FACEM VAQ 2006.1 Examiners Report

VISUAL AID QUESTIONS

• 27/40 (67.5%) 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 30 year old female is brought to your ED by ambulance following a suspected drug overdose. Her observations are: BP 90/60 mmHg (supine), RR 20/min, SaO2 99% (room air) and GCS 14. The ECG given shows a broad complex tachycardia

• The overall pass rate for this question was 30/40 (75%).
• Examiners expected that the ECG description would specify the rate of 130, broad QRS and prolonged QT likely to be TCA overdose (or other Na channel blocking agent).
• Initial management needed to focus on the need for bicarbonate/alkanisation and a low threshold for definitive airway management because of the high risk of rapid deterioration.
• Failing answers misinterpreted the ECG, including being unable to estimate the rate. Some missed the clues about a toxicological cause and assumed this was a primary cardiac problem. Others did not mention TCAs as a possible cause and saw no role for the use of bicarbonate.

Question 2

An 83 year old woman is transferred to your ED from her nursing home for assessment of abdominal pain. The abdominal Xray given shows grossly distended loops of bowel

• The overall pass rate for this question was 24/40 (60%).
• Examiners expected that the description would be detailed and lead to the likely conclusion of a volvulus. The image appeared to show both sides of a bowel wall raising the possibility of a perforation but recognising this was not essential to pass.
• The majority of the marks were for the management which needed to include decompression rectally and consider the impact of comorbidities (which are likely in such a patient) and the importance of expressed prior wishes or advance directives.

Question 3

A 23 year old male with a decreased level of consciousness is being assessed in your ED. His arterial blood gas results with reference ranges are shown

• Describe and interpret the results of his investigations. (100%)
• The overall pass rate for this question was 32/40 (80%).
• Although this was a complex set of results the only requirement was for a correct description of the results (profound metabolic acidosis, high anion and osmolar gaps) and a plausible synthesis such as an alcohol poisoning. Failing answers synthesized inappropriately (eg diabetic ketoacidosis) or merely reported the abnormalities (which could be done simply by reading the reference ranges) without qualifying their magnitude or significance.

Question 4

This 30 year old man was assaulted with a broom stick.

• A clinical photograph suggests conjunctival, corneal and anterior chamber injury.
• Overall pass rate for this question was 29/40 (72.5%)
• The examiners expected that a clear description as above would include a clear statement that this injury is sight threatening. The interpretation needed to include a differential diagnosis including a penetrating eye injury or ruptured globe. Failing answers did not offer such an interpretation

Question 5

An 11 year old female with Down’s syndrome presents with acute respiratory distress following a 3 day history of fever, rhinorrhoea and dry cough. A CXR is performed following her intubation.

• The CXR given shows extensive, bilateral pulmonary infiltrates
• The overall pass rate for this question was 35/40 (87.5%)
• It was expected that the candidates would be able to describe the CXR accurately and demonstrate that they are able to interpret the CXR in a systematic way, noting major positives and negatives, and including lung fields, cardiac size and borders, bone, diaphragms etc.
• It was also expected that the candidate could interpret the CXR sensibly in the clinical context (Down’s syndrome, dry cough) that was given, form a reasonable differential diagnosis, recognizing that the most likely diagnosis was infection, types of infection likely (both typical and atypical organisms), with other possibilities less likely

Question 6

A 40 year old man presents with delirium, scrotal pain and temperature of 390 C.

• The clinical photograph provided shows marked scrotal inflammation and necrosis.
• Overall pass rate for this question was 34/40 (85%).
• Examiners expected that candidates would recognize that the diagnosis was one of a life threatening, synergistic necrotizing cellulitis/fasciitis infection evidenced not just by the appearance of the picture but also by the presence of delirium. Management had to include early surgical involvement as well as broad spectrum antibiotics and aggressive resuscitation.
• It was expected that disposition would at least include consideration of ICU admission.
• Failing answers did not recognize how ill the patient was, resuscitated inadequately or did not involve surgeons for debridement

Question 7

A 54 year old woman presents to the ED with three days of painful swelling in her left wrist and hand.

• The clinical photograph given shows an inflamed left hand and forearm with a deforming bilateral polyarthropathy
• Overall pass rate for this question was 28/40 (70%).
• The examiners expected that the description would include the features of rheumatoid arthritis shown, the presence of vasculitic lesions on the fingers of the right hand, swelling and erythema of the left hand with a scar/healing wound on the same forearm.
• Tying this together in the interpretation meant this was probably cellulitis and/or joint/bone infection in the setting of rheumatoid arthritis. Relative immune compromise related to the disease or its treatment was likely to be a complicating factor. Failures were usually due to an inability to interpret this as rheumatoid arthritis.

Question 8

A 72 year old man presents by ambulance to your ED with onset of tachycardia and shortness of breath.

• The ECG given shows a regular, narrow complex tachycardia with widespread ischaemic changes
• Overall pass rate for this question was 25/40 (62.5%).
• The examiners noted that with the limited clinical information given and the number of ECG abnormalities present a reasonably broad range of possibilities need to be considered in the interpretation.
• The description needed to note the tachycardia which was atrial in origin and associated with significant ischaemic changes. The interpretation should have noted that this was likely to be a clinical situation requiring urgent treatment or referral.
• Failures were due to basic errors of description (often including findings that were not present) or due to providing very limited differentials.