FACEM VAQ 2008.1 Examiners Report

VISUAL AID QUESTIONS

• 46/62 (74.2%) candidates passed the VAQ section of the exam.
• To achieve this a candidate has to pass 5 or more of the 8 questions with a total mark of at least 40 / 80.
• The grade frequencies were:

Question 1:

A 78 year old man is brought to your emergency department after collapsing at the local shopping centre that morning. He is now alert with no memory of the event. His observations are normal.

a. Describe and interpret his ECG. (50%)

b. Outline the investigations prompted by his ECG. (50%)

• ECG showing showing intermittently paced rhythm with underlying complete heart block.
• The overall pass rate for this question was 49/62 (79.0%).
• The examiners felt that this was an excellent question and prop which tested appropriate knowledge.
• Good answers in part a) described the presence of a pacemaker, underlying high level heart block and intermittent pacemaker failure. Satisfactory answers to part b) had to include a discussion of the investigation of a failing pacemaker.
• Poor answers failed to identify the presence of a pacemaker and its intermittent failure.

Question 2:

An 80 year old male pedestrian is brought to your emergency department 30 minutes after being struck by a motorcycle at high speed. Describe and interpret his Chest X-ray. (100%)

• Chest X-ray of trauma patient showing multiple rib fractures and underlying area of pulmonary contusion or haemothorax.
• The overall pass rate for this question was 34/62 (54.8%).
• Good answers showed a systematic approach to reading an X-ray, identified the key abnormalities, commented on relevant negatives and suggested the possibility of a flail segment.
• Poor answers missed major findings or showed lack of a systematic approach.

Question 3:

A 62 year old, previously well woman is referred to your emergency department with a letter from her doctor that states:

Describe and interpret the results of her investigations. (100%).

• The overall pass rate for this question was 49/62 (79.0%).
• Both examiners felt that this was a very good question.
• Good responses identified the multiple abnormalities, stressed the potentially life threatening hypokalaemia, suggested mineralocorticoid excess as a potential cause and integrated the findings into relevant differential diagnoses.
• Poor answers failed to address one or more of the above facets.

Question 4:

An intoxicated 34 year old man sustains an isolated knee injury after a fall.

a. Describe and interpret this man’s photograph. (30%)

b. List the major issues to be addressed in the next four hours. (70%)

• Clinical photograph showing major knee dislocation.
• The overall pass rate for this question was 31/62 (50.0%).
• The examiners commented that this was a good quality clinical photograph which raised many consultant level issues.
• It was highly discriminative with marks ranging from 2 to 8. Most candidates described the photo adequately.
• High quality answers to Part b) addressed immediate reduction of the knee, appropriate methods of sedation/analgesia including RSI and suggested appropriate assessment for possible accompanying vascular and neurological injury.
• Poor answers failed to address the above areas or described assessment for injuries to other regions of the body despite this having been defined in the question as “an isolated knee injury”

Question 5:

An 80 year old woman presents with pain in her left axilla and arm four days after the elective insertion of a permanent pacemaker.

Describe and interpret her photograph. (100%)

• Clinical photograph of a bruised and swollen left upper arm plus subcutaneous pacemaker box swelling in pectoral region.
• The overall pass rate for this question was 47/62 (75.8%).
• This was thought to be an excellent question by the two examiners.
• A satisfactory answer required identification of the old bruising around the PPM box surgical site plus description of the separate upper arm swelling and bruising. Interpretation included possibilities of subclavian/axillary vein thrombosis, infection, arterial injury and haemorrhage.
• Poor answers failed to identify the swollen upper arm or put forward a poor differential diagnosis.

Question 6:

A 32 year old woman is brought to your emergency department by her friend who believes her to have taken a deliberate overdose earlier that morning. The patient is drowsy and denies this. Her observations are normal.

a. Describe and interpret her ECG. (50%)

b. What drugs would you consider as potential ingestants? (50%)

• ECG showing markedly prolonged QT interval.
• The overall pass rate for this question was 54/62 (87.1%)
• The examiners felt that this was a basic question on a core ECG area that should have been well handled by most well prepared candidates. Despite this, a large number of candidates failed to diagnose the prolonged QT/QTc and/or failed to realise its significance.
• Failed candidates tended to provide an incorrect or non specific list of potentially causative drugs.

Question 7:

A 27 year old motorcyclist sustains an isolated injury to his right wrist in a motor vehicle accident.

a. Describe and interpret his X-ray. (50%)

b. List the acute complications of this injury. (50%)

• X-ray showing a dislocated lunate and a fractured radial styloid process.
• The overall pass rate for this question was 49/62 (75.8%).
• This was a basic question done very poorly by a number of candidates.
• Satisfactory answers required the diagnosis of the dislocation and fracture plus identification in Part b) of the common complications of this injury.
• Poor answers missed the radial fracture, misdiagnosed perilunate dislocation and/or did not mention median nerve injury as a potential complication.

Question 8:

This 8 year old girl has been brought in to your emergency department after being injured by a cat.

a. Describe and interpret her photograph. (30%)

b. Outline your management. (70%)

• Clinical photograph showing an eyelid laceration close to inner canthus plus small corneal abrasion.
• The overall pass rate for this question was 48/62 (77.4%).
• The examiners felt that this was again a good question featuring a clear photographic prop and inviting an answer showing knowledge of the anatomy of this area especially the lacrimal apparatus and identifying need for antibiotics and ophthalmic consultation.
• Poor answers showed lack of knowledge of the anatomy of this region, failed to consider infection risk in this case and/or administered inappropriate antibiotics eg tetracyclines in a child.
• Some candidates also failed to obtain ophthalmologic consultation.

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