Medicine — Venous Thromboembolism, NMC MBBS licence examination syllabus (Nepal Medical Council).
NMC-style practice questions written for this site. They are not past questions, and no past paper has been reproduced.
1. Name the three components of Virchow's triad and give one clinical example of each.
Answer: Stasis — immobility, long travel, a plaster cast. Vessel injury — surgery, trauma, a central line. Hypercoagulability — cancer, pregnancy, oestrogen-containing medication, inherited thrombophilia.
2. Why is unilateral leg swelling more suggestive of DVT than bilateral swelling?
Answer: Because a thrombus obstructs one vein, so the consequences are confined to that limb. Bilateral swelling implies a systemic cause — cardiac, hepatic or renal — affecting both legs equally.
3. A patient three days after abdominal surgery becomes suddenly breathless with pleuritic chest pain. Both legs appear normal. Does that reduce the likelihood of pulmonary embolism?
Answer: No. Most patients with PE have no leg findings, because the clot has left the leg and may never have been large enough to notice. Recent surgery supplies both stasis and vessel injury, so the clinical probability is high and imaging should not wait.
4. Why should a D-dimer not be ordered in a patient with a high clinical probability of PE?
Answer: Because it would not change management — a high-probability patient is imaged whatever it shows. Its only possible effect is a falsely reassuring negative that talks a clinician out of a correct diagnosis. Ordering a test whose negative result you would ignore adds risk and no information.
5. A patient has a low probability score and a negative D-dimer. What is the appropriate next step, and why?
Answer: No further imaging. That combination excludes venous thromboembolism, because the test is highly sensitive — a negative result in a patient unlikely to have the disease makes it very improbable. Imaging would expose them to contrast and radiation without changing the conclusion.
6. A patient collapses with sustained hypotension, a raised jugular venous pressure and clear lung fields. How does this change management compared with a stable suspected PE?
Answer: It becomes obstructive shock — the right ventricle is failing against an obstructed pulmonary circulation. Senior help is needed immediately, and the patient must not be sent unmonitored to a scanner: these patients arrest during transfer, when monitoring and staff are furthest away.
7. Why is a raised D-dimer of limited value in a patient with sepsis?
Answer: Because D-dimer rises with any activation of coagulation and fibrinolysis — infection, malignancy, pregnancy, recent surgery and increasing age all raise it. In a septic patient it is almost always raised, so a positive result carries very little information about thrombosis specifically.
8. A patient with a very low platelet count is admitted with pneumonia and is immobile. How is thromboprophylaxis approached?
Answer: By weighing clotting risk against bleeding risk rather than applying a default. Drug prophylaxis may be unsafe at that platelet count, but the thrombotic risk from illness and immobility remains — so mechanical prophylaxis and early mobilisation are used instead, and the decision is reassessed as the platelet count changes.
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