MONASH PRACTICE EXAM
2015.2
Question 14
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