Medical Assessment and Standard Setting Techniques for ENT Surgery Course

MEDICAL ASSESSMENT
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PART A:
SECTION 1: THE KNOWLEDGE COMPONENTS QUESTION
Testing Question example Ideal answer
Knowledge What is the normal range of blood
pressure in an adult?
Systolic blood pressure of between
90 to 120 mmHg and diastolic blood
pressure of between 60 to 90 mmHg
Procedure What is the procedure of measuring blood
pressure in an adult? Get the equipment ready and have
the patient seated in a relaxed
manner in a quiet room.
Introduce yourself to the patient and
gain consent to take his blood
pressure.
Wrap a properly sized cuff of the
sphygmomanometer around the
upper arm with the lower edge of the
cuff 5 cm from the cubital fossa.
Palpate for the brachial artery pulse
then lightly press the bell of the
stethoscope on the brachial artery at
the lower edge of the cuff.
Inflate the cuff rapidly to around 200
mmHg until the brachial artery pulse
is no longer heard using the
stethoscope.
Slowly release air from the cuff at a
rate of around 3 mm per second.
Listen keenly with the stethoscope as
you observe the sphygmomanometer.
The first Korotkoff sound
corresponds to the subject's
systolicblood pressure. The diastolic
pressure corresponds to the
disappearance of the last Korotkoff
sound.
Document the pressure in both arms
and calculate the difference; repeat

the procedure with the patient in
supine position and standing
position.
Measure the blood pressure for two
additional times if the subject’s blood
pressure is elevated, waiting for
around ten minutes between
measurements.
Concept What are the dangers of chronic high
blood pressure?
Dangers of high blood pressure
include cerebrovascular accidents
due to rapture of cerebral
microvasculature, accelerated
artherosclerosis and arteriosclerosis,
renal failure, heart failure,
hypertensive retinopathy
Principle
Explain why blood pressure measurement
in different positions yield different
results.
Blood pressure discrepancies with
varying positions are caused by
inputs from compensatory
mechanisms from the autonomic
nervous system and baroreceptors to
maintain the blood pressure within
the normal range.
The knowledge question simply requires the student to state the normal blood pressure
range, which is a universal fact that can be obtained from published literature. The student is not
required to think but to only remember the information and answer the question.
The second question on the procedure requires the student to outline the steps that are to
be followed in order to take blood pressure of a person. The student in this case is expected to be
systematic and chronological in outlining the steps as well as keep in mind the rationale
informing every step in the procedure.
The third question on concept requires the student to have read and create links in
knowledge on the pathophysiology of complications of uncontrolled hypertension. Hypertension
plays a major role in the pathogenesis of vascular disease such as arteriosclerosis due to
hyalinization of the arterial and capillary walls and acceleration of formation of atheroma in

atherosclerosis due increased endothelial injury that favors the fibrogenic processes. The
complications of hypertension mainly involve end organ damage such as nephropathy,
retinopathy, heart failure and stroke. Hypertensive nephropathy is secondary to hyalinization of
capillaries in the glomerulus, inhibiting the process of ultrafiltration. Hypertensive retinopathy is
secondary to rapture of capillaries in the retina leading to haemorrhage in the retina and eventual
loss of vision. Hypertensive heart disease is caused by elevated systemic blood pressure that
makes the heart to pump harder to counter the systemic pressure. This eventually leads to
increased metabolic demands of the myocardium giving rise to ischemic heart disease and
remodeling of the left ventricle that decreases the stroke volume leading to the signs and
symptoms of heart failure. long standing hypertension can also cause haemorrhagic stroke due to
rapture of vessels in the brain such as the middle cerebral artery. This leads to haemorrhage into
the brain and eventual infarction of the areas of the brain that are supplied by the affected artery
and pressure effect caused by the haematoma. This will manifest clinically with abnormal
findings on neurological examination.
The fourth question on principle requires the student to understand the physiologic basis
of variation in blood pressure with position and the mechanisms of short term regulation of blood
pressure. In this question, the student has to remember that changing positions varies regional
flow of blood which in turn affect inputs from the autonomic nervous system and the
baroreceptor mechanisms to maintain the blood pressure within the normal ranges.
SECTION 2
Consider the following MCQ:
The following statement is false as regards head injury patients
a. Patients with acute subdural hematoma present with loss of consciousness
b. Nasogastric tube insertion is contraindicated in patients with suspected fracture of base of
the skull
c. Skull fracture is a predisposition for epidural hematoma

d. Radiograph of the skull is the investigation of choice in a patient with reduced level of
consciousness
e. The normal range of intracranial pressure is between 10-30 mm Hg
The correct answer is d
Type Describe each type of validity
Describe how you would determine
each type of validity using your MCQ
as an example
Construct Construct validity refers to the degree
to which an assessment covers a
particular trait by demonstrating the
consistency of test score
interpretations with nomological
network entailing observational and
theoretical terms (Cronbach & Meehl,
1955).
This MCQ overs the basic concepts that a
medical student should understand as
regards the physiology, pathophysiology,
investigations and management of
patients who present with head injury.
Face Face validity answers the question of
whether a test appear to assess what it
claims to. The purpose of the test
should be clear even to naïve
responders.
This MCQ has a high face validity
because it aims to test for the student
understanding of principles of
management of head injury patients. For
instance, the patient should know that
insertion of a nasogastric tube is an
absolute contraindication in patients with
suspected base of skull fracture because
the tube can divert to the brain instead of
the stomach and lead to very serious
complications when it is used to
administer fluids and for aspiration.
Furthermore, the investigation of choice
for a patient with a lucid interval is a CT
scan or MRI and not a plain radiograph of
the skull. The MCQ is testing the
student’s understanding of head injury
and not any other topic.
Content This refers to the degree to which an
assessment measures the scope of the
subject. The questions asked should be
properly chosen for the level of
students as well as the content under
examination.
This MCQ has content validity because it
tests the minimum basic knowledge that
an undergraduate student is expected to
have regarding head injury. The options
are within the confines of the medical
student knowledge and not that of a
neurosurgeon.
Concurrent This refers to the extent of This MCQ has concurrent validity

relationship between a test and an
established standard that is existing
concurrently.
because it tests on the standard published
principles of management of patients with
head injury. The correct options are in
agreement with existing protocols that
have been published to guide
management of head injury patients and
prevent unnecessary costs and life
threatening complications.
Predictive This refers to the level to which an
assessment accurately presages future
occurrence of a criterion.
Students who score this question
correctly are likely to perform better in
Emergency department and intensive care
because they understand the principles of
recognition and management of head
injury patients.
Construct validity posits a test to cover as much of the essentials of the subject matter
extensively in order to give a clear picture of the students understanding of the content of the
subject under examination. From the example of the above MCQ, the question seeks to test
different aspects of diagnosis and management of head injury patients.
Regarding face validity, the question tests basic principles of head injury management
that are contained in the undergraduate curriculum for medical students hence it will be fair for
their level of knowledge.
The content of the subject being covered in the question is within the scope of what the
medical student is taught and is required to demonstrate mastery hence the question has content
validity.
As regards concurrent validity, the correct options in the MCQ are in congruence with the
latest publications on diagnosis and management of head injury patients.
Students who are able to score this MCQ correctly are more likely to do well in
traumatology, emergency medicine and intensive care courses as well as professional practice