Venous Thromboembolism — MCQs

10 questions

All are predisposing factors of Deep Vein thrombosis, EXCEPT :

Which of the following statements about deep venous thrombosis (DVT) is incorrect?

A woman at 30 weeks of gestation is diagnosed with deep vein thrombosis (DVT). Which of the following is the most appropriate treatment for this patient?

A woman shows symptoms of massive pulmonary thromboembolism. Based on the gross appearance of the liver autopsy, which of the following statements best characterizes the patient’s condition?

Virchow's triad includes all except:-

In which one of the following is Branham's sign positive?

What is the most common site of peripheral aneurysm?

A patient developed breathlessness and chest pain, on second postoperative day after a total hip replacement. Echocardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis?

What is a potential risk for pregnant women who undertake long journeys with prolonged sitting?

Q10

In which of the following clinical conditions does the use of anticoagulants provide maximum benefit?

Venous Thromboembolism Indian Medical PG Practice Questions and MCQs

Question 1: All are predisposing factors of Deep Vein thrombosis, EXCEPT :

A. Lower limb trauma
B. Cushing's syndrome
C. Hip surgery
D. Subungual melanoma (Correct Answer)

Explanation: ***Subungual melanoma*** - This is a rare form of melanoma that develops under the nail, and while serious, it is **not a recognized predisposing factor for deep vein thrombosis (DVT)**. Its primary concerns are local invasion and metastasis. - Unlike conditions affecting blood clotting or endothelium, **subungual melanoma does not directly promote hypercoagulability, venous stasis, or endothelial damage** that contribute to DVT. *Lower limb trauma* - **Trauma to the lower limb** can cause **endothelial damage** to blood vessels and **venous stasis** due to immobility or swelling, both key components of **Virchow's triad** for DVT [1]. - **Fractures or severe soft tissue injuries** often necessitate immobilization and can lead to inflammation, further increasing the risk of clot formation [1]. *Cushing's syndrome* - **Cushing's syndrome** is associated with **hypercoagulability** due to increased levels of clotting factors, such as **factor VIII** and **fibrinogen**, and decreased fibrinolytic activity. - The **elevated cortisol levels** seen in Cushing's syndrome [2] can directly contribute to a prothrombotic state, significantly increasing DVT risk. *Hip surgery* - **Major orthopedic surgeries**, especially hip surgery [1], are well-known to cause significant **venous stasis** and **endothelial damage**. - **Post-operative immobility** and a generalized **inflammatory response** following surgery contribute to a high risk of DVT formation [1].

Question 2: Which of the following statements about deep venous thrombosis (DVT) is incorrect?

A. Mostly bilateral (Correct Answer)
B. Most common clinically presents as pain and tenderness in calf
C. Some cases may directly present as pulmonary thromboembolism
D. Clinical assessment highly reliable

Explanation: ***Mostly bilateral*** - DVT is typically **unilateral**, affecting one limb [2]. Bilateral DVT is less common, making this statement incorrect [2]. - The symptoms of **pain, swelling, and tenderness** are usually localized to one leg [1]. *Most common clinically presents as pain and tenderness in calf* - **Calf pain and tenderness** are common clinical presentations of DVT, especially in the lower extremities [1]. - Other common signs include **swelling, warmth, and redness** in the affected leg [1]. *Some cases may directly present as pulmonary thromboembolism* - A significant concern with DVT is that a **clot can dislodge** and travel to the lungs, causing a **pulmonary embolism (PE)**, which can be the initial presentation [1]. - PE is a potentially life-threatening complication and may present with **dyspnea, chest pain, and hemoptysis**. *Clinical assessment highly reliable* - **Clinical assessment alone is not highly reliable** for diagnosing DVT due to its variable and often non-specific presentation [2]. - A definitive diagnosis usually requires objective diagnostic tests such as **compression ultrasonography** or **D-dimer assay** [3].

Question 3: A woman at 30 weeks of gestation is diagnosed with deep vein thrombosis (DVT). Which of the following is the most appropriate treatment for this patient?

A. Warfarin
B. Low Molecular Weight Heparin (LMWH) (Correct Answer)
C. Apixaban
D. Fondaparinux

Explanation: ***Low Molecular Weight Heparin (LMWH)*** - **LMWH** is the preferred anticoagulant for DVT during pregnancy because it does **not cross the placenta**, making it safe for the fetus. - It also has a **predictable anticoagulant response** and a lower risk of **heparin-induced thrombocytopenia (HIT)** compared to unfractionated heparin. *Warfarin* - **Warfarin is teratogenic**, especially during the first trimester, and can cause **fetal warfarin syndrome**, which includes skeletal and central nervous system abnormalities. - It can also lead to **fetal bleeding** and miscarriage at any stage of pregnancy. *Apixaban* - **Apixaban** is a **direct oral anticoagulant (DOAC)**, and its safety in pregnancy has not been established. - There is insufficient data regarding its **placental transfer** and potential fetal effects, making its use generally contraindicated in pregnant women. *Fondaparinux* - While **fondaparinux** is an indirect Factor Xa inhibitor and might be considered in cases of heparin allergy or intolerance, its **safety profile in pregnancy is not as well-established** as LMWH. - It is generally reserved for situations where LMWH cannot be used, and its use requires careful consideration due to limited data.

Question 4: A woman shows symptoms of massive pulmonary thromboembolism. Based on the gross appearance of the liver autopsy, which of the following statements best characterizes the patient’s condition?

A. Primary liver angiosarcoma
B. Locally invaded hepatocellular carcinoma
C. Colonic adenocarcinoma with liver metastasis
D. Chronic passive congestion with centrilobular necrosis (Correct Answer)

Explanation: ***Colonic adenocarcinoma with metastasis*** - The presence of **massive pulmonary thromboembolism** often indicates **underlying malignancy** [2], particularly with **colonic adenocarcinoma** known to metastasize to the liver [1]. - This condition may present with **liver lesions** at autopsy, consistent with metastatic disease [1], supporting this diagnosis. *Metastasis from PE* - Pulmonary embolism (PE) itself does not typically give rise to **metastatic disease**; instead, it commonly arises from **deep vein thrombosis** (DVT) [2]. - This onfuses the cause of PE with its potential effects, lacking the **specificity** of a primary cancer origin. *Locally invaded hepatocellular carcinoma* - This option indicates a primary liver cancer impacting the liver directly, which would not cause **massive pulmonary thromboembolism** as its primary feature. - While hepatocellular carcinoma can cause some vascular complications, it does not correlate with **colonic adenocarcinoma** or metastatic patterns indicative of PE. *Angiosarcoma* - Though angiosarcoma is a **primary liver tumor**, it is rare and does not typically present with **massive pulmonary embolism** as a hallmark manifestation. - This type of cancer generally has a different clinical picture and distinct risk factors compared to **colonic adenocarcinoma**, making it an **unlikely option** in this context. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Neoplasia, p. 282. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Lung, p. 705.

Question 5: Virchow's triad includes all except:-

A. Stasis of blood flow
B. Endothelial injury
C. Platelet thrombus (Correct Answer)
D. Hypercoagulability

Explanation: ***Platelet thrombus*** - Virchow's triad describes the three primary categories of factors that are thought to contribute to **thrombosis**, but it does not specifically include a formed **thrombus** itself. [1] - While **platelet thrombus** formation is an outcome of an imbalance in these factors, it is not one of the predisposing conditions identified by Virchow's triad. *Stasis of blood flow* - **Stasis** refers to a reduction in the rate of blood flow, which allows clotting factors to accumulate and endothelial cells to become hypoxic, increasing the risk of **thrombosis**. [1] - This is a well-established component of Virchow's triad, explaining why factors like immobility or venous insufficiency predispose to clot formation. *Endothelial injury* - **Endothelial injury** or dysfunction exposes the subendothelial collagen, leading to platelet adhesion and activation, and the initiation of the coagulation cascade. [1] - It is a critical component of Virchow's triad, often seen in conditions like **atherosclerosis** or trauma, which directly promotes thrombus formation. [2] *Hypercoagulability* - **Hypercoagulability**, or thrombophilia, refers to an increased propensity for coagulation due to genetic or acquired abnormalities in clotting factors. [1] - This imbalance in the coagulation system is a central part of Virchow's triad, leading to an exaggerated thrombotic response even in the absence of significant stasis or injury. [2] **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Hemodynamic Disorders, Thromboembolic Disease, and Shock, pp. 132-133. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 142-143.

Question 6: In which one of the following is Branham's sign positive?

A. Arterial stenosis
B. Arteriovenous fistula (Correct Answer)
C. Deep vein thrombosis
D. Arterial aneurysm

Explanation: ***Arteriovenous fistula*** - **Branham's sign**, also known as Nicoladoni-Branham's sign, is characterized by a **sudden decrease in heart rate** upon compression of an arteriovenous fistula. - This occurs because *compression of the fistula increases systemic vascular resistance, leading to improved venous return and a reflex bradycardia* via vagal stimulation. *Arterial stenosis* - **Arterial stenosis** involves narrowing of an artery and does not typically present with Branham's sign. - While it may cause a **bruit** or **reduced pulse**, compressing the stenotic vessel would not lead to an immediate change in heart rate. *Deep vein thrombosis* - **Deep vein thrombosis (DVT)** is a blood clot in a deep vein, causing pain and swelling, but it is not associated with Branham's sign. - Compression in the area of a DVT would likely worsen pain or dislodge the clot, not alter heart rate in this manner. *Arterial aneurysm* - An **arterial aneurysm** is a localized bulging of an artery wall, which can pulsate but generally does not elicit Branham's sign upon compression. - Compressing an aneurysm could be dangerous and would not result in the reflex bradycardia seen with an arteriovenous fistula.

Question 7: What is the most common site of peripheral aneurysm?

A. Popliteal artery (Correct Answer)
B. Brachial artery
C. Femoral artery
D. Radial artery

Explanation: ***Popliteal artery*** - **Popliteal artery aneurysms** are the most common type of peripheral artery aneurysm, accounting for about **70-80% of all cases**. - They are often **bilateral (50-70%)** and can be associated with **abdominal aortic aneurysms (30-50%)**. - Most commonly occur in **elderly males** with atherosclerotic disease. *Femoral artery* - Although **femoral artery aneurysms** are the **second most common** type of peripheral aneurysm, they account for only **20-25%** of cases. - They often occur in the **common femoral artery** and may be associated with atherosclerotic disease. - Less likely to be bilateral compared to popliteal aneurysms. *Brachial artery* - **Brachial artery aneurysms** are relatively rare and often result from **trauma, iatrogenic injury, or infection**. - They are not considered a common site for peripheral aneurysms. *Radial artery* - **Radial artery aneurysms** are quite uncommon and are typically caused by **trauma, repetitive motion, or iatrogenic injury**. - They are rarely spontaneous and do not represent a common site for peripheral aneurysms.

Question 8: A patient developed breathlessness and chest pain, on second postoperative day after a total hip replacement. Echocardiography showed right ventricular dilatation and tricuspid regurgitation. What is the most likely diagnosis?

A. Pulmonary embolism (Correct Answer)
B. Cardiac tamponade
C. Acute MI
D. Hypotensive shock

Explanation: ***Pulmonary embolism*** - Postoperative state, sudden onset of **breathlessness**, and **chest pain** are classic symptoms of pulmonary embolism (PE). - **Right ventricular dilatation** and **tricuspid regurgitation** on echocardiography are strong indicators of acute right heart strain due to increased pulmonary artery pressure caused by the embolus. *Cardiac tamponade* - Characterized by muffled heart sounds, **pulsus paradoxus**, and **hypotension**, often due to fluid accumulation in the pericardial sac. - While it can cause breathlessness, the echocardiographic findings of **right ventricular dilatation** and **tricuspid regurgitation** are not typical of tamponade. *Acute MI* - Myocardial infarction typically presents with ischemic chest pain, often radiating, and is primarily diagnosed by **ECG changes** and **cardiac enzymes**. - While acute MI can cause breathlessness, the combination of a postoperative setting and the specific echocardiographic findings of **right heart strain** points away from an initial diagnosis of MI. *Hypotensive shock* - Hypotensive shock is a state of severe low blood pressure leading to organ hypoperfusion, with various underlying causes. - While PE can *lead to* hypotensive shock due to hemodynamic compromise, the question describes the specific pathology (right heart strain) rather than just the resultant shock state.

Question 9: What is a potential risk for pregnant women who undertake long journeys with prolonged sitting?

A. Venous thromboembolism
B. Deep vein thrombosis (Correct Answer)
C. Pulmonary embolism
D. Leg swelling

Explanation: ***Deep vein thrombosis*** - **Pregnancy** is a **hypercoagulable state** due to increased levels of clotting factors (fibrinogen, factors VII, VIII, X) and decreased protein S activity. - **Prolonged sitting** during long journeys causes **venous stasis** in the lower extremities, which is a key component of **Virchow's triad** for thrombosis (stasis, hypercoagulability, endothelial injury). - **DVT** is the **direct and most specific pathological consequence** of prolonged immobilization during travel in pregnancy. - The risk of **VTE in pregnancy** is **4-5 times higher** than in non-pregnant women, with travel-related DVT being a recognized complication. *Venous thromboembolism* - VTE is an **umbrella term** that encompasses both **DVT and pulmonary embolism**. - While technically correct as a broader category, DVT is the **more specific and direct answer** to what prolonged sitting causes. - In medical education and clinical practice, identifying the **specific pathology** (DVT) is more appropriate than using the general category (VTE). *Pulmonary embolism* - PE is a **complication** of DVT, occurring when a thrombus dislodges and embolizes to the pulmonary circulation. - PE is a **secondary consequence**, not the **primary risk** from prolonged sitting itself. - The direct mechanism of prolonged sitting → venous stasis → **DVT formation** → potential embolization to lungs. *Leg swelling* - **Leg swelling** (edema) is a **symptom**, not a pathological diagnosis. - While leg edema can indicate DVT, it's also common in normal pregnancy due to increased venous pressure and fluid retention. - The question asks for a **risk** (pathological condition), not a symptom.

Question 10: In which of the following clinical conditions does the use of anticoagulants provide maximum benefit?

A. Prevention of recurrences of myocardial infarction
B. Prevention of venous thrombosis and pulmonary embolism (Correct Answer)
C. Prevention of cerebrovascular accident (stroke)
D. Retinal artery thrombosis

Explanation: ***Prevention of venous thrombosis and pulmonary embolism*** - Anticoagulants are highly effective in inhibiting the formation and extension of **venous thrombi**, thereby directly preventing **deep vein thrombosis (DVT)** and **pulmonary embolism (PE)**. - The mechanism of action targets the **coagulation cascade**, directly reducing the risk of these venous thromboembolic events, which are a major indication for anticoagulant therapy. *Prevention of recurrences of myocardial infarction* - While anticoagulants may play a secondary role, **antiplatelet agents** (e.g., aspirin, clopidogrel) are the primary therapy for preventing recurrent myocardial infarction, as **arterial thrombi** are predominantly platelet-rich. - Anticoagulants are used in specific high-risk situations post-MI (e.g., **atrial fibrillation**, left ventricular thrombus) but are not generally considered the primary preventive strategy. *Cerebrovascular accident* - The benefit of anticoagulants for stroke prevention is primarily significant in cases of **cardioembolic stroke** (e.g., due to **atrial fibrillation**) where they prevent clot formation in the heart. - For non-cardioembolic **ischemic strokes** (e.g., thrombotic or lacunar), antiplatelet agents are generally preferred for secondary prevention. *Retinal artery thrombosis* - **Retinal artery thrombosis** is often caused by **arterial atherosclerosis** and **embolism** from the carotid arteries or heart, where antiplatelet agents are typically primary. - The role of anticoagulants here is limited to specific causes like **atrial fibrillation** or in patients already on anticoagulation for other indications.

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