Deep Vein Thrombosis

Question 1

Deep vein thrombosis (DVT) is the formation of a thrombus (blood clot) in a deep vein, which partially or completely obstructs blood flow. What is the incidence of DVT?

1 - 1 cases per 100,000
2 - 10 cases per 100,000
3 - 100 cases per 100,000
4 - 1000 cases per 100,000

Answer 1

3 - 100 cases per 100,000

Equally as likely in men and women

Question 2

Deep vein thrombosis (DVT) is the formation of a thrombus (blood clot) in a deep vein, which partially or completely obstructs blood flow. What age does the incidence of DVT typically peak?

1 - 20-30
2 - 30-40
3 - 50-60
4 - 60-70

Answer 2

4 - 60-70

Question 3

What is an embolism?

1 - blockage of an artery
2 - blood clot blocking a deep vein
3 - atherosclerotic development in a deep vein
4 - part of blood clot that has broken off into blood

Answer 3

4 - part of blood clot that has broken off into blood

• original clot is formed by primary and secondary haemostasis

Question 4

There are a number of risk factors that increase the risk of a DVT. Which of the following are NOT part of Virchows triad?

1 - circulatory stasis
2 - fatty streaks identified
3 - hypercoagulablestate
4 - endothelial injury

Answer 4

2 - fatty streaks identified

Question 5

Virchow’s triad relates to stasis, hypercoagulable state and endothelial damage. All of the following are risk factors for PE that can cause stasis, EXCEPT which one?

1 - immobility
2 - sepsis
3 - obesity
4 - pregnancy
5 - long haul flight
6 - low cardiac output

Answer 5

2 - sepsis

Question 6

Virchow’s triad relates to stasis, hypercoagulable state and endothelial damage. All of the following are risk factors for PE that can cause hypercoagulable state, EXCEPT which one?

1 - malignancy
2 - thrombophilia
3 - obesity
4 - pregnancy
5 - post-partum
6 - OCP
7 - Sepsis

Answer 6

3 - obesity

Question 7

Virchow’s triad relates to stasis, hypercoagulable state and endothelial damage. All of the following are risk factors that can lead to endothelial damage, EXCEPT which one?

1 - previous DVT
2 - thrombophlebitis
3 - lower limb trauma
4 - low cardiac output

Answer 7

4 - low cardiac output

Question 8

The 3 key risk factors for deep vein thrombosis (DVT) are circulator stasis, endothelial injury and a hypercoagulablestate, all part of Virchows triad. There are additional risk factors, but which of the following is NOT a typical risk factor?

1 - pregnancy
2 - increasing age
3 - gender
4 - synthetic oestrogen
5 - cancer
6 - previous DVT
7 - obesity

Answer 8

3 - gender

Question 9

Where are DVTs most common in the body?

1 - thigh
2 - calf
3 - abdomen
4 - upper limbs

Answer 9

2 - calf

Typically occur in popliteal and tibial veins

Question 10

The calf is the most common location for a DVT, but they can also occur in the thigh. Which 2 veins are the most likely location for the DVT to occur in the thigh?

1 - popliteal and tibial veins
2 - popliteal and iliac veins
3 - dorsal pedis and tibial veins
4 - femoral and iliac veins

Answer 10

4 - femoral and iliac veins

Question 11

50% of VTEs occur within 90 days following what?

1 - surgery
2 - antibiotic medication
3 - stop anti-coagulant medication
4 - hospital discharge

Answer 11

4 - hospital discharge

Question 12

What are the 2 most typical features of a patient experiencing a DVT?

1 - pain and dizziness
2 - dizziness and swelling
3 - swelling and pain
4 - pain and confusion

Answer 12

3 - swelling and pain

Pain is throbbing/cramping in nature

Question 13

In DVT, pain and swelling are the 2 most common symptoms, are these typically unilateral or bilateral?

Answer 13

• unilateral

Question 14

In DVT, pain and swelling are the 2 most common symptoms, is the severity of the pain associated with the severity of the DVT?

Answer 14

• n0

Question 15

In DVT, pain and swelling are the 2 most common symptoms. Is swelling isolated to the calves typically, or does it spread through the leg?

Answer 15

• typically isolated to the calf

Pitting oedema may be present

Question 16

Is pallor or rubor more common in patients with DVT?

Answer 16

• rubor

But pallor (pale) can occur

Question 17

In addition to pain and swelling, all of the following may occur in DVT, but which is least likely?

1 - increased temperature
2 - increased calf size
3 - tender calf
4 - ulceration

Answer 17

4 - ulceration

Could occur, but least likely option

Question 18

Does a patient with a DVT always present with symptoms?

Answer 18

• No

Question 19

A 2-level DVT Wells score can be calculated if a DVT is suspected. Using the image below, what 2-level DVT Wells score would suggest a DVT?

1 - >2
2 - >4
3 - >6
4 - >8

Answer 19

1 - >2

<2 suggest DVT is unlikely

Question 20

If a patient has a score of >2 using the 2-level DVT Wells score, a DVT is likely. Which of the following should be used first to try and diagnose the patient?

1 - d-dimer
2 - CTPA
3 - ultrasound leg
4 - whole body MRI

Answer 20

3 - ultrasound leg
Performed in <4h

If negative a d-dimer is performed
If ultrasound of leg and d-dimer are negative, DVT is unlikely

Question 21

If a patient has a score of <2 using the 2-level DVT Wells score, a DVT is unlikely. Which of the following should be used first to try and diagnose the patient?

1 - d-dimer
2 - CTPA
3 - ultrasound leg
4 - whole body MRI

Answer 21

1 - d-dimer

This can be a finger prick or a laboratory test

Question 22

If a patient is waiting for a leg ultrasound or results from a d-dimer, which of the following should be performed?

1 - admit to hospital for monitoring
2 - administer LMWH
3 - reassure and arrange outpatient appointment
4 - administer DOACs

Answer 22

4 - administer DOACs
Apixaban or Rivaroxaban

If ultrasound of leg is negative, but d-dimer is positive, offer another leg ultrasound <6-8 days later

Question 23

Which of the following is NOT included in the differential diagnosis of a DVT due to unilateral calf swelling?

1 - Cellulitis
2 - Baker’s cyst
3 - Peripheral nerve disease
4 - Muscular pain
5 - Lymphoedema
6 - Chronic venous insufficiency
7 - Superficial thrombophlebitis
8 - Trauma

Answer 23

3 - Peripheral nerve disease

Question 24

If a patient has a confirmed pulmonary embolism or a massive thrombolysis, they can be treated with which 2 of the following medications?

1 - Dabigatran
2 - Alteplase
3 - Tenecteplase
4 - Dalteparin

Answer 24

2 - Alteplase
3 - Tenecteplase

• both are Tissue plasminogen activator (tPA)
• streptokinase can also be used

Question 25

Alteplase and Tenecteplase are both issue plasminogen activators (tPA) that are able to break clots in when a patient has a pulmonary embolism. What time frame does this need to be performed in though? 1 - <2.5h 2 - <4.5h 3 - <6.5h 4 - <8.5h

Answer 25

2 - <4.5h

Question 26

Which 2 of the following are 1st line medications for patients with a confirmed or high clinical suspicion of DVT? 1 - Dalteparin 2 - Apixaban 3 - Rivaroxaban 4 - Fondaparinux

Answer 26

2 - Apixaban 3 - Rivaroxaban Both are direct anti-coagulants

Question 27

In a confirmed diagnosis of DVT, how long should Apixaban or Rivaroxaban (DOACs) typically be given for? 1 - 7 days 2 - 4 weeks 3 - 3 months 4 - 12 months

Answer 27

3 - 3 months This is 3-6 months for active cancer Following this time, patients are reviewed for potentially stopping or continuing DOAC

Question 28

Apixaban or Rivaroxaban (DOACs) are 1st line for patients with DVT. If these are unsuitable, which 2 of the following can be offered? 1 - enoxaparin 2 - dalteparin 3 - fondaparinux 4 - clopidogrel

Answer 28

1 - enoxaparin 2 - dalteparin Both are LMWH Following this dabigatran should be given

Question 29

If a patient has active cancer, which 2 of the following should be used to treat confirmed DVT? 1 - Dalteparin 2 - Apixaban 3 - Rivaroxaban 4 - Fondaparinux

Answer 29

2 - Apixaban 3 - Rivaroxaban

Question 30

If a patient has significant renal impairment, which 2 of the following should be used to treat confirmed DVT? 1 - Dalteparin 2 - Apixaban 3 - Enoxaparin 4 - Fondaparinux

Answer 30

1 - Dalteparin 3 - Enoxaparin Both are Low molecular weight heparins

Question 31

What can be offered to patients if they have recurrent DVTs and high risk of PEs? 1 - lifelong DOAC use 2 - lifestyle modification 3 - leg amputation 4 - inferior vena cava (IVC) filters

Answer 31

4 - inferior vena cava (IVC) filters

Question 32

If a patient has a confirmed pulmonary embolism or a massive thrombolysis, they can be treated with which 2 of the following medications? 1 - Dabigatran 2 - Alteplase 3 - Tenecteplase 4 - Dalteparin

Answer 32

2 - Alteplase 3 - Tenecteplase - both are Tissue plasminogen activator (tPA) - streptokinase can also be used

Question 33

Alteplase and Tenecteplase are both issue plasminogen activators (tPA) that are able to break clots in when a patient has a pulmonary embolism. What time frame does this need to be performed in though? 1 - <2.5h 2 - <4.5h 3 - <6.5h 4 - <8.5h

Answer 33

2 - <4.5h

Question 34

d-dimers are a byproduct of blood clots breaking down, and are suggestive of DVT and PE. Do d-dimers have a good sensitivity or specificity?

Answer 34

- sensitivity of 95-98% sensitivity = correctly identify people with a PE or DVT specificity = correctly rule out people with no PE or DV

Question 35

Prior to starting patients on anti-coagulant medication, all of the following must be assessed, but which is least likely to be essential? 1 - liver function 2 - thyroid function 3 - clotting profile 4 - renal function 5 - FBC

Answer 35

2 - thyroid function

Question 36

Prior to starting any anti-coagulation medication, the patient should be screened. Which of the following poses the greatest risk for patients with a DVT, or increases the risk of developing DVT and PEs? 1 - Haemophilia A 2 - Haemophilia B 3 - Von Willebrand disease 4 - Antiphospholipid syndrome

Answer 36

4 - Antiphospholipid syndrome This is a thrombophilia disease that increases the risk of clotting All others are haemophiliac diseases that increase the risk of bleeding

Question 37

How does antiphospholipid syndrome (AS), which is an autoimmune condition lead to a hypercoagulable state and increase the risk of a PE? 1 - antibodies target von Willebrand factor 2 - antibodies target apolipoprotein H 3 - antibodies target lymphocytes 4 - antibodies target endothelium

Answer 37

2 - antibodies target apolipoprotein H - apolipoprotein H normally inhibits agglutination (clumping of RBCs) - in AS agglutination occurs more often and increases the risk of blood clots

Question 38

Prior to starting any anti-coagulation medication, the patient should be screened. Which of the following poses the least risk for patients with a DVT due to an increased risk of developing DVT and PEs? 1 - Prothrombin gene mutation (factor II) 2 - Factor V Leidans disease 3 - Von Willebrand disease 4 - Antiphospholipid syndrome 5 - protein S and C deficiency

Answer 38

3 - Von Willebrand disease Haemophiliac diseases that increase the risk of bleeding All others are thrombophilia disease that increases the risk of clotting

Question 39

3 - Factor V Leiden is the most common inherited form of thrombophilia. How does a mutation in the factor V (5) gene cause hypercoagulability? 1 - increases conversion of prothrombin to thrombin 2 - protein C is unable to modulate factor V (5) activity 3 - protein S is unable to inhibit factor V (5) 4 - prothrombin is not produced

Answer 39

2 - protein C is unable to modulate factor V (5) activity - prothrombin (factor II) is proteolytically cleaved to form thrombin - thrombin converts soluble fibrinogen into insoluble strands of fibrin, as well as catalysing many other coagulation-related reactions.

Question 40

What do proteins S and C produced by the liver bind with in the haemostasis? 1 - initiate the intrinsic cascade 2 - bind with von willebrans factor 3 - bind factor X (10) in common pathway 4 - bind thrombin bound to thrombomodulin

Answer 40

4 - bind thrombin bound to thrombomodulin - thrombin binds to thrombomodulin on undamaged endothelial cells - protein S and C also bind inactivating thrombin - protein C also cleaves factors V (5) and VIII (8) in secondary haemostasis Without proteins S and C, the risk of blood clot formation increases, which is bad in DVT and PE

Question 41

Which 2 of the following are 1st line medications for patients with a confirmed or high clinical suspicion of PE? 1 - Dalteparin 2 - Apixaban 3 - Rivaroxaban 4 - Fondaparinux

Answer 41

2 - Apixaban 3 - Rivaroxaban Both are direct anti-coagulants

Question 42

In a confirmed diagnosis of PE, how long should Apixaban or Rivaroxaban (DOACs) typically be given for? 1 - 7 days 2 - 4 weeks 3 - 3 months 4 - 12 months

Answer 42

3 - 3 months This is 3-6 months for active cancer Following this time, patients are reviewed for potentially stopping or continuing DOAC

Question 43

If a patient has an unprovoked occurrence of DVT (no trauma, bed rest, active cancer, etc), how long should they be placed on a DOAC? 1 - 1 month 2 - 3 months 3 - 6 months 4 - 12 months

Answer 43

2 - 3 months If it is provoked this is 3 months, but will then be reviewed appropriately

Question 44

Apixaban or Rivaroxaban (DOACs) are 1st line for patients with PE. If these are unsuitable, which 2 of the following can be offered? 1 - enoxaparin 2 - dalteparin 3 - fondaparinux 4 - clopidogrel

Answer 44

1 - enoxaparin 2 - dalteparin Both are LMWH Following this dabigatran should be given

Question 45

If a patient has active cancer, which 2 of the following should be used to treat confirmed PE? 1 - Dalteparin 2 - Apixaban 3 - Rivaroxaban 4 - Fondaparinux

Answer 45

2 - Apixaban 3 - Rivaroxaban

Question 46

If a patient has significant renal impairment, which 2 of the following should be used to treat confirmed PE? 1 - Dalteparin 2 - Apixaban 3 - Enoxaparin 4 - Fondaparinux

Answer 46

1 - Dalteparin 3 - Enoxaparin Both are Low molecular weight heparins

Question 47

What can be offered to patients if they have recurrent PEs? 1 - lifelong DOAC use 2 - lifestyle modification 3 - leg amputation 4 - inferior vena cava (IVC) filters

Answer 47

4 - inferior vena cava (IVC) filters

Question 48

If a patient has unprovoked PE or Thrombophilia (blood clotting diseases), typically how long would their anticoagulation be for? 1 - 12 months 2 - <3 months 3 - lifetime 4 - 3-6 months

Answer 48

3 - lifetime

Question 49

In pregnant women who are suspected of having a DVT what is the treatment of choice? 1 - Warfarin 2 - Apixaban 3 - LMWH 4 - Rivaroxaban

Answer 49

3 - LMWH - Warfarin (teratogenic) and DOACs cross the placenta and should not be used - Rivaroxaban and Apixaban are both DOACs - PE is the biggest cause (23-30%) of maternal death in the UK

Question 50

Which 2 of the drugs below have been shown to be safe in women who are breastfeeding? 1 - DOACs 2 - Warfarin 3 - LMWH 4 - Heparin

Answer 50

2 - Warfarin 3 - LMWH - DOACs are new so not data on this yet

Question 51

Which 2 of the following can be offered to a patient with antiphospholipid syndrome experiencing a DVT? 1 - LMWH 2 - warfarin 3 - DOACs 4 - vitamin K antagonist

Answer 51

1 - LMWH 4 - vitamin K antagonist