This blog entry will be updated as we move along through the ACE the ACEM course.
Please review the blog entries on first steps and the cognitive matrix for starting your exam processes.
The exam committee usually provides 30-35 question topics with some suggested details and specific modifiers to the SAQ question setters to follow as a guide. All questions must be referenced to syllabus approved resources.
The topics are usually interrogated in the following modalities:
1. core knowledge
– eg treatment of meningitis – dexamethasone 4mg IV, ceftriaxone 2g IV stat
this is content that needs to be accurate, specific and detailed
eg – csf fluid lab result provided – interpretation required – this requires much practice in answering questions, but also understanding what consultant level thinking and clinical reasoning entail
databases on ECG’s, imaging, acid base, lab results, skin and clinical photos are important to be reviewing regularly
eg list a differential of organisms likely responsible in an elderly patient vs neonate
or state your management steps
4.Using consultant level language in answers
a regular error made in exams and stated in most exam reports published by the college – this ‘language’ can only be gained by reading good resources such as Rosens and UpToDate
It is important to focus on these modifiers and create some standard documents for yourself on each modifier
The modifier list is available in the curriculum framework document
eg Alcoholic patients: – I use an ABCDEFGHIJKLM…. approach
A – poor dentition, friable mucosa / bleeding- usually no issues with laryngoscopy but low FRC reserve means less time achieve intubation. Beware RSI and hypotension re cardiomyopathy or encephalopathy, chronic dehydration / unrecognised GI bleeding.
B – aspiration pneumonia, klebsiella pneumonia – immunocompromised
C – cardiomyopathy , AF, high cardiac output failure
D – encephalopathy, wernickes, unrecognised chronic subdural, cerebellar ataxia, risks of aspiration
E – cellulitis risks, hypothermia, poor skin barrier, electrolytemia Na.
F – dehydration, postural hypotension
G – peptic ulcer disease / varices / GI haemorrhage/ portal hypertension / ascites / spontaneous bacterial peritonitis / pancreatitis
H – bleeding diathesis – Childs Pugh score dependent
I – immunocompromised – lung, sepsis, klebsiella, staph skin, SBP, tooth abscess related endocarditis
Metabolic – alcoholic ketoacidosis – multiple medications, noncompliance / polypharmacy
Psychological – depression, suicidal, aggressive in ED
Social – itinerant / isolated / substance abuse
common modifiers in the exam include (but not a complete list)
ex premature neonate graduate
Neonates, toddlers and children
metabolic disease in children
syndromic children esp Trisomy 21
spinal patients / spina bifida
chemotherapy / bone marrow transplant
coad / asthma / CF
cardiomyopathy / vasculopath
IBD / chronic liver disease
severe autoimmune – RA or SLE or scleroderma – steroid dependent
chronic renal failure / dialysis patients / Peritoneal Dialysis
Stroke / parkinsons / schizophrenic
chronic pain / frequent attenders / recurrent abdominal pain
Violence / NAI / foster care / elder abuse / institutionalised / prisoners
NESBackground / refugees
hope that helps – happy studying!