipid for the intrinsic pathway
D) Release of prostacyclin, promoting plug formation

17