The FRCEM Intermediate Question Style:

An example of a question about cardiology. We'll try to share different sample questions to prepare for the exam. The questions in the FRCEM Intermediate exam are short answer questions (SAQs). SAQs require the ability to formulate an answer based on the information given in the question without the advantage of having options to choose from. They usually take the form of a clinical scenario followed by a list of questions that require knowledge about the subject matter presented. The answers to the questions are usually agreed upon by a board of examiners before the examination. Additional answers encountered in the marking process can be added to the marking scheme if they hadn’t been thought of initially and they are agreed to be appropriate by the examining board. For this reason they are an excellent means of assessing candidates but require a great deal of input. An example of a typical FRCEM Intermediate SAQ is shown below: Dizziness: A 60-year-old man presents with dizziness and palpitations. Whilst in the Emergency Department the following rhythm strip is recorded:

(a) What is shown on the rhythm strip? (1 mark) Torsades de pointes (b) Which drug treatment should be initiated (please include dose)? (1 mark) 1-2 g of IV magnesium sulphate over 2-3 minutes (c) Give an electrolyte abnormality that is commonly associated with this condition? (1 mark) Any of: Hypokalaemia Hypomagnesaemia Hypocalcaemia Explanation: Torsades de pointes is a specific form of polymorphic ventricular tachycardia that occurs in the presence of prolongation of the QT interval. It has a very characteristic appearance in which the QRS complex appears to twist around the isoelectric baseline. A prolonged QT interval reflects prolonged myocayte repolarisation due to ion channel malfunction and also gives rise to early after-depolarisations (EADs). EADs can manifest as tall U waves, which can cause premature ventricular contractions (PVCs). Torsade de pointes is initiated when a PVC occurs during the preceding T wave (‘R on T’ phenomenon). It can be caused by any cause of prolongation of the QT interval: Myocardial infarction Electrolyte disturbance e.g. hypokalaemia, hypomagnesaemia and hypocalcaemia Congenital e.g. Romano-ward syndrome and Lange-Nielson syndrome Drugs e.g. disopyramide, amiodarone, sotalol, terfenadine The drug treatment of choice for torsades de pointes is IV magnesium sulphate. Magnesium sulphate acts by decreasing the influx of calcium and lowering the amplitude of EADs. DC cardioversion is usually kept as a last resort in a haemodynamically stable patient because of the paroxysmal and recurrent nature of torsade de pointes. Torsade de pointes can degenerate into ventricular fibrillation and result in sudden cardiac death.