Question MCCQE

[Puppo]

Please try answer this question: thanks


A 28-year-old woman has had two normal pregnancies and an essentially negative past history otherwise. She had her second child at term by spontaneous uncomplicated vaginal delivery 5 days ago, and was discharged home 2 days ago. At the time of discharge, she noted an aching tender left inguinal area, both when active and when at rest, but she informed no one. Today, the left leg is slightly discolored throughout its length, aches when dependent, and feels "swollen and full". She has no other symptoms. She is breast-feeding.

Physical examination: temperature 37.2°C; blood pressure 124/74 mm Hg; pulse 84/minute, regular; respiratory rate 14/minute; jugular venous pressure -0 cm; heart sounds unremarkable; chest sounds clear; abdominal examination negative; vaginal examination and episiotomy site normal; left calf circomference 34 cm compared with right calf circumference of 31 cm; left calf slightly tender to palpation; superficial veins prominent on left leg; peripheral pulses easily palpable.


Use the information above to answer the following questions about Case 2.Question 1 Question 2 Question 3





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QUESTION 1 (Case 1)

What tests, if any, would you now order?

Select up to three or select #18, No tests, if none is indicated.
(N.B. There are 18 options.)

Arterial blood gases
Blood cultures
Complete blood count
Doppler ultrasound
Ear oximetry
Electrocardiogram
Endometrial culture
Erythrocyte sedimentation rate
Fibrinogen leg scanning
Impedance plethysmography
Pelvic ultrasound examination
Prothrombin time, partial thromboplastin time
Radionuclide phlebography of left leg
Thermography of legs
Vaginal culture
Venogram of left leg
Ventilation-perfusion lung scan
No tests


QUESTION 2 (Case 1)

This patient is admitted to the hospital with her baby. To initiate management over the first 4 to 6 hours, what specific orders would you write?

Select up to five.
(N.B. There are 24 options.)

Acetaminophen (Tylenol)
Acetylsalicylic acid 325 mg p.o. daily
Antibiotics intravenously
Bedrest routine
Chest x-ray
Complete blood count
Daily impedance plethysmography
Daily partial thromboplastin time
Greenfield (umbrella) filter
Heparin intramuscularly
Heparin intravenous bolus
Heparin intraveous infusion by constant drip
Heparin subcutaneously
Initial partial thromboplastin time
Partial thromboplastin time 4 hours after heparin bolus
Platelet count every 3 days
Stop breast-feeding
Streptokinase intravenous infusion
Support hose
Surgery consultation
Traction left leg
Tubal ligation
Vitamin K intramuscularly
Warfarin sodium p.o.


QUESTION 3 (Case 1)

The patient has received appropriate treatment. In preparation for her discharge from hospital, what orders and instructions would you give?

Select as many as are appropriate.
(N.B. There are 11 options.)

Avoidance of acetylsalicylic acid
Effective contraception
Elastic stockings or tensor bandage
Heparin for 3-4 months
Heparin for 5-6 weeks
Regular prothrombin time, partial thromboplastin time
Regular prothrombin time
Stop breast-feeding
Vitamin K
Warfarin for 3-4 months
Warfarin for 5-6 weeks

Answer # 1

Doppler ultrasound
Impedance plethysmography
Venogram of left leg


Answer # 2

Bedrest routine
Strptokinase intravenous infusion
Heparin intravenous bolus
Heparin intravenous infusion by constant drip
Partial thromboplastin time 4 hours after heparin bolus.


Because question is first 4 to 6 hours,
Thrombolytic drugs like streptokinase, originally used for treatment of deep venous thrombosis. On discontinuation of treatment heparin should be administersd.

Answer # 3

Elastic stockings or tensor bandage
Heparin for 5 to 6 weeks
Regular prothrombin time, partial thromboplastin time,
Effective contraception

If I am wrong, please let me know with reasons.

Thanks

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[tussy]

Just to disagree with some of your answers:

1. I disagree with venography of the leg. Although the gold standard to diagnose DVT it is invasive. this patient has a high pretest probability and if the doppler studies are positive that is the only test needed. If it is negative then you could move on to other tests.

2. You would never give a thrombolytic to a patient that is post partum. Actually I would never use it for treatment of a DVT - just too risky. Also, bed rest used to be used, but there is no evidence that it prevents a PE and it puts the pt. at risk of a clot in the other leg, so I wouldn't restrict activity.

My management would be:
Heparin bolus and then drip (alternately you could use LWMheparin s.c.)
Partial thromboplastin time 4 hours after heparin bolus (so that the rate can be adjusted)
Platelet count every 3 days (to make sure patient isn't getting H.I.T.)
Support hose (will help with edema in the leg)
Start warfarin 2 days after initiation of heparin (some people say that it can be started the same day). Don't think she can breastfeed on it, so alternatively you could send her home on LMW heparin SC for 3-6 months.

 

[hot4teacha]

Puppo,

Was this an actual exam question? What is the source you used for this question. I also agree with using doppler instead of venogram and heparin for pelvic thrombophlebitis.

~Jeff

PS - Basically, wondering if there is a bank of questions besides those provided by mcc.ca. Thanks guys.