MONASH PRACTICE EXAM Question 14

A 60 year old female presents with left sided chest pain and shortness of breath. A CXR - (AP and lateral) is taken. They are shown on pages 11 and 12 of the props booklet. i. List three (3) positive and two (2) negative findings on the CXR. (5 marks)

Marks Cut score 12/19 (which I felt was generous) Pass rate 19/38 (50%) – Had cut score been 13/19, pass rate was 11/38 (29%) Mean 11.2

This is a description question Positive – Large left sided opacity – Raised hemi-diaphragm – Left lung collapse/atelactasis – Opacification left lunf field – Left hemi-diaphragm partially obscured – Pleural thickening/loculation – Left clavicular fracture (likely old due to callus)

Negative findings Normal heart size Trachea midline (though not marked down if mentioned deviated) Aorta and mediastinum normal No mediastinal shift No obvious Ptx No mastectomy Bones otherwise normal

Errors Not giving appropriate findings – Question asks for 3 +ve and 2 –ve Giving answer without any real understanding what the finding implies – Eg Trachea midline Writing a description without giving a site or location – “obscured left base” Writing something that isn’t relevant – “No radiological tension” Describing the same finding in multiple ways

Part ii Give three (3) relevant details about the major abnormality. (3 marks) Well circumscribed/smooth Large - roughly ½ hemithorax distance Pleural based Probably loculated Local mass effect Uniform density/no air fluid levels

Errors Repeating things already said in part I Not saying things relevant to the major abnormality Writing differentials Just saying it was big – a bit simplistic

Part iii List three (3) differential diagnoses. (3 marks) Pleural effusion/fluid – Reactive/post infective – Empyema – Malignant effusion Lung Pleural based – Blood Solid – Pleural based tumour (mesothelioma) – Soft tissue tumour (sarcoma)

Errors Wrong differentials – Abscess, TB, aspegilloma, pulmonary infarct, pneumonia Saying the same differential three ways – “Lung adenoca, lung small cell ca, mesothel” Medical student grade answers – “malignancy”, “tumour” – “trauma” – “Infection”

Part iv List and justify four (4) investigations you would perform on the day of her presentation. (8 marks)

Ix Bedside – ECG – BSL – Blood gas – FAST

Ix (cont) Radiological – USS (not FAST) – CT

Ix (Cont) Inflammatory markers – FBC, CRP Biochemistry – EUC, lipase Coags – NOT D-dimer

Errors Not completing the table Medical student grade answers – eg EUC to check renal function – CT to further characterize/gain more information about lesion Listing CTPA without CT Blood cultures/sputum without appropriate justification

Errors (cont) Stating things you’re unlikely to do on day of presentation – ICC – Quantiferon ABG for oxygenation Over emphasizing trauma Not putting appropriate emphasis – “Bedside USS”

Summary Fellowship level exam = Fellowship level description Read the questions!!! Leaving something blank = zero marks If the question seems hard, break it down into parts. Some may be much easier than others