The FRCEM Intermediate (and the MRCEM Part B before it) is a difficult but essential step entering the Specialist Register. The paper is three hours long and comprises 60, three mark short answer questions (SAQs). The majority of the questions are 2 or 3 parts and some questions require two answers to earn a single mark i.e. each answer is worth half a mark.

The exam is mapped to the competences of Year 1-3 of the Emergency Medicine 2016 Curriculum (ACCS Plus), which is available on RCEM website. All applicants for the FRCEM Intermediate Certificate examinations are strongly advised to familiarise themselves with the Year 1-3 competencies in preparation for sitting the FRCEM Intermediate Certificate examinations, which can be found in the 2016 curriculum here.

The FRCEM Intermediate SAQ examination is mostly clinical and tests topics that are commonly encountered in the Emergency Department setting. The areas tested include:

  • General medicine
  • Toxicology
  • Trauma & Orthopaedics
  • Paediatrics
  • Surgery
  • Anaesthesia
  • Ophthalmology
  • ENT
  • Maxillofacial surgery
  • Obstetrics & Gynaecology
  • Psychiatry
  • Ethics & Law

 

The exam is marked using a modified Angoff method where a cut-off score is defined as the score a minimally acceptable candidate is likely to achieve. One standard error of measurement will be added to the cut-off scores identified using the Angoff method to calculate the required final pass mark for the paper.

Sitting practice questions is a great way to prepare for the FRCEM Intermediate SAQ exam. Here are a few to get you started.

  1. A 30-year-old businessman presents with sudden onset breathlessness and left sided pleuritic chest pain. He has recently returned from a trip to Australia. His observations are as follows: temp 38.2°C,oxygen saturations 93% on air, heart rate 110 bpm, RR 24, BP 122/63 mmHg. On examination he has a tender swollen right calf. His chest X-ray reveals no obvious abnormalities.

(a) What is the most likely diagnosis? (1 mark)
(b) Which two investigations should be arranged? (2 marks)

 

Show Answer

Answers:

(a) Pulmonary embolus
(b) CT pulmonary angiogram & Doppler ultrasound scan of right leg

 

The clinical history and examination in this case is highly suggestive of a pulmonary embolus secondary to a deep vein thrombosis in his right leg. He should have a CT pulmonary angiogram and doppler ultrasound scan of his right leg organized to confirm this.

The clinical features of a pulmonary embolus include:

  • Shortness of breath
  • Pleuritic chest pain
  • Cough and/or haemoptysis
  • Symptoms suggestive of co-existing deep vein thrombosis
  • Tachypnoea and tachycardia
  • Pyrexia

 

In severe cases there may be signs of systemic shock, a gallop heart rhythm and elevated jugular venous pressure.

  1. A 27-year-old woman presented ten days earlier with a fever, suprapubic tenderness, and vaginal discharge. A diagnosis of pelvic inflammatory disease was made and antibiotics commenced. She initially improved but re-presents 10 days later with severe lower abdominal pain and a temperature of 39.5°C.

(a) What is the most likely diagnosis? (1 mark)
(b) What is the most appropriate initial investigation? (1 mark)
(c) What is the definitive treatment for this condition? (1 mark)

Show Answer

Answers:

(a) Tubo-ovarian abscess
(b) Ultrasound scan
(c) Draining of the abscess (Ultrasound or CT guided)

 

This patient is highly likely to have developed a tubo-ovarian abscess (TOA). It is a complication of pelvic inflammatory disease, where an encapsulated pocket of pus forms in the fallopian tube and/or ovary. TOA can be life-threatening if the abscess ruptures and results in sepsis.

Transabdominal and endovaginal ultrasound is the initial imaging modality of choice, and often shows multilocular complex retro-uterine/adnexal mass(es) with debris, septations, and irregular thick walls. These masses can also be bilateral.

Urgent hospital admission is required and management is usually with drainage of the abscess along with the administration of intravenous antibiotics. Drainage of the abscess can be guided by ultrasound or CT scanning.

Laparotomy or laparoscopy with drainage of abscess may be required in some cases.

  1. A 21-year-old man suffers a lower limb as a consequence of a motorcycle accident. As a consequence of his injuries he is unable to dorsiflex his left foot and toes, and he has loss of sensation over the posterior and lateral surface of his lower leg.

(a) Which nerve has been injured in this case? (1 mark
(b) Which X-ray should be performed? (1 mark)
(c) Which fracture is likely to be present? (1 mark)

Show Answer

Answers:

(a) The common peroneal nerve
(b) Knee X-ray
(c) Neck of fibula fracture

 

Foot drop is significant weakness of ankle and toe dorsiflexion and is caused by damage to the common peroneal nerve.

The common peroneal nerve is the most commonly damaged nerve in the lower limb and is relatively unprotected as it traverses the lateral aspect of the head of the fibula. It can be damaged by:

  • Acute trauma e.g. fractures to head or neck of the fibula
  • Nerve compression e.g. poorly fitted plaster casts, sleeping in abnormal positions
  • Surgery e.g. total knee replacement
  • Masses e.g. Baker’s cysts
  • Mononeuritis multiplex

 

The common peroneal nerve has two motor branches and one sensory branch:

  • The superficial peroneal nerve – supplies peroneus longus and peroneus brevis (responsible for foot eversion and plantarflexion)
  • The deep peroneal nerve – supplies tibialis anterior, extensor hallucis longus, extensor digitorum longus, peroneus tertius and some of the intrinsic muscles of the foot (responsible for foot dorsiflexion and toe extension)
  • The lateral sural cutaneous nerve – supplies the skin on the posterior and lateral surface of the leg

 

The principal clinical features of common peroneal nerve palsy are foot drop and loss of sensation over the dorsal surface of the foot and portions of the anterior and lower lateral leg.

  1. An 88-year-old woman is brought to the Emergency Department by her son with chest pain. She collapses in the department and is unconscious. The previous month she had handed over any decisions about her health to her son as she was concerned that she would develop dementia sometime in the future.

(a) What is the name of the position that her son now has in reference to decisions about her health? (1 mark)
(b) With whom does this have to be registered to be valid? (1 mark)
(c) When would the son’s role become valid? (1 mark)

Show Answer

(a) He has Lasting Power of Attorney
(b) With the Office of the Public Guardian
(c) When his mother lacks the capacity to make decisions herself

 

A Lasting Power of Attorney (LPA) allows a person over 18 to appoint one or more people to look after their health and welfare and/or financial decisions if, at some point in the future, they lack the capacity to do this for themselves. The person making the LPA is the donor. The person (or persons) appointed to make decisions is known as an attorney.

There are two different types of LPA:

  1. A Personal Welfare LPA is for decisions about both health and personal welfare; and
  2. A Property and Affairs LPA is for decisions about financial matters.

 

An LPA must be registered with the office of the public guardian in order to be valid. This process takes 8-10 weeks and costs £82 per LPA.

  1. A 27-year-old man presents with pain in his left testis that has been present for the past 2 days. The pain has been getting gradually worse and there is now also noticeable swelling of the testis. On examination he is febrile with a temperature of 38.3°C and the scrotum appears red and oedematous on the affected side. The testis is tender on palpation.

(a) What is the most likely diagnosis? (1 mark)
(b) What are the two most likely causative organisms in a patient of this age? (2 marks)

Show Answer

Answers:

(a) Epididymo-orchitis
(b) Chlamydia trachomatis & Neisseria gonorrhoeae

 

Epididymo-orchitis is inflammation of the testis and epididymis from an infective cause. The most common route of infection is local extension and it is mainly due to infections spreading from the urethra or the bladder.

In patients under the age of 35 it is most commonly caused by sexually transmitted pathogens, such as Chlamydia trachomatis and Neisseria gonorrhoeae. In patients over the age of 35 it is most commonly non-sexually transmitted and due to Gram negative enteric organisms causing urinary tract infections.

Patients with epididymo-orchitis usually present with unilateral scrotal pain and swelling of a relatively acute onset. The affected testis will be tender to palpation and there is usually a palpable swelling of the epididymis starting with the tail at the lower pole of the testis and spreading towards the head at the upper pole of the testis. The testis itself can be involved and there is sometimes erythema and/or oedema of the scrotum on the affected side. Patients may be pyrexial and urethral discharge may also be present.

The most important differential diagnosis is that of testicular torsion. It should be considered in all patients with acute onset testicular pain, as testicular salvage is required within 6 hours of onset. Torsion is more likely in men under the age of 20 and if the pain is very acute and severe. It typically presents around fours hours after onset. In this case the patients age, more protracted history and the presence of a pyrexia is more suggestive of epididymo-orchitis.

 


Thank you to the joint editorial team of www.frcemexamprep.co.uk for this ‘Exam Tips’ post.

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