Thrombotic Disorders — MCQs
An Infant with severe dehydration secondary to diarrhea suddenly presents with proteins and blood in urine. The most probable diagnosis is _______
A 36-week pregnant woman with mitral stenosis has been on warfarin for anticoagulation. What is the most appropriate next step in her management?
Which of the following does not cause deep venous thrombosis (DVT)?
A newborn presents with petechiae, skin lesions, hematuria, and a platelet count of 22,000/L. This is most likely caused by:
Deep vein thrombosis most commonly occurs at which site?
Which congenital heart disease is associated with the defect shown?
The risk of recurrence of congenital heart disease for subsequent pregnancies in families with one affected child is:
An 8-year-old child presents with hematuria 5 days after a throat infection. What is the most likely diagnosis?
A 5 year old child presented with periorbital swelling and oliguria. Nephrotic syndrome is suspected. Which of the following is the commonest type of nephrotic syndrome in this child?
A 1-month-old baby brought by the mother complaining of a mass on back associated with wetness and inability of both legs to move ever since birth. Possible diagnosis: (Recent NEET Pattern 2016-17)
Thrombotic Disorders Indian Medical PG Practice Questions and MCQs
Question 1: An Infant with severe dehydration secondary to diarrhea suddenly presents with proteins and blood in urine. The most probable diagnosis is _______
- A. Pyelonephritis
- B. Renal vein thrombosis (Correct Answer)
- C. Nephrotic syndrome
- D. Acute glomerulonephritis
Explanation: ***Renal vein thrombosis*** - Severe dehydration in infants can lead to **hypercoagulability** and **venous stasis**, predisposing to renal vein thrombosis. - Presence of **proteinuria** and **hematuria** along with sudden deterioration in a severely dehydrated infant is highly suggestive of acute renal injury due to thrombosis. *Pyelonephritis* - While pyelonephritis can cause **proteinuria** and **hematuria**, it typically presents with fever, flank pain, and signs of infection, which are not mentioned as primary concerns. - The sudden onset in the context of severe dehydration makes acute thrombotic event more likely than primary infection. *Nephrotic syndrome* - Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, edema, and hyperlipidemia, but it does not primarily present with acute, gross hematuria. - It is typically a more insidious onset condition and not triggered acutely by dehydration in this manner. *Acute glomerulonephritis* - Acute glomerulonephritis typically involves inflammatory damage to the glomeruli, leading to hematuria, proteinuria, hypertension, and edema. - While it can cause hematuria and proteinuria, it's less directly linked to sudden onset following severe dehydration in infants compared to a thrombotic event.
Question 2: A 36-week pregnant woman with mitral stenosis has been on warfarin for anticoagulation. What is the most appropriate next step in her management?
- A. Continue Warfarin
- B. Aspirin + Heparin
- C. Shift to Low Molecular Weight (LMW) Heparin (Correct Answer)
- D. Switch to Aspirin
Explanation: ***Shift to Low Molecular Weight (LMW) Heparin*** - At 36 weeks gestation, **warfarin is contraindicated** due to its teratogenic effects and increased risk of **fetal bleeding**, especially during labor and delivery. - **LMW heparin** does not cross the placenta, making it a safer option for both mother and fetus in late pregnancy, and it can be discontinued prior to delivery to reduce bleeding risk. *Continue Warfarin* - Continuing warfarin at 36 weeks could lead to **fetal warfarin syndrome** if exposure occurred earlier, and significantly increases the risk of **fetal intracranial hemorrhage** during labor. - Warfarin has a narrow therapeutic window and requires close monitoring, making it less practical for ensuring fetal safety during an unpredictable labor and delivery. *Aspirin + Heparin* - While heparin is appropriate, the addition of **aspirin** to anticoagulation in a patient already on warfarin for mitral stenosis does not provide significant additional benefit and could **increase bleeding risk**. - **Unfractionated heparin (UFH)** is generally preferred over LMWH for patients requiring rapid reversal or close monitoring around delivery. *Switch to Aspirin* - **Aspirin alone is insufficient** for anticoagulation in a pregnant woman with mitral stenosis who has been on warfarin, as it does not adequately prevent thromboembolic events. - Mitral stenosis carries a high risk of **thrombus formation** and systemic embolization, necessitating more potent anticoagulation than aspirin provides.
Question 3: Which of the following does not cause deep venous thrombosis (DVT)?
- A. Lower limb trauma
- B. Subungual hematoma (Correct Answer)
- C. Hip & pelvic surgeries
- D. Cushing's syndrome
Explanation: ***Subungual hematoma*** - A **subungual hematoma** is a collection of blood under the fingernail or toenail, usually caused by trauma. - It is a localized injury that **does not affect systemic coagulation** or venous blood flow, thus not increasing DVT risk. *Lower limb trauma* - **Trauma to the lower limb**, especially involving fractures or significant soft tissue damage, can lead to **venous stasis** due to immobility and direct vessel injury [1]. - This immobility and vessel damage activate the **coagulation cascade**, significantly increasing the risk of DVT [1]. *Cushing's syndrome* - **Cushing's syndrome** is characterized by **hypercortisolism**, which leads to a **hypercoagulable state**. - **Elevated cortisol levels** increase circulating procoagulant factors and decrease fibrinolytic activity, predisposing patients to DVT. *Hip & pelvic surgeries* - **Major surgeries**, particularly those involving the **hip and pelvis**, frequently cause **endothelial injury**, blood stasis, and activate the coagulation system [1]. - Patients undergoing these procedures are at a **very high risk for DVT** due to prolonged immobility and surgical trauma [1].
Question 4: A newborn presents with petechiae, skin lesions, hematuria, and a platelet count of 22,000/L. This is most likely caused by:
- A. Congenital rubella infection
- B. Both CMV and rubella infection
- C. Congenital CMV infection (Correct Answer)
- D. Premature infants
Explanation: ***Congenital CMV infection*** - **Congenital CMV** is the **most common congenital infection** (0.5-2% of live births) and presents with the classic triad of **petechiae**, **thrombocytopenia**, and **blueberry muffin rash** (dermal erythropoiesis). - The severe **thrombocytopenia** (platelet count 22,000/μL) with **petechiae**, **skin lesions**, and **hematuria** is characteristic of symptomatic congenital CMV. - Other features include **hepatosplenomegaly**, **microcephaly**, **periventricular calcifications**, **chorioretinitis**, and **sensorineural hearing loss**. - CMV is the leading **non-genetic cause of sensorineural hearing loss** and a major cause of neurodevelopmental disability. *Congenital rubella infection* - While **congenital rubella syndrome** can also cause **petechiae**, **thrombocytopenia**, and **blueberry muffin rash**, it is now **rare** due to widespread **rubella vaccination**. - Classic rubella triad: **Cardiac defects** (PDA, pulmonary stenosis), **cataracts**, and **sensorineural hearing loss**. - The question presentation is compatible with rubella, but **CMV is epidemiologically more likely** in the current era. *Both CMV and rubella infection* - While both infections can cause this presentation, this is **not an appropriate answer choice** for a single best answer question format. - In clinical practice and exam contexts, when presented with this constellation of findings, **congenital CMV** is the most likely diagnosis given its higher prevalence. - Questions should test the ability to identify the **most likely single diagnosis**, not list multiple possibilities. *Premature infants* - Prematurity alone does not cause the **specific constellation** of petechiae, distinct skin lesions (blueberry muffin spots), hematuria, and severe thrombocytopenia. - While premature infants may have **immature coagulation** and **fragile capillaries**, this presentation is **pathognomonic for congenital infection**, particularly TORCH infections. - The **blueberry muffin rash** specifically indicates **dermal erythropoiesis**, which is a feature of intrauterine infections, not prematurity.
Question 5: Deep vein thrombosis most commonly occurs at which site?
- A. Femoral vein (Correct Answer)
- B. Subclavian vein
- C. External jugular vein
- D. Internal jugular vein
Explanation: ***Femoral vein*** - The **femoral vein**, along with the **popliteal** and **iliac veins**, are the most common sites for **deep vein thrombosis (DVT)** in the lower extremities [1]. - Due to their size and the dynamics of blood flow in these regions, they are prone to clot formation, especially in the presence of **Virchow's triad**. *Subclavian vein* - While DVT can occur in the subclavian vein (an **upper extremity DVT**), it is less common than in the lower extremities [1]. - Upper extremity DVTs are often associated with **central venous catheters** or **thoracic outlet syndrome**. *External jugular vein* - **External jugular vein thrombosis** is rare and usually associated with local trauma, infection, or central line placement, not typically primary DVT [1]. - It is a superficial vein and not considered a common site for typical deep vein thrombosis. *Internal jugular vein* - **Internal jugular vein thrombosis** is also uncommon as a primary DVT and often secondary to neck infections, malignancies, or indwelling catheters [1]. - Like the subclavian vein, it's considered an upper extremity DVT site, but less frequent than lower extremity sites.
Question 6: Which congenital heart disease is associated with the defect shown?
- A. Tricuspid atresia
- B. Double outlet right ventricle
- C. Aortic regurgitation
- D. Endocardial cushion defect (Correct Answer)
Explanation: ***Endocardial cushion defect*** - The image displays a **single palmar crease** (also known as a **simian crease**), which is a common dermatological feature observed in patients with **Down syndrome (Trisomy 21)**. - Approximately 40-50% of individuals with Down syndrome have **congenital heart disease**, with **endocardial cushion defects** (also known as atrioventricular septal defects) being the most common type. *Tricuspid atresia* - This is a complex cyanotic congenital heart defect characterized by the **absence of the tricuspid valve**, preventing blood flow from the right atrium to the right ventricle. - While it is a congenital heart defect, it is **not specifically associated with a single palmar crease** or Down syndrome as commonly as endocardial cushion defects. *Double outlet right ventricle* - This is a rare cyanotic congenital heart defect where **both the aorta and pulmonary artery arise primarily from the right ventricle**. - It is not typically associated with specific dermatological signs like a single palmar crease or specifically linked to Down syndrome. *Aortic regurgitation* - This is a condition where the **aortic valve does not close tightly**, causing blood to leak back into the left ventricle during diastole. - Aortic regurgitation is an **acquired or congenital valve defect**, but it is not directly linked to genetic syndromes like Down syndrome or the presence of a single palmar crease.
Question 7: The risk of recurrence of congenital heart disease for subsequent pregnancies in families with one affected child is:
- A. 10-12%
- B. 1%
- C. 2-6% (Correct Answer)
- D. 0.80%
Explanation: ***2-6%*** - The recurrence risk for **congenital heart disease (CHD)** in subsequent pregnancies after one affected child is generally cited as **2-6%**, reflecting an increased familial predisposition. - This risk is higher than the general population risk but still relatively low, primarily due to the complex, multifactorial etiology of most CHDs. *10-12%* - A **10-12% recurrence risk** is generally too high for most common congenital heart defects, which are typically multifactorial. - Such a high risk might be seen in specific **syndromic forms** of CHD (e.g., genetic aneuploidies or single gene defects), but not for isolated CHD in general. *1%* - A **1% recurrence risk** is comparable to the general population incidence of congenital heart disease (approximately 0.8-1%). - This value does not adequately reflect the established **increased risk for siblings** of an affected child, which is known to be higher than the background population risk. *0.80%* - **0.80%** represents the approximate **general population incidence** of congenital heart disease in live births without a prior affected sibling. - This figure does not account for the **increased familial risk** that exists once one child in a family is already affected.
Question 8: An 8-year-old child presents with hematuria 5 days after a throat infection. What is the most likely diagnosis?
- A. Post streptococcal nephropathy (Correct Answer)
- B. Nephrotic syndrome
- C. IgA nephropathy
- D. Alport syndrome
Explanation: ***Post streptococcal glomerulonephritis*** - **Post-streptococcal glomerulonephritis (PSGN)** is the most common cause of acute glomerulonephritis in children aged 5-12 years. - Typically presents with **hematuria 1-2 weeks (7-21 days, average 10 days)** after a streptococcal pharyngitis or 3-6 weeks after skin infection. - **5 days post-throat infection** falls within the early range of the latent period for PSGN. - Clinical features include **gross hematuria ("cola-colored" urine)**, **edema**, **hypertension**, and **low C3 complement levels**. - The time interval and clinical presentation in this 8-year-old child are classic for PSGN. *IgA nephropathy* - IgA nephropathy presents with **synpharyngitic hematuria** - occurring **within 1-2 days** (24-48 hours) of an upper respiratory infection. - The **5-day interval** in this case is too long for typical IgA nephropathy presentation. - More common in older children and young adults, and shows normal C3 complement levels. *Nephrotic syndrome* - **Nephrotic syndrome** is characterized by **massive proteinuria (>40 mg/m²/hr)**, **hypoalbuminemia (<2.5 g/dL)**, **edema**, and **hyperlipidemia**. - The primary presentation is **edema and frothy urine**, not acute gross hematuria following infection. - Hematuria, if present, is typically microscopic rather than macroscopic. *Alport syndrome* - **Alport syndrome** is a hereditary nephritis caused by **collagen type IV defects**. - Presents with **persistent microscopic hematuria** from early childhood, often with **sensorineural hearing loss** and **ocular abnormalities**. - Does not have the acute temporal relationship with throat infection seen in this case.
Question 9: A 5 year old child presented with periorbital swelling and oliguria. Nephrotic syndrome is suspected. Which of the following is the commonest type of nephrotic syndrome in this child?
- A. Focal segmental glomerulosclerosis (FSGS)
- B. Chronic glomerulonephritis
- C. Minimal change disease (Correct Answer)
- D. Congenital nephrotic syndrome
Explanation: ***Minimal change disease*** - This is the **most common cause of nephrotic syndrome** in children, accounting for approximately 80% of cases. - It presents with sudden onset of **periorbital edema**, **generalized edema**, and often **oliguria** due to severe proteinuria. *Focal segmental glomerulosclerosis (FSGS)* - While a significant cause of nephrotic syndrome in children, it ranks second to minimal change disease in frequency. - FSGS tends to have a **poorer response to steroids** and a higher risk of progression to **end-stage renal disease**. *Chronic glomerulonephritis* - This is a broad category of glomerular diseases, typically having a **more insidious onset** and often associated with hematuria and hypertension, which are not mentioned in this acute presentation. - It usually presents with features that suggest **nephritic syndrome** (e.g., hematuria, hypertension) rather than primarily nephrotic syndrome features. *Congenital nephrotic syndrome* - This is a **rare genetic condition** that presents within the first 3 months of life, which is much earlier than the 5-year-old age of this patient. - It is characterized by severe proteinuria from birth and is typically part of inherited syndromes.
Question 10: A 1-month-old baby brought by the mother complaining of a mass on back associated with wetness and inability of both legs to move ever since birth. Possible diagnosis: (Recent NEET Pattern 2016-17)
- A. Pilonidal cyst
- B. Spina bifida
- C. Meningomyelocele (Correct Answer)
- D. Sacrococcygeal teratoma
Explanation: ***Meningomyelocele*** - This is a severe form of spina bifida where the **spinal cord and nerves protrude** through an opening in the back, encased in a fluid-filled sac. - The associated symptoms of a **mass on the back**, **wetness** (due to neurogenic bladder/bowel), and **inability to move both legs** (paralysis from nerve damage) are classic for meningomyelocele. *Pilonidal cyst* - A pilonidal cyst is usually a **small sinus or cyst** found at the top of the natal cleft (buttock crease) and is typically acquired or presents later in life. - While it can cause discharge/wetness if infected, it does **not cause neurological deficits** like leg paralysis in an infant. *Spina bifida* - Spina bifida is a broader term for a birth defect where there is **incomplete closing of the backbone and membranes around the spinal cord**. - While meningomyelocele is a type of spina bifida, and the symptoms fit, **meningomyelocele is a more specific and accurate diagnosis** given the description of a protruding mass and severe neurological deficits. *Sacrococcygeal teratoma* - A sacrococcygeal teratoma is a **tumor** that develops at the base of the tailbone, often appearing as a large mass. - While it's a mass on the back, it is typically a **solid or cystic tumor** and does not primarily present with wetness due to neurological incontinence or paralysis of the lower limbs.
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