Let's have a look at another VAQ from the old exam. This one is an ENT
question from 2006. Have a go at the questions, and then we'll go
through the examiner's comments as an illustration of where candidates
need to be prepared to go. Incidentally, it's not a large step from this
"old" question to one in the new format....
"A 12 year old boy presents with a 2 day history of fever and sore throat".
1. Describe and interpret the clinical image. (30%)
2. Describe your initial management (70%)
"A 12 year old boy presents with a 2 day history of fever and sore throat".
1. Describe and interpret the clinical image. (30%)
2. Describe your initial management (70%)
ANSWER & COMMENTARY
So here we are again. What are the examiners thinking? So, let's have a go at answering, and compare what we have to say to the examination report.
1. Describe the image
Several features stand out:
- a large asymmetric swelling of the right tonsil
- displacement of the uvula
As well as at least one important negative
- the absence of pus seen on the tonsils
So, how to we put all of that together? Given the way the mouth looks it seems like the obvious answer is a quinsy, so we need to mention that. Given the absence of pus it would be a reasonable thought that this might be an asymmetric tonsillitis, possibly due to EBV. We probably should mention that too....
So, what did the examiners have to say?
From the relevant exam report:
2. Describe your management.
In the old exam, this seemed to be a type of question that threw candidates badly.
The best way of answering management questions (in the old and new exams) is to visualize the patient in your ED, and ask yourself what you would do.
So, given that we have a 12 year old boy (expected weight 36kg) with a quinsy the elements I see myself involving in this patient's care are:
- IV antibiotics (benzylpenicillin 25-50mg/kg)
- analgesia: paracetamol 15mg/kg, ibuprofen 10mg tds and IN fentanyl 1.5ug/kg as needed
- I usually give these patients dexamethasone 0.15mg/kg
- he probably should be kept NBM, and have IV fluid maintenance ~76ml/hr
- ENT should be consulted to admit the patient and consider whether they want to perform a primary aspiration or surgical drainage of the infection
- if the child has signs of airway compromise (not stated in the question) a plan to secure his airway needs to be urgently formulated (hopefully in theater with ENT present).
- finally as this patient is a child the parents should be given information and involved in his care.
Now, there's nothing revolutionary in my reasoning there. I've simply written down (albeit in a reasonably long format) what I'd do for this patient.
What did the examiners say?
Remember that:
- care needs specific details
- supportive care (particularly analgesia) is an important part of managing patients
- disposition is an important part of management
- children should have their parents involved
- but most of all, unless you are able to write all of this down you won't score any marks! So, get used to visualizing the patient and putting down what you would do in real life. (After that the only challenge is doing it in a time efficient fashion!).
So here we are again. What are the examiners thinking? So, let's have a go at answering, and compare what we have to say to the examination report.
1. Describe the image
Several features stand out:
- a large asymmetric swelling of the right tonsil
- displacement of the uvula
As well as at least one important negative
- the absence of pus seen on the tonsils
So, how to we put all of that together? Given the way the mouth looks it seems like the obvious answer is a quinsy, so we need to mention that. Given the absence of pus it would be a reasonable thought that this might be an asymmetric tonsillitis, possibly due to EBV. We probably should mention that too....
So, what did the examiners have to say?
From the relevant exam report:
- The accompanying clinical photograph of the oropharynx shows an extensive unilateral peritonsillar swelling.
- Examiners expected a description that recognized the extensive peritonsilar swelling and gave prominence to quinsy as a likely diagnosis.
- Better answers mentioned other plausible diagnoses such as infectious mononucleosis.
2. Describe your management.
In the old exam, this seemed to be a type of question that threw candidates badly.
The best way of answering management questions (in the old and new exams) is to visualize the patient in your ED, and ask yourself what you would do.
So, given that we have a 12 year old boy (expected weight 36kg) with a quinsy the elements I see myself involving in this patient's care are:
- IV antibiotics (benzylpenicillin 25-50mg/kg)
- analgesia: paracetamol 15mg/kg, ibuprofen 10mg tds and IN fentanyl 1.5ug/kg as needed
- I usually give these patients dexamethasone 0.15mg/kg
- he probably should be kept NBM, and have IV fluid maintenance ~76ml/hr
- ENT should be consulted to admit the patient and consider whether they want to perform a primary aspiration or surgical drainage of the infection
- if the child has signs of airway compromise (not stated in the question) a plan to secure his airway needs to be urgently formulated (hopefully in theater with ENT present).
- finally as this patient is a child the parents should be given information and involved in his care.
Now, there's nothing revolutionary in my reasoning there. I've simply written down (albeit in a reasonably long format) what I'd do for this patient.
What did the examiners say?
- Supportive care such as analgesics and antipyretics were considered vital parts of management as well as specific antibiotic therapy.
- Better answers considered other options including drainage, dexamethasone, possible airway compromise (although this was not the major point of the question) and the likely need for admission – at least to a short stay ward. Since the scenario was one of a child it was important that the parents were involved in management
Remember that:
- care needs specific details
- supportive care (particularly analgesia) is an important part of managing patients
- disposition is an important part of management
- children should have their parents involved
- but most of all, unless you are able to write all of this down you won't score any marks! So, get used to visualizing the patient and putting down what you would do in real life. (After that the only challenge is doing it in a time efficient fashion!).