Chest Radiology Practice Questions

Q: A 12-year-old child presents with mild fever, runny nose, sore throat, and cough for 3 days. Clinical examination is consistent with an upper respiratory tract infection (URTI). There is no respiratory distress, oxygen desaturation, or focal chest findings. What is the most appropriate next step regarding imaging?

No further radiological investigation is required. ***No further radiological investigation is required*** - In a patient with a straightforward, **uncomplicated upper respiratory tract infection** (URTI) and no concerning signs such as respiratory distress, hypoxia, or abnormal lung auscultation, clinical diagnosis is sufficient. - **Radiological investigations** like chest X-rays are not indicated for suspected viral URTIs unless there is clinical evidence of **lower respiratory tract involvement** or complications like pneumonia. *Digital chest X-ray* - An X-ray is generally not recommended for **mild, self-limiting respiratory symptoms** where physical exam findings are normal. - Routine imaging in pediatric patients with uncomplicated URTI exposes the child to **unnecessary ionizing radiation** and rarely changes management. *Plain CT chest* - A **computed tomography (CT) scan** provides significant radiation exposure and is completely inappropriate for evaluating a standard pediatric URTI. - It is a diagnostic tool reserved for complex, **diagnostic dilemmas** or suspected deep-seated thoracic disease after initial, less invasive imaging has been inconclusive. *HRCT chest* - **High-resolution computed tomography (HRCT)** is an advanced imaging modality specifically used for evaluating interstitial lung disease or complex airway pathology. - It is contraindicated as an initial screening tool in this scenario due to its high cost, radiation dose, and lack of clinical indication.

Q: Mediastinal lymph node calcification is seen in which one of the following?

Bronchiectasis. **Explanation:** **1. Why Bronchiectasis is the Correct Answer:** In the context of this specific question, mediastinal lymph node calcification is a recognized feature of **Bronchiectasis**, particularly when it occurs secondary to chronic granulomatous infections like **Tuberculosis (TB)**. TB is the most common cause of both bronchiectasis and mediastinal nodal calcification in the Indian subcontinent. Chronic inflammation and recurrent infections in bronchiectatic lungs lead to reactive lymphadenopathy, which subsequently undergoes dystrophic calcification. **2. Analysis of Incorrect Options:** * **Metastatic Neoplasm:** While some mucinous adenocarcinomas (colon, ovary) or osteosarcomas can cause calcified nodes, it is not a primary or classic feature of general metastatic spread to the mediastinum. * **Lymphoma:** Lymph nodes in lymphoma are typically large and homogenous. Calcification is **rarely** seen before treatment. If present, it usually occurs *after* radiotherapy or chemotherapy. * **Sarcoidosis:** While sarcoidosis classically causes bilateral hilar and paratracheal lymphadenopathy, calcification (specifically "eggshell calcification") occurs in only about 5% of cases and usually in the late, chronic stages. **3. NEET-PG Clinical Pearls:** * **Eggshell Calcification:** Classically seen in **Silicosis** (most common) and Sarcoidosis. * **Popcorn Calcification:** Pathognomonic for **Pulmonary Hamartoma**. * **Stippled/Eccentric Calcification:** Often associated with **Malignancy** (Bronchogenic carcinoma). * **Dense/Homogenous Calcification:** Usually indicates a benign process like **Healed TB** or Histoplasmosis. * **Tram-track signs and Signet ring signs** are the classic radiological hallmarks of bronchiectasis itself on HRCT.

Q: All of the following radiologic features are seen in patients with chronic cor pulmonale, except?

Kerley's B lines. **Explanation:** **Cor pulmonale** refers to right ventricular hypertrophy and/or dilatation resulting from pulmonary hypertension (PH) caused by diseases of the lung parenchyma or pulmonary vasculature. **1. Why Kerley’s B lines is the correct answer:** Kerley’s B lines are short, horizontal lines seen at the lung bases, representing thickened interlobular septa. They are a hallmark of **pulmonary venous hypertension**, most commonly seen in **left-sided heart failure** (e.g., mitral stenosis or left ventricular failure). In pure cor pulmonale, the pathology is "pre-capillary"; therefore, pulmonary venous pressure remains normal, and Kerley’s B lines are typically absent. **2. Analysis of incorrect options:** * **Options A & C (Prominence/Dilatation of pulmonary arteries):** Chronic PH leads to increased pressure in the pulmonary circuit, causing compensatory dilatation of the **main pulmonary artery** and its major branches (hilar vessels). A main pulmonary artery diameter >29 mm on CT is a classic sign of PH. * **Option D (Attenuated peripheral vessels):** As central arteries dilate, there is a "pruning" effect where peripheral vessels become narrow and attenuated (the " Westermark-like" appearance). This discrepancy between large central and small peripheral vessels is a key feature of chronic cor pulmonale. **Clinical Pearls for NEET-PG:** * **Egg-shell calcification** of hilar nodes is associated with Silicosis, not Cor Pulmonale. * **Right Ventricular Enlargement** on CXR is best seen on the lateral view (obliteration of the retrosternal air space). * **Gold Standard** for diagnosing pulmonary hypertension remains **Right Heart Catheterization** (mean PAP >20 mmHg).

Q: Non-visualization of the gastric fundic bubble in the retrocardiac region suggests which of the following?

Achalasia cardia. ### Explanation **Correct Answer: C. Achalasia cardia** **Why it is correct:** Achalasia cardia is a primary esophageal motility disorder characterized by the failure of the Lower Esophageal Sphincter (LES) to relax and the absence of esophageal peristalsis. In a normal chest X-ray (CXR), the **gastric fundic bubble** is visible due to swallowed air reaching the stomach. In Achalasia, the tonic contraction of the LES acts as a functional barrier, preventing swallowed air from entering the stomach. Consequently, the gastric bubble is absent or significantly diminished in size. **Analysis of Incorrect Options:** * **A. Carcinoma Esophagus:** While advanced malignancy can cause obstruction, it is usually irregular and rarely results in the complete, chronic absence of the gastric bubble seen in Achalasia. CXR is more likely to show a retrocardiac mass or mediastinal widening. * **B. Esophageal Web:** These are thin mucosal folds (commonly seen in Plummer-Vinson syndrome) that cause partial obstruction in the upper esophagus. They do not prevent air from reaching the stomach. * **D. Congenital Hypertrophic Pyloric Stenosis (CHPS):** This is a gastric outlet obstruction. Since the obstruction is distal to the stomach, the gastric bubble is typically **enlarged** (distended stomach) rather than absent. **High-Yield Clinical Pearls for NEET-PG:** 1. **CXR Findings in Achalasia:** Absent gastric bubble, mediastinal widening (dilated esophagus), and occasionally an air-fluid level in the posterior mediastinum. 2. **Barium Swallow:** Shows the classic **"Bird’s Beak"** or "Rat-tail" appearance (smooth tapering). 3. **Gold Standard Diagnosis:** **Esophageal Manometry** (shows incomplete LES relaxation and aperistalsis). 4. **Heller’s Myotomy:** The definitive surgical treatment, often combined with a partial fundoplication to prevent reflux.

Q: A 53-year-old woman presents with mild dyspnea. PA and lateral chest radiographs are shown, demonstrating a well-defined, lobulated mass forming obtuse angles with the chest wall, consistent with a pleural-based origin. Which one of the following is the MOST likely diagnosis?

Solitary fibrous tumor. ***Solitary fibrous tumor*** - Presents as a **well-defined, lobulated, pleural-based mass** on chest radiograph, characteristic of this usually benign tumor arising from pleural mesenchymal cells. - Typically occurs in **middle-aged adults** and can cause mild dyspnea due to mass effect, fitting this patient's presentation. *Mesothelioma* - Characterized by **diffuse pleural thickening** and **pleural effusion**, not a well-defined solitary mass. - Associated with **asbestos exposure** and presents with more severe symptoms including chest pain and weight loss. *Empyema* - Appears as a **lenticular-shaped fluid collection** with **air-fluid levels** on lateral chest X-ray, not a solid mass. - Associated with **fever**, **purulent pleural effusion**, and history of pneumonia or chest trauma. *Bronchogenic carcinoma* - Typically arises from the **lung parenchyma** or **hilum**, not as a pleural-based mass. - Often presents with **irregular, spiculated margins** and may have associated **hilar lymphadenopathy** or lung nodules.

Q: What is the investigation of choice for a solitary pulmonary nodule?

CT Scan. **Explanation:** A **Solitary Pulmonary Nodule (SPN)** is defined as a single, well-circumscribed opacity measuring $\leq$ 3 cm in diameter, surrounded by aerated lung, and without associated atelectasis or lymphadenopathy. **Why CT Scan is the Investigation of Choice:** Contrast-Enhanced Computed Tomography (CECT) of the chest is the gold standard for evaluating an SPN. It provides superior spatial resolution, allowing for the precise assessment of morphological features that help differentiate benign from malignant lesions. Key features evaluated on CT include: * **Margins:** Spiculated (malignant) vs. smooth (benign). * **Calcification patterns:** Eccentric/stippled (malignant) vs. central/popcorn/diffuse (benign). * **Density:** Measured in Hounsfield Units (HU); fat density suggests a hamartoma. * **Growth:** Comparing doubling time with previous scans. **Why other options are incorrect:** * **X-ray:** Usually the initial modality where a nodule is first detected, but it lacks the sensitivity to characterize the internal features or detect small nodules (< 5 mm). * **MRI:** Limited role in lung parenchyma due to low proton density and motion artifacts from respiration. It is generally reserved for evaluating chest wall invasion or Pancoast tumors. * **Ultrasound:** Ineffective for lung parenchyma because air reflects ultrasound waves. It is only useful for peripheral lesions abutting the pleura or for guiding biopsies. **High-Yield Clinical Pearls for NEET-PG:** * **Size Matters:** Lesions > 3 cm are termed "Lung Masses" and have a much higher risk of malignancy. * **Popcorn Calcification:** Pathognomonic for **Pulmonary Hamartoma**. * **Fleischner Society Guidelines:** These are used to determine the follow-up frequency of nodules based on size and patient risk factors. * **PET-CT:** The best non-invasive modality to assess the metabolic activity of a nodule (standardized uptake value, SUV > 2.5 suggests malignancy).

Q: What findings are shown on the chest X-ray of the patient?

Reticulonodular shadows. ***Reticulonodular shadows*** - **Reticular pattern** appears as a fine, net-like or lace-like pattern of linear opacities on chest X-ray, typically indicating **interstitial lung disease**. - This pattern is commonly associated with **pulmonary fibrosis** and represents thickened interstitial septa and alveolar walls. *Emphysema* - Characterized by **hyperinflation** and **flattened diaphragms** with increased lung volumes, not reticular patterns. - Shows **decreased vascular markings** and **hyperlucent lung fields** due to destruction of alveolar walls. *Batwing edema* - Presents as bilateral **perihilar opacities** in a butterfly or bat-wing configuration, typically seen in **acute pulmonary edema**. - Associated with **cardiogenic pulmonary edema** and shows **air-space consolidation**, not reticular patterns. *Kerley B lines* - Appear as thin, horizontal **septal lines** at the lung periphery, typically in the **lower zones**. - Represent thickened interlobular septa due to **pulmonary edema** or **lymphatic congestion**, distinct from reticular shadows.

Question 1

A 12-year-old child presents with mild fever, runny nose, sore throat, and cough for 3 days.
Clinical examination is consistent with an upper respiratory tract infection (URTI). There is no
respiratory distress, oxygen desaturation, or focal chest findings. What is the most appropriate
next step regarding imaging?

Accepted Answer

No further radiological investigation is required

Answer

Digital chest X-ray

Answer

Plain CT chest

Answer

HRCT chest

Question 2

A 58-year-old male smoker presents with a 3-month history of progressive dyspnoea, haemoptysis, and 8 kg weight loss. Spirometry shows a mild obstructive pattern. Examination reveals reduced breath sounds at the right apex. A PA chest radiograph is shown in Image 2. Which of the following is the most likely diagnosis?

Accepted Answer

A. Right upper lobe collapse secondary to a central obstructing endobronchial lesion

Answer

D. Fibrocavitary pulmonary tuberculosis with right upper lobe scarring

Answer

B. Right upper lobe consolidation due to post-obstructive pneumonia

Answer

C. Right-sided pleural effusion with passive atelectasis of the upper lobe

Question 3

Mediastinal lymph node calcification is seen in which one of the following?

Accepted Answer

Bronchiectasis

Answer

Metastatic neoplasm

Answer

Lymphoma

Answer

Sarcoidosis

Question 4

All of the following radiologic features are seen in patients with chronic cor pulmonale, except?

Accepted Answer

Kerley's B lines

Answer

Prominence of pulmonary artery segment

Answer

Dilatation of the main pulmonary arteries

Answer

Attenuated pulmonary vessels in lateral one third of the lung fields

Question 5

Non-visualization of the gastric fundic bubble in the retrocardiac region suggests which of the following?

Accepted Answer

Achalasia cardia

Answer

Carcinoma esophagus

Answer

Esophageal web

Answer

Congenital hypertrophic pyloric stenosis

Question 6

A 53-year-old woman presents with mild dyspnea. PA and lateral chest radiographs are shown, demonstrating a well-defined, lobulated mass forming obtuse angles with the chest wall, consistent with a pleural-based origin. Which one of the following is the MOST likely diagnosis?

Accepted Answer

Solitary fibrous tumor

Answer

Bronchogenic carcinoma

Answer

Empyema

Answer

Mesothelioma

Question 7

What is the investigation of choice for a solitary pulmonary nodule?

Accepted Answer

CT Scan

Answer

Ultrasound (USG)

Answer

MRI

Answer

X-ray

Question 8

A chest X-ray of an industrial worker with 20 years of asbestos exposure shows a diffuse appearance of the lower lobe with a 'comet tail' infarct on a PA view. What is the most likely diagnosis?

Accepted Answer

Mesothelioma

Answer

Lobular collapse

Answer

Bronchogenic carcinoma

Answer

Round atelectasis

Question 9

What findings are shown on the chest X-ray of the patient?

Accepted Answer

Reticulonodular shadows

Answer

Kerley B lines

Answer

Batwing edema

Answer

Emphysema

Question 10

Which of the following conditions can present with miliary mottling?

Accepted Answer

Tuberculosis, Sarcoidosis, Silicosis, Pneumocystis pneumonia

Answer

Sarcoidosis, Silicosis

Answer

Tuberculosis, Silicosis, Pneumocystis pneumonia

Answer

Sarcoidosis, Silicosis, Pneumocystis pneumonia

Chest Radiology — MCQs

Chest Radiology — MCQs

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