FACEM VAQ 2007.1 Examiners Report

VISUAL AID QUESTIONS

36/55 (65.5%) 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:

	Grade (/10)	Frequency (N)
	10	-
	9	-
	8	4
	7	5
	6	3
	5	24
	4	8
	3	8
	2	1
	1	1
	0	1

Question 1

A 54 year old man presents with one hour of severe central chest pain. His 12 lead ECG is shown, with three additional right-sided praecordial leads.

ECG showed changes of Infero-postero-lateral AMI
The overall pass rate for this question was 38/55 (69.1%).
This question was regarded as highly discriminative by the examiners. Good answers provided a systematic approach to the ECG and a good discussion of fluid loading and reperfusion strategies.
Failed responses failed to adequately interpret the ECG and/or mention reperfusion

Question 2

An 8 month old child presents with one day of vomiting and abdominal distension. His abdominal X-ray is shown.

X-ray showed small bowel dilatation with fluid levels in the L upper quadrant and soft tissue shadowing in the R lower quadrant suggestive of an intussusceptum within the bowel lumen.
The overall pass rate for this question was 32/55 (58.2%).
The examiners felt that this was an excellent question. Poor responses failed to describe the image adequately and/or featured poor management options.

Question 3

An 85 year old woman is in your emergency department awaiting a surgical ward bed for treatment of a bowel obstruction. After becoming increasingly tired and breathless, the following investigations are performed. Describe and interpret the results of her investigations.

Clinical Chemistry showed a mixed acid–base abnormality (resp acidosis and low Chloride metabolic acidosis) plus evidence of hypoperfusion/dehydration (raised lactate and urea with normal creatinine)
The overall pass rate for this question was 40/55 (72.7%).
This question was regarded as a good mid-level discriminator with a wide spread of marks allocated. Poor responses failed to show an understanding of mixed acid/base disturbances, the causes of metabolic alkalosis and compensatory responses to this condition. Better responses calculated secondary values for anion gap and A-a gradient plus discussed possible causes for the renal impairment and elevated lactate.

Question 4

A 25 year old man sustains facial injuries in a high speed motor vehicle crash in which he was the unrestrained driver.

Photo showed a badly swollen face with bilateral periorbital bruising and a haemoserous nasal discharge.
Overall pass rate for this question was 44/55 (80.0%)
The examiners felt that this was a good image with multiple findings to discuss. The area of concern for the markers was a lack of appreciation by many candidates of the difficulty that might accompany the need to intubate such a patient.

Question 5

A 7 year old child has had these lesions on his legs for seven days. His 4 year old sister has the same skin eruption.

Photo showed multiple pustular lesions on the shin typical of impetigo.
The overall pass rate for this question was 35/55 (63.6%).
Examiners agreed that this a good image of a common paediatric skin infection.
Candidates failing the question failed to make the diagnosis of impetigo and/or discuss directly relevant treatment options.

Question 6

A 52 year old woman presents to your emergency department with gradually increasing breathlessness over the preceding three days. It is one week since her last chemotherapy treatment for cancer.

X-ray showed a large left pleural effusion, multiple discrete lung parenchymal lesions typical of metastatic lung disease and a PIC line.
Overall pass rate for this question was 39/55 (70.9%).
This was a high discrimination question in the opinion of the examiners.
Good responses provided a good description of the radiograph and a reasoned discussion of the possible diagnoses.
Candidates failed because of poor use of x-ray descriptives, lack of a systematic technique and vague/ inadequate differentials.

Question 7

A 49 year old woman presents to your emergency department with central chest pain.

ECG showed widespread T wave inversion, concave up ST elevation and PR depression inviting in this clinical context a discussion re a number of differentials.
Overall pass rate for this question was 32/55 (58.2%).
This was viewed as a difficult but relevant ECG which was satisfactorily interpreted by most candidates.
The discussion re echocardiography was generally superficial and was the major reason for poor scores.

Question 8

A 4 year old boy arrives at your urban district emergency department one hour after falling from a playground slide. He opens his eyes to speech, uses inappropriate words and obeys commands (GCS 12). The nearest neurosurgical service is twenty minutes away by road ambulance.

Scan showed a large L extradural haematoma with mass effect.
Overall pass rate for this question was 40/55 (72.7%).
The examiners felt that this was an excellent question backed by a high quality image. The CT scan description was generally well done. Major reason for poor scores on this question was failure to provide adequate reasons pro and con intubation in this case.
Writing was particularly problematic to the examiners in interpreting the answers.