MBBS OSCE · cardiology

OSCE — Venous Thromboembolism

Eight-minute OSCE on suspected PE after hip replacement: probability, imaging, DOAC dosing, and when to lyse.

8 min stationVerification in progress
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NEET-PGINICETUSMLEPLAB

Brief (to candidate)

You will assess a patient with a presentation consistent with venous thromboembolism. You have 8 minutes to take a focused history, outline examination, investigations, and management including red flags.[1]

Clinical context

A 67-year-old man, day 5 after total hip replacement, has sudden pleuritic pain, heart rate 112/min, saturations 92 percent on air, and a swollen right calf. Blood pressure is 128/78 mmHg. VTE is DVT plus PE — ESC's third acute cardiovascular syndrome after MI and stroke. He is currently normotensive, so this is not high-risk PE.[1]

Candidate tasks

  1. Clarify onset, severity, associated features, and red-flag symptoms (syncope, hypotension, haemoptysis, tearing back pain).
  2. State focused examination: calf asymmetry, JVP, lung fields, pulse/BP differential (dissection mimic).
  3. Name first-line tests: Wells/clinical probability, D-dimer if PE-unlikely, CTPA, leg ultrasound. Quote Christopher: PE-unlikely plus normal D-dimer — subsequent nonfatal VTE 0.5 percent.[4]
  4. Immediate care if he drops his blood pressure: rtPA 100 mg over 2 hours; do not send unstable patients to CT.[1][2]
  5. Definitive anticoagulation if he stays stable: apixaban 10 mg twice daily for 7 days then 5 mg twice daily (AMPLIFY).[3]
  6. Complications: CTEPH (Pengo 3.8 percent at 2 years), bleeding, HIT, warfarin necrosis.
  7. Pregnancy modifier: LMWH over UFH (ASH strong). Do not lyse intermediate-risk PE routinely (PEITHO tenecteplase increased stroke).[5]

Examiner checklist

DomainPass behaviours
DefinitionDVT + PE as one disease; this stem is stable/provoked
AssessmentRed flags for high-risk PE and for dissection
InvestigationsProbability then D-dimer or CTPA; Christopher 0.5 percent
Emergency carertPA 100 mg/2 h only if hypotensive; no scanner delay
Definitive careNamed DOAC loading dose (AMPLIFY or EINSTEIN)
SafetyPEITHO is tenecteplase, not a licence to lyse every RV-strain PE
References5Show
  1. [1]Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) Eur Heart J, 2020.PMID 31504429
  2. [2]Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism Blood Adv, 2020.PMID 33007077
  3. [3]Agnelli G, Buller HR, Cohen A, et al. Oral apixaban for the treatment of acute venous thromboembolism N Engl J Med, 2013.PMID 23808982
  4. [4]van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography JAMA, 2006.PMID 16403929
  5. [5]Meyer G, Vicaut E, Danays T, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism N Engl J Med, 2014.PMID 24716681
OSCE — Venous Thromboembolism · MBBS OSCE · NeetVellum