A 72 year old woman presents to her GP having noticed a lesion on her ankle. It seems to have developed over the past few weeks. She is worried it is skin cancer. She is overweight and has a background of hypertension that is well controlled on amlodipine.

On examination, the skin around both ankles is erythematous, dry and eczematous. There is an approximately 3cm lesion where the top of her foot meets her lower leg. This corresponds to where the top of her shoe ends. The skin is open at the site of the lesion and the surface is moist and erythematous with a yellow slough present. The borders are irregular, difficult to define and slope gently into the lesion.

What is the most likely diagnosis?

A 59 year old man presents to his GP concerned about his risk of having an abdominal aortic aneurysm. His friend recently passed away unexpectedly after having a ruptured abdominal aortic aneurysm.

He has no other health conditions, is a non-smoker, drinks 12 units of alcohol per week, exercises regularly and maintains a normal BMI.

Based on the screening program in England, when would he receive a routine ultrasound to assess for an abdominal aortic aneurysm?

A 34 year old man presents with new swelling to his left leg for the past 2 days. Two weeks ago he significantly injured his left ankle, requiring the ankle to be immobilised in a brace. He has been using crutches to move around and spends most of his time sitting or lying down. He recently travelled 250 miles by car to visit family, returning home 3 days ago. He denies any chest pain or shortness of breath. He is otherwise fit and well with no health issues.

On examination, there is swelling of his left leg extending up to the knee. The left calf measures 10cm more than the right calf. There is pitting oedema and tenderness to the left lower leg and ankle. His chest sounds clear, with normal breath sounds throughout his lung fields.

Blood pressure: 123/81. Heart rate: 86. Respiratory rate: 14. Temperature: 36.8°C. Oxygen saturation: 98%.

A d-dimer test is performed, with a result of 1400 ng/ml (normal <500).

The ultrasound department advises that is it not possible to arrange a scan of his leg until the next day.

Which of the following is the most appropriate treatment in the meantime?

You are on your medical elective in Malaysia, working in a local hospital. As you are walking through the outpatient department, you notice a middle-aged man with a right leg that is very swollen, mostly from the knee downwards. The skin is thickened and hardened.

What is the most likely diagnosis?

A 64 year old man presents with a cramping sensation in his calf muscles that occurs when he walks more than about 100 meters, or any distance uphill. His symptoms settle within a few minutes of resting. 

He very rarely visits his GP and has only come in because these symptoms are now severely affecting his quality of life. He has two dogs and finds it difficult to walk them. He has smoked since he was 15 years old.

On examination, he has weak pulses in his feet. His feet are perfused, but slightly cool and there is noticeable loss of hair. The skin is intact.

Tar staining is visible on his fingertips. There are yellow skin bumps in several places around his body, most notably around his eyes. 

Which of the following will be most helpful in establishing the cause of his symptoms?

A 36 year old woman presents with the gradual development of engorged and dilated superficial veins, visible under the skin on the back of her legs. She works in retail and spends most of her time on her feet. They cause a dragging and aching sensation, which causes her problems at work. She is also concerned about the cosmetic appearance. 

What is the underlying pathophysiology?

A 32 year old man presents with pain and blue discolouration of several of his fingertips and the tips of his toes. This discolouration does not vary with the weather. 

He is otherwise healthy, regularly exercises and has a BMI of 25. His blood pressure is 125/81 and the pulses are palpable throughout his arms and legs. He admits to smoking 20 cigarettes per day and drinking around 50 units of alcohol per week, mostly at the weekend. 

What is the most likely diagnosis?

A 68 year old lady presents with sudden onset weakness in her right arm and leg. She is diagnosed with an ischaemic stroke and treated with thrombolysis. Her condition stabilises and she is admitted to the acute stroke service for monitoring and ongoing management.

Which of the following investigations is indicated following her stroke?

A 70 year old man presents to A&E with a “tearing” pain throughout his chest. He is unable to specify a specific location to the pain. The pain came on suddenly about 6 hours ago and has since settled in severity. At the time he was lifting some heavy plant pots around his garden. He says initially the pain was 10/10 but is now stable at around 4/10. 

His past medical history include hypertension and hypercholesterolaemia. He has a 40 pack year smoking history. He also occasionally uses cocaine. 

Blood pressure: 168/100 left arm, 117/70 right arm. Heart rate: 88. Respiratory rate: 18. Temperature: 36.8°C. Oxygen saturation: 98%.

Which investigation will be most helpful in confirming the diagnosis?

A 74 year old woman presents to her GP with sore skin on her lower legs. She is known to have skin changes to her lower legs. Over the past few weeks, the skin between her calf muscles and ankles has been dry, red, itchy and sore. She otherwise feels well in herself.

On examination, she has narrowing of her lower leg with hardening and tightening of the skin. Her leg appears to taper inwards between the calf and ankle. The skin is erythematous and dry. The erythema does not track up or down her leg. There are small patches of white, scarred skin. This appearance is equal on both sides. The legs and feet are mildly warm to the touch. The skin is intact without ulceration. Her dorsalis pedis and posterior tibial pulses are palpable. She is afebrile.

Which of the following is most likely to lead to an improvement in her symptoms?

A 28 week pregnant woman presents with swelling of her left leg. She is otherwise well in herself. 

She undergoes a Doppler ultrasound, which confirms a deep vein thrombosis. 

Which of the following would be the most appropriate choice of treatment?

You are shadowing a vascular surgeon in an outpatient clinic. A 64 year old man presents with pain in both calves when walking distances beyond 200 meters. This pain gradually worsens until he has to stop. After resting for 5 minutes, the pain eases off and he is able to start walking again. 

The surgeon has the patient lie on his back and lifts the patient’s legs to an angle of 45 degrees at the hip, one at a time. She holds them there. After 30 seconds the leg being lifted turns a very pale colour. 

Then, she asks the patient to sit upright on the bed with his legs hanging over the side. Initially, the legs turn a blue colour, before turning dark red. 

What clinical test is the surgeon performing?