Medical review
dossier.

01 / Purpose & review status

English medical-review dossier for an interactive educational case intended for cardiology, vascular medicine/angiology and vascular surgery specialists. The game contains five single-best-answer decisions, option-specific feedback and a final diagnostic, treatment/prescribing and prognostic assessment.

Learning objectives

• Describe a provisional CEAP clinical phenotype without inventing aetiology, reflux or obstruction.
• Recognise possible medication-related and systemic contributors to bilateral oedema.
• Select the appropriate first-line venous imaging investigation.
• Interpret symptom-treatment evidence within its limitations and local prescribing requirements.
• Build a practical non-pharmacological plan and identify escalation triggers.

Derived from the five supplied quiz JPGs. The noir visual identity is retained, while all gameplay, feedback and dossier text is in English. The final question contains no product reference. The images illustrate the fictional narrative; they are not clinical evidence.

02 / Fictional case record

Presentation

Jane Fatalsmith, 62, is a retired shop assistant. She reports months of bilateral leg heaviness/pain, nocturnal cramps and ankle swelling, worse later in the day. The case describes bilateral truncal varicose veins and ankle oedema.

Background

Hypertension, type 2 diabetes and BMI 32 kg/m². Previous prolonged standing at work; now largely sedentary.

Medication record

Metformin, empagliflozin, valsartan/hydrochlorothiazide, amlodipine 5 mg and atorvastatin. Other doses and the chronology of medication changes are not supplied.

Not yet established

No duplex findings, renal function, blood pressure, arterial pressures, neuropathy assessment, cardiac status, albumin, allergies or thrombotic history are supplied. Pigmentation, eczema and ulcers are not documented; this is not equivalent to a negative examination. Illustrations are not diagnostic images.

References: [1], [2], [10]

03 / Questions & all answer feedback

Single best answer. Answer key: C / B / D / A / B. Each option below has its own explanation; the evidence note appears after every answer to that question.

04 / Final clinical report

The report is identical regardless of score. Only the participant’s learning recap is personalised.

Diagnostic assessment

Working hypothesis

Symptomatic chronic venous disease with varicose veins and a working C3s clinical phenotype. Venous causation of oedema and the anatomical/pathophysiological classification remain unconfirmed.

Next diagnostic step

Obtain full lower-limb venous duplex before assigning reflux, obstruction or a procedural target. Reassess symptom chronology, symmetry, skin findings, previous thrombosis and medication changes; examine for cardiac, renal, hepatic and lymphatic contributors.

Targeted additional assessment

Select renal function, urinalysis/protein assessment, albumin/liver tests, thyroid or cardiac investigations according to findings. These are proposed investigations, not existing results.

References: [1], [2], [10]

Treatment & prescribing

Conservative plan

Agree on feasible walking and ankle movement, breaks from prolonged immobility, weight management and appropriate elevation. Consider below-knee compression at 20–40 mmHg for C3 oedema only after assessing arterial perfusion, neuropathy, skin, cardiac status, fit and tolerance. In diabetes, ABI may be unreliable; assess toe pressures where indicated. Severe arterial disease or other contraindications require modification or avoidance.

Antihypertensive review

Review amlodipine with the treating clinician; do not stop it automatically. Any reduction or alternative depends on blood pressure and the overall regimen. Jane already receives valsartan/HCTZ: do not add an ACE inhibitor for hypertension or empirically escalate diuretics for presumed CCB-related oedema.

Venous intervention

If duplex demonstrates clinically relevant truncal reflux and she is suitable, discuss intervention, alternatives and preferences. Compression for symptom control does not replace evaluation for treatable reflux; it is not presented as definitive treatment when an appropriate intervention is available.

Pharmacotherapy decision

Sulodexide has symptom/oedema evidence, with important uncertainty. The guideline suggestion is weak and applies to selected symptomatic patients. A decision requires current Portuguese SmPC confirmation, a defined indication and an individual benefit–risk assessment. This game issues no sulodexide dose or treatment order.

Safety information to verify

The historical Portuguese leaflet (March 2022) lists hypersensitivity to sulodexide/heparin-related substances and haemorrhagic conditions among contraindications, and warns about bleeding and concomitant anticoagulants. It does not verify the current SmPC. Review the complete current label and concomitant antithrombotics before prescribing.

References: [2], [3], [4], [5], [6], [7], [11]

Prognosis & follow-up

Expected course

Symptoms and oedema may improve with an individualised plan, but the case cannot support a promise of cure or a personal ulcer-risk percentage. Chronic venous disease can progress or recur; Jane’s trajectory needs duplex assessment and follow-up.

Reassessment

Agree on follow-up after the investigations and any treatment adjustment, with timing determined by findings and the local pathway. Review symptoms, swelling, skin condition, function, adherence, treatment tolerance and response. Record changes rather than inferring benefit from the score.

References: [2], [7], [9]

When to escalate

Acute changes require a different pathway

New acute painful swelling requires urgent assessment for DVT. Sudden breathlessness, chest pain or haemoptysis requires urgent assessment for PE. Bleeding varicose veins requires immediate vascular referral.

References: [7], [8]

05 / Game logic & content controls

Sequence

The centred logo opens four case files. Jane opens Part I; its end starts the five-decision landscape quiz. Finishing the last feedback opens Part II; its end returns to the case files. The completed clinical report remains accessible. The two supplied films are embedded using Vimeo. End-of-video events advance the sequence; playback errors expose retry and manual continuation controls.

Scoring

One point for each best first confirmed answer; maximum five points. Key: C, B, D, A, B. Confirmed choices cannot be changed within a run. A fresh case resets the score.

Clinical independence

The final clinical assessment is identical for all participants. The score changes only the educational recap and answer review. An incorrect answer does not produce an unsafe fictional prescription.

Evidence boundaries

No investigation result is generated, no personal probability of ulceration is estimated, and no dose or treatment order is issued. The clinical summary is deterministic, not AI-generated at runtime.

Data and access

The game asks for no patient or clinician identifying data. Answers are stored in localStorage in the current browser; restarting replaces them. No analytics scripts are added by the game. Vimeo is embedded with dnt=1; technical requests to Vimeo and provider/hosting logs are outside this browser-local answer storage.

Audience and release

The visible review banner and private review deployment are not professional credential verification. Medical/legal reviewers must decide the appropriate HCP access controls and publication setting before wider distribution.

Claim-to-source map

06 / Evidence register

Source review date: 28 October 2026. Guideline recommendations, evidence syntheses, observational evidence and regulatory information have different roles. This register is targeted to the case; it is not an exhaustive systematic review. The current local SmPC remains outstanding.

07 / Medical approval checklist

Every item requires review. No approval has been inferred or recorded. The sponsor/company and reviewers must be identified by the commissioning team.

1. Confirm the fictional case record, symptom chronology and examination findings. Missing information must not be presented as a negative test.
2. Validate the provisional C3s wording and ensure no duplex result or complete E/A/P classification is invented.
3. Review all five questions, all 20 option-specific feedback messages and the C / B / D / A / B answer key. Keep Question 5 product-free.
4. Obtain and archive the current Portuguese SmPC/INFOMED record. Confirm indication, availability, full safety wording and any required prescribing information before releasing the product discussion.
5. Approve the Q4 evidence balance, uncertainty and relevant company/author relationships. Do not imply cure, automatic prescription, high-certainty benefit or prevention of progression.
6. Validate the compression wording and local vascular pathway, including arterial disease, diabetes/neuropathy and cardiac contraindications.
7. Confirm the antihypertensive advice: no automatic amlodipine withdrawal, no ACE inhibitor added to valsartan, and no empirical diuretic escalation for CCB oedema.
8. Validate the differential diagnosis, proposed investigations, follow-up and acute escalation advice against the intended country’s clinical pathways.
9. Confirm that final clinical advice is independent of game score, and that the score assesses five learning decisions rather than professional competence.
10. Approve English copy, fictional images and their rights, intended audience, publication setting, references, version/date, pharmacovigilance requirements and any company-mandated notices.

Any change to the case, scoring, feedback, prescribing language, sources or artwork requires version control and reassessment of the relevant approval items. Approval of this dossier does not automatically approve later edits.

08 / Future episode concepts

Additional reference register