Deep Vein Thrombosis Flashcards
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
3 - 100 cases per 100,000
Equally as likely in men and women
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
4 - 60-70
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
4 - part of blood clot that has broken off into blood
- original clot is formed by primary and secondary haemostasis
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
2 - fatty streaks identified
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
2 - sepsis
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
3 - obesity
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
4 - low cardiac output
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
3 - gender
Where are DVTs most common in the body?
1 - thigh
2 - calf
3 - abdomen
4 - upper limbs
2 - calf
Typically occur in popliteal and tibial veins
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
4 - femoral and iliac veins
50% of VTEs occur within 90 days following what?
1 - surgery
2 - antibiotic medication
3 - stop anti-coagulant medication
4 - hospital discharge
4 - hospital discharge
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
3 - swelling and pain
Pain is throbbing/cramping in nature
In DVT, pain and swelling are the 2 most common symptoms, are these typically unilateral or bilateral?
- unilateral
In DVT, pain and swelling are the 2 most common symptoms, is the severity of the pain associated with the severity of the DVT?
- n0
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?
- typically isolated to the calf
Pitting oedema may be present
Is pallor or rubor more common in patients with DVT?
- rubor
But pallor (pale) can occur
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
4 - ulceration
Could occur, but least likely option
Does a patient with a DVT always present with symptoms?
- No
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
1 - >2
<2 suggest DVT is unlikely
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
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
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
1 - d-dimer
This can be a finger prick or a laboratory test
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
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
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
3 - Peripheral nerve disease
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
2 - Alteplase
3 - Tenecteplase
- both are Tissue plasminogen activator (tPA)
- streptokinase can also be used
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
2 - <4.5h
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
2 - Apixaban
3 - Rivaroxaban
Both are direct anti-coagulants
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
3 - 3 months
This is 3-6 months for active cancer
Following this time, patients are reviewed for potentially stopping or continuing DOAC
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
1 - enoxaparin
2 - dalteparin
Both are LMWH
Following this dabigatran should be given
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
2 - Apixaban
3 - Rivaroxaban
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
1 - Dalteparin
3 - Enoxaparin
Both are Low molecular weight heparins
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
4 - inferior vena cava (IVC) filters
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
2 - Alteplase
3 - Tenecteplase
- both are Tissue plasminogen activator (tPA)
- streptokinase can also be used
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
2 - <4.5h
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?
- sensitivity of 95-98%
sensitivity = correctly identify people with a PE or DVT
specificity = correctly rule out people with no PE or DV
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
2 - thyroid function
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
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
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
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
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
3 - Von Willebrand disease
Haemophiliac diseases that increase the risk of bleeding
All others are thrombophilia disease that increases the risk of clotting
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
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.
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
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
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
2 - Apixaban
3 - Rivaroxaban
Both are direct anti-coagulants
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
3 - 3 months
This is 3-6 months for active cancer
Following this time, patients are reviewed for potentially stopping or continuing DOAC
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
2 - 3 months
If it is provoked this is 3 months, but will then be reviewed appropriately
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
1 - enoxaparin
2 - dalteparin
Both are LMWH
Following this dabigatran should be given
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
2 - Apixaban
3 - Rivaroxaban
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
1 - Dalteparin
3 - Enoxaparin
Both are Low molecular weight heparins
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
4 - inferior vena cava (IVC) filters
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
3 - lifetime
In pregnant women who are suspected of having a DVT what is the treatment of choice?
1 - Warfarin
2 - Apixaban
3 - LMWH
4 - Rivaroxaban
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
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
2 - Warfarin
3 - LMWH
- DOACs are new so not data on this yet
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
1 - LMWH
4 - vitamin K antagonist
