FACEM VAQ 2005.2 Examiners Report

VISUAL AID QUESTIONS

• 39/56 (69.6%) candidates passed the VAQ section of the exam.
• 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 34 year old woman presents to your emergency department with a history of abdominal pain, vomiting and diarrhoea for two weeks. Examination reveals dehydration and generalised abdominal tenderness.

• The overall pass rate for this question was 47/56 (83.9%).
• Examiners expected that candidates would correctly interpret this as normal anion gap metabolic acidosis which could be due to GI or renal causes given the scenario presented.
• Reasons for failing answers included omission of renal failure in the interpretation, stating that the hypokalaemia was due to acidosis and misinterpreting the anion gap.

Question 2

A 70 year old man with past history of COAD presents with two days of rash and fever. His only medications are metered aerosol inhalers of salmeterol and fluticasone. His observations are all within normal limits.

• The accompanying picture picture shows generalized skin erythema and desquamation.
• The overall pass rate for this question was 46/56 (82.1%).
• Examiners expected a thorough description of the rash highlighting the erythema and desquamation.
• They noted that most candidates were able to do this. Although the syndrome was erythroderma it was expected that good answers would give causes relevant to the scenario such as drug reactions, TEN, Staph scalded skin, Stevens Johnson syndrome, psoriasis, generalised eczema and polymorphous light eruption.
• It was incorrect to over emphasise bullous conditions. Irrespective of the diagnosis it was expected that a number of complications would be mentioned such as heat loss, fluid/electrolyte loss, protein wasting, heart failure and secondary infection/sepsis

Question 3

A 26 year old man presents with a 24 hour history of a painful penis. There is no history of trauma.

• The clinical photograph shows a grossly oedematous foreskin suggesting a parphimosis.
• The overall pass rate for this question was 42/56 (75%).
• A high level of knowledge was expected in answers to this question as the diagnosis of paraphimosis should have been clear from the image.
• It was expected that candidates would be able to describe systematically how they would attempt reduction by manual compression preceded by appropriate analgesia or local anaesthesia.
• It was not adequate to simply refer for surgical management.

Question 4

A 15 year old boy is injured in a high speed motor vehicle crash. He was resuscitated at a local hospital and has just arrived in your emergency department. He was intubated, ventilated and resuscitated at a local hospital. A chest X-ray was taken on arrival.

• The chest X-ray shows an intubated patient with bilateral chest tubes, multiple rib fractures, lung contusion and fractured clavicle.
• Overall pass rate for this question was 31/56 (55.4%)
• There were many abnormalities to detect on this xray but examiners felt this was emergency medicine “core business” and so expected a high standard.
• The fractures, lung opacification, various lines/tubes all needed to be noted. It was then also expected that this would be synthesized into important diagnoses that shoudnt be missed (eg aortic injury) as well as the diagnoses that had been made (eg bony injuries) and the future problems that could be anticipated (eg impaired gas exchange).
• Some candidates failed by overreading the xray to report false positive findings.

Question 5

An 8 year old boy is brought to your emergency department after injuring his right arm in a fall from his bicycle. This is an isolated injury.

• The X-ray shows a displaced supracondylar fracture
• The overall pass rate for this question was 44/56 (78.6%).
• This was considered a straight forward question that most well prepared candidates would easily pass. The description/interpretation needed to include not only the grossly displaced fracture but also specifically mention that this is associated with the risk of neurovascular injury.
• Failing answers incorrectly described the film as a dislocation, did not emphasise the need for urgent reduction if there was vascular compromise and did not mention the paediatric specific issues of parental involvement (ie they only managed the fracture and not the child).

Question 6

An 80 year old woman presents to your emergency department with palpitations and breathlessness for three days. She had undergone coronary bypass grafting two weeks earlier.

• The ECG provided shows a narrow complex tachycardia with electrical alternans.
• Overall pass rate for this question was 45/56 (80.4%).
• Examiners noted that better answers correctly diagnosed the electrical alternans but it was still possible to pass by noting that this was a narrow complex rhythm of which possible causes included a pericardial effusion post surgery. It was incorrect to call the rhythm atrial fibrillation.
• It was expected that the list of possible causes for her breathlessness would be structured so as to highlight the important or likely causes in this particular patient.

Question 7

A 40 year old man presents to the emergency department with a history of chest pain two hours previously. He is now pain free.

• The ECG provided shows a change from broad to narrow complex rhythm across the ECG and ST/T changes suggesting a proximal LAD stenosis.
• Overall pass rate for this question was 36/56 (64.3%).
• The key to this question was to recognize ECG changes strongly indicative of a proximal left coronary stenosis which was visible in the second half of the ECG when the broad complex rhythm was no longer present.
• Candidates who failed did not appreciate the clinical significance of the ECG changes and the presumed site of stenosis, and therefore did not make clear the need for early angiography.

Question 8

A 65 year old man presents with painless loss of vision in his left eye. His fundoscopic examination is shown.

• The image of the retina suggests retinal vein occlusion.
• Overall pass rate for this question was 48/56 (85.7%).
• The examiners expected that candidates would highlight in their description the features of central retinal vein occlusion seen in the image such as venous tortuosity and retinal haemorrhages.
• The second part of the answer needed to make clear that this was an atherosclerotic/clotting process (and not an embolic one) and as such the causes were the systemic causes of these processes.
• Failing answers did not identify this as a central retinal vein occlusion or incorrectly described it as an embolic phenomenon.

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