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ACEM Fellowship VAQ

January 10, 2010 By sandnsurf 9 Comments

VAQ’s test a candidates ability to process visually presented information such as X-rays, pathology results and clinical images. The nature of the sources used for each exam is broadly outlined in the ACEM Training and Examination Handbook.

Each VAQ examination is run twice a year by the ACEM. To assist trainees studying for the examination, the Life in the Fast Lane team have reviewed the questions and examiners comments for each examination from 2003 to the present day. Although we do not have the original examination images we have used clinical images as close as possible to the true examination images in format and quality.

We hope this educational material will be of benefit to candidates studying for the exam as well as trainees in all disciplines around the world.

Updates to this table along with additional questions can be found at the FACEM VAQ permalink.

The VAQ examination contains 8 questions in 60 minutes (7.5 minutes per question). The 8 questions must include at least one of each of the following five sections

[ECG] Electrocardiogram [INVX] Investigations
[TRM] Trauma [PAED] Paediatric
[RAD] Radiology

It is also useful to define a section on clinical photographs [CLIN], which are not strictly a category in their own right, but which afford good revision material. There is obviously crossover between these sections, but in essence the commonest combination of questions includes

  • ECG [2 questions]
  • Radiology [2 questions - especially CXR and CT head]
  • Investigations [2 questions - usually an ABG and one of FBC/ELFT/Tox interpretation]
  • Clinical Image [2 photos - covering areas such as trauma, burns, rashes for example]

ACEM Fellowship VAQ Examination by Year

SittingQ1Q2Q3Q4Q5Q6Q7Q8Report
2009.1 ECG RAD INVX TRM PAED TRMECG RAD Report
2008.2ECG RADINVX CLIN PAED ECGINVX CLIN Report
2008.1ECG RADINVX TRM CLIN ECGRAD PAEDReport
2007.2ECG RADINVX TRM PAED ECGRAD INVXReport
2007.1ECG PAEDINVX TRM PAED ECGECG INVX Report
2006.2ECG RADRAD TRM PAED CLINECG CLIN Report
2006.1ECG RADINVX CLIN PAED CLINCLIN ECG Report
2005.2INVXRADCLIN TRM PAED ECGECG CLIN Report
2005.1INVXPAEDINVX TRM RAD ECG RAD PAED Report
2004.2CLININVXECGCLINRADPAEDTRMCLINReport
2004.1ECGRADCLINTRMINVXPAEDRADCLINReport
2003.2INVXPAEDCLINRADRADCLINECGTRMReport
2003.1ECGRADINVXTRMRADCLINTRMRADReport

** Items Marked in Red are without Clinical Images

Filed Under Clinical Case, Clinical Interpretation, Education, Exam, FACEM II, Featured, VAQ, eLearning Tagged With clinical cases, Exam, FACEM, VAQ

Neurological Mind-boggler #001

November 24, 2009 By Paul Young 3 Comments
Consider a 45 year-old HIV positive male with right hemiparesis and fluctuating conscious state.
His CT head is shown below.

CT #1

CT #2

Questions

Q1.Describe the CT Head findings.

This scan shows a left frontoparietal hypodense lesion with surrounding oedema and mass effect which shows enhancement with contrast.

Q2. Outline the differential diagnosis.

In HIV CNS lesions can be divided into those which exhibit mass effect and those that do not.

CNS lesions with mass effect include:

  1. toxoplasma encephalitis
  2. primary CNS lymphoma
  3. tuberculoma (more common in the developing world)
  4. other lesions are less common but include brain abscesses secondary to Staph, Strep, Salmonella, Aspergillus, Nocardia, Listeria & cryptococcus

NB: toxoplasmosis and primary CNS lymphoma are the most common

CNS lesions without mass effect are commonly due to progressive multifocal encephalopathy or HIV-associated encephalitis.

Filed Under CT scan, Clinical Case, Exam, Intensive Care, Investigation [tests], JFICM Tagged With clinical cases, JFICM, VAQ

Quiz Radiology 023

November 8, 2009 By sandnsurf Leave a Comment

An 18 year old woman with a history of asthma since childhood presents with a one month history of weight loss, cough and malaise. She has been treated with two courses of antibiotics by her local GP. She now presents with increasing shortness of breath. A CXR is shown.

Question

a. Describe the X-ray. (50%)
b. List your differential diagnosis. (50%)

20031 8 CXR 590x635 Quiz Radiology 023

Answer

FACEM VAQ Exam 2003.1 – Question 8

  • Overall pass rate for this question was 65 / 83 (78.3%).
  • This question also posed problems with image quality which made answering and marking difficult for candidates and examiners alike.
  • Examiners noted that answers rarely had a systematic approach for describing the X-ray and for listing causes of fluid in the pleural space.

Filed Under Chest X-Ray, Exam, FACEM II, Investigation [tests], VAQ Tagged With cxr, FACEM II, Radiol, VAQ

Quiz Trauma 013

November 8, 2009 By sandnsurf Leave a Comment

This 12 year old boy was a back seat passenger in a high speed road traffic accident. An X-ray of the thoraco lumbar spine is shown.

Question

a. Describe the X-ray and suggest possible mechanism for any injury identified. (50%)
b. What associated injuries should be sought for in this patient. (50%)

20031 7 XR Quiz Trauma 013

Answer

FACEM VAQ Exam 2003.1 – Question 7

  • Overall pass rate for this question was 80 / 83 (96.4%).
  • Examiners felt that this was a good trauma question but feedback from them was that the poor image quality was a distraction.
  • This issue was also noted by other commentators. The FEC was aware of the problem but unable to resolve it at short notice.
  • Examiners expected more than just naming it a chance fracture and were seeking an assessment of the posterior columns.
  • The associated injuries expected included spinal cord injury, intraabdominal related to flexioddistraction around a seatbelt fulcrum and other injuries related to a high speed RTC.
  • Inadequate answers only named (not described) the fracture and left out many of the important associated diagnoses.

Filed Under Exam, FACEM II, Investigation [tests], VAQ, X-Ray Tagged With FACEM II, Spine, Thoracic Spine, Trauma, VAQ, XR

Quiz Clinical 021

November 8, 2009 By sandnsurf Leave a Comment

A 19 year old female presents with a painful right eye and decreased vision after being out for most of the night previously at clubs. She is normally myopic. Her visual acuity is 6/24 in her right eye and 6/12 in her left eye. A photograph of the eye is shown.

Question

a. Describe the features and list your differential diagnosis. (50%)
b. Outline your further assessment. (50%)

20031 6 Eye s Quiz Clinical 021

Answer

FACEM VAQ Exam 2003.1 – Question 6

  • Overall pass rate for this question was 61 / 83 (73.5%).
  • This was thought to be a good question overall that had a number of levels enabling better candidates to do very well.
  • Failures were due to a combination of limited differentials for corneal haziness combined with limited assessment that followed from this.

Filed Under Exam, FACEM II, Ophthalmology, VAQ Tagged With clinical, Eye, FACEM II, VAQ

Quiz Radiology 022

November 8, 2009 By sandnsurf Leave a Comment

An 18 year old woman who is 26 weeks pregnant, presents with a two week history of malaise, cough and shortness of breath. She has a history of poorly controlled asthma. A CXR shows a moderately large right pleural effusion.

Her pleural aspirate shows:

InvestigationParameterResultReference Range
PLEURAL ASPIRATEAppearanceHazy
PLEURAL ASPIRATESupernatantClear, Yellow
CELL COUNTWCC800x106/L
CELL COUNTRCC31400x106/L
DIFFERENTIAL
(Deposit film)		Lymphocytes95%
DIFFERENTIAL
(Deposit film)		Monocytes5%
GRAM STAINNo Organisms seen
BIOCHEMISTRYProtein45g/L
BIOCHEMISTRYGlucose5mm/L

Question

a. What is the differential diagnosis? (50%)
b. What other investigations would be useful? (50%)

Answer

FACEM VAQ Exam 2003.1 – Question 5

  • The overall pass rate for this question was 65 / 83 (78.3%).
  • This was judged to be an appropriate question, though the 2nd question posed greater difficulty and could have arguably been allocated more time.
  • It was expected that major differentials would be covered in the first question such as TB, PE, malignancy, atypical infections and autoimmune disease.
  • The second question would then focus on investigations that supported or excluded these diagnoses including further tests on the pleural fluid.
  • Answers to the second question were often unstructured and showed a lack of knowledge. Some candidates did not appreciate the significance of the lymphocytosis in the film differential.

Filed Under Exam, FACEM II, Investigation [tests], VAQ Tagged With FACEM II, Radiology, VAQ

Quiz Investigation 016

November 7, 2009 By sandnsurf Leave a Comment

An 18 year old woman who is 26 weeks pregnant, presents with a two week history of malaise,cough and shortness of breath. She has a history of poorly controlled asthma. A CXR shows a moderately large right pleural effusion.

Her pleural aspirate shows:

Question

a. Describe and interpret her ECG (50%)
b. Outline your disposition considerations (50%)

Answer

FACEM VAQ Exam 2003.1 – Question 1

  • The overall pass rate for this question w26/81 (32.1%)
  • ECG showing first degree heart block, leevon and RBBB.
  • The examiner pair felt t trly by the ma of candidates.
  • Pass criteria were to identor monitorg ntially pacing.
  • Pass criteria were to identor monitorg ntially pacing.

Filed Under Exam, FACEM II, VAQ Tagged With Exam, FACEM, VAQ

Quiz Trauma 012

November 7, 2009 By sandnsurf Leave a Comment

This 19 year old man presents with an extremely painful knee after a tackle at soccer. He is unable to weight bear. A photograph of the knee is shown.

Question

a. Describe the findings on the photograph. (50%)
b. List the possible complications. (50%)

20031 4 Clin 590x440 Quiz Trauma 012

Answer

FACEM VAQ Exam 2003.1 – Question 4

  • Overall pass rate for this question was 64 / 83 (77.1%)
  • They expected a comprehensive description and an awareness of the neurovascular complications of knee dislocation.
  • Failures were due to misdiagnosis as a patella dislocation or a lack of knowledge of the neurovascular complications.

Filed Under Exam, FACEM II, Medical Specialty, Orthopedics, VAQ Tagged With FACEM II, Knee, Trauma, VAQ

Quiz Investigation 015

November 7, 2009 By sandnsurf Leave a Comment

A 29 year old woman is brought into the emergency department by a friend after being found in an agitated state. The woman is reluctant to be assessed and declines to give a history. The only available blood test is an arterial blood gas and electrolytes on room air.

Her results are:

InvestigationParameterReference range
PH7.31(7.35-7.45)
PC0230(35-45)
PO2104(75-100)
HC0318.5(22-33)
BE-4.8(-3.0-+3.0)
Sat99%(95-98%)
Fi 020.21
Na+141(135-145)
K+8.4(3.2-4.5)
Ca2+1.21(1.15-1.35)
Cl-113(100-110)

Question

a. Describe the blood test results. (50%)
b. List the differential diagnosis. (50%)

Answer

FACEM VAQ Exam 2003.1 – Question 3

  • The overall pass rate for this question was 55 1 83 (66.3%).
  • Examiners felt that this was a good question but were aware that, given the number of calculations that can be made from a combined gas 1 electrolyte result, that it was a big ask in the available time.
  • It was expected that an answer would note the normal anion gap metabolic acidosis, the respiratory alkalosis, hyperkalaemia and normal Aa gradient.
  • The differential diagnosis list could then include the causes of each of these.
  • Failures were due to arriving at the wrong summary / diagnosis and then trotting out the usual MUDPILES causes for an increased anion gap.

Filed Under Blood Results, Exam, FACEM II, Investigation [tests], VAQ Tagged With FACEM II, Investigations, VAQ

Quiz Radiology 021

November 7, 2009 By sandnsurf Leave a Comment

A head CT scan of an 83 year old woman has been performed, who has presented with a 3 day history of increasing confusion and unsteady gait following a fall. Her GCS is 12 (M5, V3, E4).

Question

a. Describe the CT scan. (50%)
b. What factors are important in determining this patient’s treatment? (50%)

20031 2 CT 590x582 Quiz Radiology 021

Answer

FACEM VAQ Exam 2003.1 – Question 2

  • The overall pass rate for this question was 71 / 83 (85.5%).
  • Examiners felt that this was an easy question. They noted that a comprehensive description of the features of the subdural was expected given this was half of the question and hence marks.
  • In the second part it was expected input would be required from multiple sources including patient, family, physician and neurosurgeon.
  • Failures were due to not addressing these issues or by making an incorrect diagnosis.

Filed Under CT scan, Exam, FACEM II, Investigation [tests], VAQ Tagged With CT, FACEM II, Radiology, VAQ

Quiz ECG 023

November 7, 2009 By sandnsurf 2 Comments

A 38 year old man collapses while playing squash. He spontaneously recovers during transport by ambulance. He has no known past medical problems. His observations are: BP 120/70, GCS 15, O2 sat 100% on 6L/min. An ECG is shown.

Question

a. Describe this ECG. (50%)
b. Outline this patient’s disposition and explain why. (50%)

ECG 20031 1 s Quiz ECG 023

Answer

FACEM VAQ Exam 2003.1 – Question 1

  • The overall pass rate for this question was 64 / 83 (77.1%).
  • ECG showed atrial flutter with variable block.
  • The examiners expected an accurate description of the rhythm and a plan to admit to a monitored bed with justifications for doing so (such as unstable rhythm or high grade block).
  • Failures were due to ECG misinterpretation or giving a treatment plan when disposition and why was asked for.

Filed Under ECG, Exam, FACEM II, Investigation [tests], VAQ Tagged With ECG, FACEM II, VAQ

Quiz Trauma 011

November 7, 2009 By sandnsurf Leave a Comment

An 40 year old man has sustained a crush injury to his left foot at work.

Question

a. Describe the X-ray. (40%)
b. How would you manage him? (60%)

20032 7 Foot 590x511 Quiz Trauma 011

Answer

FACEM VAQ Exam 2003.2 – Question 8

  • Overall pass rate for this question was 55 / 82 (67.1%%).
  • An X-ray showing tarsometatarsal disruption is shown.
  • This question generated remarks from invigilators about image quality but was not seen as an issue by the examiners who expected that the description would demonstrate the obvious fracture dislocations.
  • It was expected that there would be an appreciation of the potential for vascular compromise, compartment syndrome and long term disability.
  • Management should have included early referral for definitive orthopaedic repair.

Filed Under Exam, FACEM II, Investigation [tests], Medical Specialty, Orthopedics, VAQ, X-Ray Tagged With FACEM II, Foot, Trauma, VAQ

Quiz ECG 022

November 7, 2009 By sandnsurf Leave a Comment

This 23 year old man complains of palpitations and dizziness. His blood pressure is 70/50.

Question

a. Describe the ECG. (50%)
b. How would you manage this man. (50%)

20032 7 ECG s Quiz ECG 022

Answer

FACEM VAQ Exam 2003.2 – Question 7

  • Overall pass rate for this question was 42 / 82 (51.2%).
  • An ECG showing a rapid, regular tachycardia with borderline QRS width is shown.
  • Examiners felt that this was a good ECG demonstrating a problem that was important for an emergency physician to be able to interpret and manage.
  • It was expected that the ECG description would include a synthesis and mention of the factors that could be used to differentiate VT from PSVT with aberrancy.
  • Management was expected to include the use of cardioversion in this unstable patient.
  • Extra points were given for treating any underlying causes. Failures occurred due to use of inappropriate therapies such as verapamil or an unstructured approach to the ECG with VT not included in the differential.

Filed Under Exam, FACEM II, VAQ Tagged With ECG, FACEM, VAQ

Quiz Clinical 020

November 7, 2009 By sandnsurf Leave a Comment

A 26 year old man presents to the ED having been hit in the right eye with a wooden block thrown by his young child.

Question

a. Describe the photograph. (50%)
b. What are the potential complications of this injury? (50%)

20032 6 Eye s Quiz Clinical 020

Answer

FACEM VAQ Exam 2003.2 – Question 6

  • Overall pass rate for this question was 29 / 82 (35.4%).
  • A photograph showing a subconjunctival haemorrhage and hyphaema, with an irregular pupil is shown.
  • Examiners were very disappointed in the standard of answers to this question particularly as the key information in the stem guided the candidates towards the likely diagnoses.
  • They were concerned that answers also focused on injuries that were not consistent with the stated mechanism such as head injury, cervical spine trauma and skull fractures.
  • Such answers were specifically penalized as they showed lack of perspective and a tendency towards formulaic rather than considered answers.
  • Since the question specifically asked for complications related to this injury they were at a loss to explain why answers focused on issues other than the eye.

Filed Under Exam, FACEM II, Medical Specialty, Ophthalmology, VAQ Tagged With clinical, Eye, FACEM II, VAQ

Quiz Radiology 020

November 7, 2009 By sandnsurf Leave a Comment

An 45 year old man presents to your emergency department with vertigo and ataxia.

Question

a. Describe the CT. (30%)
b. What further investigations are indicated in this case? (70%)

20032 5 CT O 590x691 Quiz Radiology 020

Answer

FACEM VAQ Exam 2003.2 – Question 5

  • The overall pass rate for this question was 48 / 82 (58.5%).
  • A CT scan is performed. A CT scan showing bilateral areas of decreased attenuation in the cerebellum is shown.
  • This proved to be a testing question that highlighted many candidates’ inability to interpret CT scans.
  • It was considered to be an excellent test of consultant level knowledge.
  • To pass candidates needed to accurately report the areas of decreased attenuation and relate this to possible causes including cardiac, embolic, vascular and malignancy. Appreciating possible causes would then lead to common sense investigations as would occur “on the floor” in the ED.
  • Failures resulted from neglecting many of these issues or due to misreading the CT as a haemorrhage.

Filed Under CT scan, Exam, FACEM II, Investigation [tests], VAQ Tagged With CT, FACEM II, Radiology, VAQ

Quiz Radiology 019

November 7, 2009 By sandnsurf Leave a Comment

A distressed 60 year old man from a nursing home is brought into the ED having ‘choked on his dentures’.

Question

a. Describe the CXR findings. (50%)
b. What further investigations may be indicated in this man? (50%)

20032 4 CXR 590x484 Quiz Radiology 019

Answer

FACEM VAQ Exam 2003.2 – Question 4

  • Overall pass rate for this question was 57 / 82 (69.5%)
  • A CXR showing dentures overlying the mediastinum with probable air in the neck soft tissues.
  • The examiners felt that this was an extremely good question that tested candidates’ diagnostic ability, perception, common sense and knowledge.
  • Nevertheless it could be passed largely by considering the possibility of oesophageal perforation due to a foreign body.
  • Common errors included not considering oesophageal perforation, indicating tracheal perforation more likely, thinking the denture wires to be sternotomy wires, use of barium in diagnostic studies and failure to include a preoperative workup in investigations.

Filed Under Exam, FACEM II, VAQ Tagged With cxr, FACEM II, Radiology, VAQ

Quiz Clinical 019

November 7, 2009 By sandnsurf Leave a Comment

A 45 year old female gardener presented with a 5 day history of painful left middle finger. It is her dominant hand.

Question

a. Describe the photograph. (30%)
b. What are the possible complications in this case? (70%)

20032 3 Finger O 590x438 Quiz Clinical 019

Answer

FACEM VAQ Exam 2003.2 – Question 3

  • The overall pass rate for this question was 76 / 82 (92.7%).
  • A photograph of a blistered finger with a cellulitic hand is shown.
  • Although examiners liked the picture they found the questions did not allow them to differentiate candidates’ performance.
  • They expected that the description would include an assessment of severity and synthesis of a possible cause.
  • The management needed to be structured.
  • Failing candidates wrote very little in part a.

Filed Under Exam, FACEM II, VAQ Tagged With clinical, FACEM II, finger, VAQ

Quiz Paediatrics 015

November 7, 2009 By sandnsurf Leave a Comment

A 2½ year old girl presented with a history of injuring her feet on hot bitumen. Her feet have been cleaned.

Question

a. Describe the photograph. (30%)
b. What are the management issues? (70%)

20032 2 Burns Paed O 2jpg 590x441 Quiz Paediatrics 015

Answer

FACEM VAQ Exam 2003.2 – Question 2

  • The overall pass rate for this question was 61 / 82 (74.4%).
  • A picture of the child with burnt feet is shown
  • Examiners felt that this was a straightforward question but nevertheless noted deficiencies such as failing to describe the (whole) photograph as requested and not just the burns, wasting time covering resuscitation and burns fluid management when this was unlikely to be required and failing to appreciate this was a burn to a special area.
  • They expected an answer would include first aid, analgesia, consideration of NAI and referral as part of the disposition plan.

Filed Under Exam, FACEM II, VAQ Tagged With FACEM II, paediatrics, VAQ

Quiz Investigation 014

November 7, 2009 By sandnsurf Leave a Comment

A 45 year old alcoholic man presents following malaena and haematemesis. Urgent biochemistry is performed which shows:

InvestigationParameterUnitsReference Range
Na124mmol/L(135-145)
K3.4 mmol/L(3.2-4.5)
Cl91mmol/L(100-110)
Bicarb 27mmol/L(22-33)
Anion Gap26(4-13)
Osm(calc)257(270-290)
Glucose 7mmol/L(3.0-7.8)
Urea 10mmol/L(3.0-8.0)
Creat0.12mmol/L(0.07-0.12)
Protein83g/L(62-83)
Alb20g/L(33-47)
Bil254μmol/L(<20)
ALP178U/L(40-110)
AST107U/L(<40)
GGT 101U/L(<50)
ALT22U/L(<45)
LD393U/L(110-250)

Question

a. Describe the findings. (50%)
b. What further investigations are indicated in this case? (50%)

Answer

FACEM VAQ Exam 2003.2 – Question 1

  • The overall pass rate for this question was 44 / 82 (53.7%).
  • Examiners expected that the description of the results should be more than just a restating with reference to the printed normal ranges and indeed should include some synthesis of the major abnormalities with speculation as to the likely aetiologies.
  • The investigations ordered ideally included those relevant to both the scenario with GI bleeding (e.g. cross match and gastroscopy) and to the aetiology of the blood result abnormalities.
  • Those candidates who gave a rationale for their investigations were further rewarded.
  • The question could probably have been improved by allowing more time for part a) which was time consuming to answer.

Filed Under Blood Results, Exam, FACEM II, Investigation [tests], VAQ Tagged With FACEM II, Investigation [tests], VAQ

Quiz Clinical 018

November 7, 2009 By sandnsurf Leave a Comment

This 65 year old woman with diabetes presented one week after some minor trauma to her right foot.

Question

a. Describe and interpret the photograph. (50%)
b. What further investigations are indicated? (50%)

20041 8 Foot O 590x442 Quiz Clinical 018

Answer

FACEM VAQ Exam 2004.1 – Question 8

  • Overall pass rate for this question was 53 / 69 (76.8%).
  • An infected, necrotic foot ulcer is shown in the appended photograph.
  • This question demanded that the candidate not only describe the ulcer shown but also describe all of the features of the leg and speculate on the likely diagnosis and important differentials.
  • Investigations needed to address not just the ulcer itself but also search for underlying cause and possible complications.
  • Candidates who failed usually neglected to address some or all of these
    issues.

Filed Under Endocrinology, Exam, FACEM II, Medical Specialty, VAQ Tagged With clinical, FACEM II, VAQ
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