EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Susan’s symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What findings would suggest deep vein thrombosis (DVT) or pulmonary embolism (PE)?
• Prompt: What initial investigations would you consider?

Q3. How would you manage Susan’s condition?

• Prompt: What conservative and pharmacological treatments would you recommend?
• Prompt: When would anticoagulation or referral be necessary?

Q4. Susan is worried about recurrence and clotting risk. How would you counsel her?

• Prompt: How would you explain her risk of future clots?
• Prompt: What lifestyle changes or preventive measures should she take?

Q5. What preventive strategies can Susan implement to reduce her risk of future thrombophlebitis?

• Prompt: What role does activity and compression therapy play?
• Prompt: When should she consider stopping the oral contraceptive pill?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Susan’s symptoms?

Susan’s most likely diagnosis is superficial thrombophlebitis (STP), given the palpable, tender, cord-like vein with mild erythema and swelling. Her risk factors include varicose veins, recent long-haul travel, and oral contraceptive use.

Key Differential Diagnoses:

1. Superficial Thrombophlebitis – Tender, cord-like vein with local erythema, often self-limiting.
2. Deep Vein Thrombosis (DVT) – Unilateral calf swelling >3cm, tenderness, warmth, and oedema. Requires urgent assessment.
3. Cellulitis – Diffuse erythema, warmth, and tenderness with systemic symptoms (fever, malaise).
4. Lymphoedema – Chronic painless swelling without erythema or warmth.
5. Venous Stasis Dermatitis – Skin changes from chronic venous insufficiency, often bilateral with hyperpigmentation.

A focused history, examination, and investigations (if needed) will confirm the diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral or additional tests:

• Suspicion of DVT – Calf swelling >3cm, unilateral pitting oedema, pain on dorsiflexion (Homans’ sign), or dilated superficial veins.
• Possible Pulmonary Embolism (PE) – Sudden dyspnoea, pleuritic chest pain, haemoptysis, tachycardia, or hypoxia.
• Systemic symptoms (fever, rigors, tachycardia) – Consider septic thrombophlebitis or cellulitis.

Recommended Investigations:

• Venous ultrasound (doppler) – If DVT is suspected.
• D-dimer – Useful in low-risk cases to rule out DVT.
• FBC, CRP, blood cultures – If infection is suspected.

Immediate hospital referral is warranted if PE or septic thrombophlebitis is suspected.

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Q3: How would you manage Susan’s condition?

Conservative Management:

• Warm compresses and elevation – Reduces discomfort.
• Compression stockings – Improves venous circulation.
• Encourage mobility – Reduces clot progression risk.

Pharmacological Therapy:

• NSAIDs (e.g., ibuprofen, naproxen) – Reduces pain and inflammation.
• Topical heparinoid gel (Hirudoid) – May improve resolution.
• Consider anticoagulation (low-molecular-weight heparin or DOAC) if:
  • Clot extends above the knee.
  • History of prior DVT/PE.
  • Multiple risk factors (e.g., OCP use, obesity, recent travel).

Follow-up & Monitoring:

• Review in 1 week to assess symptom resolution.
• Repeat ultrasound if symptoms progress.

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Q4: Susan is worried about recurrence and clotting risk. How would you counsel her?

1. Acknowledge her concerns
   • “Having superficial thrombophlebitis means you have some risk of future clots, but we can minimise this risk.”
2. Explain Risk Factors and Prevention
   • “The OCP, recent travel, and varicose veins contributed to this.”
   • “Stopping the OCP may be advisable if clotting risk remains high.”
3. Reassure About Management
   • “Superficial clots rarely lead to serious complications if managed early.”
   • “Your ultrasound ruled out a deep clot, so anticoagulation is likely unnecessary.”
4. Encourage Lifestyle Changes
   • “Staying active, using compression stockings, and avoiding prolonged immobility will help prevent recurrence.”

Regular follow-up is important to assess ongoing risk and preventive strategies.

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Q5: What preventive strategies can Susan implement to reduce her risk of future thrombophlebitis?

1. Reduce Modifiable Risk Factors:
   • Consider stopping the OCP and exploring alternative contraception.
   • Maintain a healthy weight and active lifestyle.
2. Venous Health & Circulation:
   • Use compression stockings, especially on long flights.
   • Avoid prolonged immobility – regular breaks during travel or desk work.
3. Early Recognition & Management:
   • Seek medical review if new symptoms develop.
   • Monitor for signs of worsening venous disease (e.g., persistent swelling, hyperpigmentation).

Preventing recurrence requires a multifactorial approach, combining lifestyle changes, vascular health optimisation, and early intervention.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing superficial thrombophlebitis from DVT, cellulitis, and other vascular conditions.
• Identification of red flags, recognising when DVT, PE, or infection requires urgent referral.
• Structured evidence-based management plan, incorporating conservative, pharmacological, and anticoagulation considerations.
• Clear patient-centred counselling, addressing recurrence, clotting risk, and contraception choices.
• Preventive strategies, focusing on mobility, compression therapy, and lifestyle modifications.

PITFALLS

• Failing to assess for DVT, leading to missed deep vein thrombosis or PE.
• Not addressing modifiable risk factors, such as OCP use and prolonged immobility.
• Overprescribing anticoagulation unnecessarily, without evidence of DVT progression.
• Inadequate follow-up, missing worsening symptoms or new clot formation.
• Not considering alternative contraception, leaving OCP-associated thrombosis risk unaddressed.

REFERENCES

• RACGP – RACGP Guidelines for VTE Risk and Management
• GP Exams – Phlebitis/thrombophlebitis

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Takes a thorough history to assess risk factors for thrombophlebitis.
1.2 Provides clear explanations of the diagnosis, treatment, and red flags.

2. Clinical Information Gathering and Interpretation

2.1 Performs a systematic vascular examination.
2.2 Identifies red flags indicating need for further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between superficial thrombophlebitis and deep vein thrombosis.
3.2 Determines when further investigations are warranted.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate treatment plan, including conservative and pharmacological options.
4.2 Identifies when anticoagulation or referral is required.

5. Preventive and Population Health

5.1 Provides education on lifestyle modifications and thrombosis prevention.

6. Professionalism

6.1 Demonstrates empathy when addressing patient concerns regarding clotting risks.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for patients at risk of thrombosis.

9. Managing Uncertainty

9.1 Recognises when specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious complications, including deep vein thrombosis and pulmonary embolism.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD