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Question 3A 22 year-old motorcyclist is brought in by ambulance following a high-speed crash.
Current vital signs are
HR 130 bpm
RR 26 bpm
BP 95/50 mmHg
SaO2 95 % on high flow oxygen
GCS 11
A chest x-ray is taken following initial treatment.
a. Describe and interpret this x-ray (70%).
b. List your management priorities (30%).
2003.1 VAQ 8
An 18 year old woman with a history of asthma since childhood presents with a one month history of weight loss, cough and malaise. She has been treated with two courses of antibiotics by her local GP. She now presents with increasing shortness of breath. A CXR is shown.
Questiona. Describe the X-ray. (50%)b. List your differential diagnosis. (50%)
FACEM VAQ Exam 2003.1 – Question 8
Overall pass rate for this question was 65 / 83 (78.3%). This question also posed problems with image quality which made answering and
marking difficult for candidates and examiners alike. Examiners noted that answers rarely had a systematic approach for describing the X-
ray and for listing causes of fluid in the pleural space.
2003.2 VAQ 4
A distressed 60 year old man from a nursing home is brought into the ED having ‘choked on his dentures’.
Questiona. Describe the CXR findings. (50%)b. What further investigations may be indicated in this man? (50%)
FACEM VAQ Exam 2003.2 – Question 4
Overall pass rate for this question was 57 / 82 (69.5%) A CXR showing dentures overlying the mediastinum with probable air in the neck soft
tissues. The examiners felt that this was an extremely good question that tested candidates’
diagnostic ability, perception, common sense and knowledge. Nevertheless it could be passed largely by considering the possibility of oesophageal
perforation due to a foreign body. Common errors included not considering oesophageal perforation, indicating tracheal
perforation more likely, thinking the denture wires to be sternotomy wires, use of barium in diagnostic studies and failure to include a preoperative workup in investigations.
2004.1 VAQ 6
A two month old baby girl has been intubated for respiratory distress and drowsiness. The PaO2 is 82% post intubation.
Questiona. Describe and interpret the CXR findings. (50%)b. List the steps you would take to improve this infant’s poor arterial O2 saturation.
FACEM VAQ Exam 2004.1 – Question 6
Overall pass rate for this question was 57 / 69 (82.6%). A CXR demonstrating a right main intubation is shown. Examiners expected that the right main bronchus intubation would be recognized and
were surprised that some candidates interpreted the xray as showing a pneumothorax.
The question was an opportunity for candidates to demonstrate practical paediatric resuscitation knowledge.
It was expected that the answer in b) would include resorting to BVM with an Fi02 of 1.0 while other steps were being taken to improve oxygenation.
2005.2 VAQ 4
A 15 year old boy is injured in a high speed motor vehicle crash. He was resuscitated at a local hospital and has just arrived in your emergency department. He was intubated, ventilated and resuscitated at a local hospital. A chest X-ray was taken on arrival.
Questiona. Describe and interpret his chest X-ray. (100%)
FACEM VAQ Exam 2005.2 – Question 4
Overall pass rate for this question was 31/56 (55.4%) The chest X-ray shows an intubated patient with bilateral chest tubes, multiple rib
fractures, lung contusion and fractured clavicle. There were many abnormalities to detect on this xray but examiners felt this was
emergency medicine “core business” and so expected a high standard. The fractures, lung opacification, various lines/tubes all needed to be noted. It was then also expected that this would be synthesized into important diagnoses that
shoudnt be missed (eg aortic injury) as well as the diagnoses that had been made (eg bony injuries) and the future problems that could be anticipated (eg impaired gas exchange). Some candidates failed by overreading the xray to report false positive findings.
2006.1 VAQ 5
An 11 year old female with Down’s syndrome presents with acute respiratory distress following a 3 day history of fever, rhinorrhoea and dry cough. A CXR is performed following her intubation.
Questiona. Describe and interpret her CXR. (100%)
FACEM VAQ Exam 2006.1 – Question 5
The overall pass rate for this question was 35/40 (87.5%). The CXR given shows extensive, bilateral pulmonary infiltrates It was expected that the candidates would be able to describe the CXR accurately and
demonstrate that they are able to interpret the CXR in a systematic way, noting major positives and negatives,and including lung fields, cardiac size and borders, bone, diaphragms etc.
It was also expected that the candidate could interpret the CXR sensibly in the clinical context (Down’s syndrome, dry cough) that was given, form a reasonable differential diagnosis, recognizing that the most likely diagnosis was infection, types of infection likely (both typical and atypical organisms), with other possibilities less likely.
2007.1 VAQ 6
A 52 year old woman presents to your emergency department with gradually increasing breathlessness over the preceding three days. It is one week since her last chemotherapy treatment for cancer.
His observations are:
BP 130/70 mmHg supineRR 28 /minTemp 36.5 Celcius02 90 %RA
Questiona. Describe her Chest X-ray. (50%)b. Outline your differential diagnoses (50%)
FACEM VAQ Exam 2007.1 – Question 6
Overall pass rate for this question was 39/55 (70.9%). X-ray showed a large left pleural effusion, multiple discrete lung parenchymal lesions
typical of metastatic lung disease and a portocath. This was a high discrimination question in the opinion of the examiners. Good responses provided a good description of the radiograph and a reasoned
discussion of the possible diagnoses. Candidates failed because of poor use of x-ray descriptives, lack of a systematic
technique and vague/ inadequate differentials.
2007.2 VAQ 2
A 20 year old man presents to your emergency department with central chest pain that commenced after recreational drug use at a party two hours earlier.His observations are:
HR 108 /minHR 150/85 mmHg supineSO2 98 %
Questiona. Describe and interpret his Chest X-ray (50%)b. Outline your management. (50%)
FACEM VAQ Exam 2007.2 – Question 2
The overall pass rate for this question was 38/77 (49.4%). Chest X-ray showed mediastinal and subcutaneous emphysema. The examiners felt that this was an easy question poorly answered by many
candidates. Satisfactory answers systematically described the image and interpreted it in the light
of the clinical scenario. Management required knowledge of the supportive care of this condition and safe disposition of a drug affected patient.
Unsatisfactory answers failed to address the above or suggested the inappropriate insertion of an intercostal catheter.
2008.1 VAQ 2
An 80 year old male pedestrian is brought to your emergency department 30 minutes after being struck by a motorcycle at high speed.
QuestionDescribe and interpret his Chest X-ray (100%)
FACEM VAQ Exam 2008.1 – Question 2
Chest X-ray of trauma patient showing multiple rib fractures and underlying area of pulmonary contusion or haemothorax.
The overall pass rate for this question was 34/62 (54.8%). Good answers showed a systematic approach to reading an X-ray, identified the key
abnormalities, commented on relevant negatives and suggested the possibility of a flail segment.
Poor answers missed major findings or showed lack of a systematic approach.
A previously well 23 year old man is brought to your Emergency Department acutely short of breath after developing left sided chest pain at work. On arrival, he appeared pale and sweaty and was hypotensive. A CXR was taken immediately after a procedure was performed to stabilise his condition. His vital signs are now normal.
a. Describe and interpret his CXR (30%)b. Outline your treatment options (70%)
FACEM VAQ Exam 2009.1 – Question 2
The overall pass rate for this question was 71/81 (87.7%) Chest X-ray showing a pneumothorax with needle thoracostomy catheter in situ and
no evidence of radiological tension. The examiners viewed this as a good prop investigating a core emergent condition. Pass criteria were to identify the X-ray features, institute definitive drainage and
organize appropriate inpatient disposition. Fail criteria included failure to adequately describe the X-ray, treating the remaining
pneumothorax conservatively and sending the patient home.
Question 5
A 21 year old carpenter tells you that he has been stabbed in the chest by a colleague at work. He complains of pain and shortness of breath.On examination: GCS 15, P120, BP100/70, RR 30, O2 sats 94% on airAbove is an erect CXR of the patient.
a) Describe the x-ray.b) Describe your management.
Question 3A 22 year-old motorcyclist is brought in by ambulance following a high-speed crash.
Current vital signs are
HR 130 bpm
RR 26 bpm
BP 95/50 mmHg
SaO2 95 % on high flow oxygen
GCS 11
A chest x-ray is taken following initial treatment.
a. Describe and interpret this x-ray (70%).
b. List your management priorities (30%).
Preliminary Thoughts This guy is in trouble!
How can someone with a tracheostomy have “RR” and “high flow oxygen”?
Lots to write – better condense it.
Better not forget the stem.
Part A
Positive Findings Tension PTx on L
Subcutaneous emphysema
Bilateral ICC – not working on L (? misplaced)
Multiple L # ribs, incl 1st rib
Ruptured L hemidiaphragm
# L clavicle
Intra-tracheal device – looks like tracheostomy
Traumatic head injury
Shock – haemorrhagic, and also secondary to tension PTx
Relevant Negatives No radiological signs of haemothorax
Mediastinum not widened
Only one ECG lead point seen (L chest wall)
Interpretation Major Trauma – airway, ventilation and circulation concurrently compromised
Life threatening scenario
Needs action now
PART B Activate Trauma Response
Assume leadership – delegate tasks
Commence primary survey, concurrent with emergent Rx
Secure airway – if tracheostomy, establish patency and function
C spine immobilization (in line immob, if intubation required)
Decompress L chest with needle – then re-insert or re-position L ICC
Fluid resuscitation – crystalloids and O neg blood
Secondary survey following initial stabilisation
Fast track to definitive care – urgent laparotomy and probable thoracotomy
Communicate to resus team and all stakeholders, such as OT and ICU
2. A 40 year old man, who is previously well apart from a history of hypertension, presents via private car with a two hour history of severe chest pain.
His vital signs are:
GCS 15/15BP 185/110RR 12Sp02Afebrile
98% (room air)
a) Describe his CXR.
b) Outline your management.
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