Chest Radiology — MCQs
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Mediastinal lymph node calcification is seen in which one of the following?
Which of the following is NOT a chest X-ray feature suggestive of Ventricular Septal Defect (VSD) in a child?
Golden S sign is seen in which of the following conditions?
All of the following radiologic features are seen in patients with chronic cor pulmonale, except?
Minimum pneumothorax is best seen in which of the following views?
Non-visualization of the gastric fundic bubble in the retrocardiac region suggests which of the following?
Dilatation of upper lobe veins is a reliable sign of which condition?
What is the investigation of choice for the detection and characterization of interstitial lung disease?
Which X-ray view is best for detecting minimal pleural effusion?
Which condition is associated with a 'figure of 8' appearance on a chest X-ray?
Chest Radiology Indian Medical PG Practice Questions and MCQs
Question 1: Mediastinal lymph node calcification is seen in which one of the following?
- A. Metastatic neoplasm
- B. Lymphoma
- C. Sarcoidosis
- D. Bronchiectasis (Correct Answer)
Explanation: **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.
Question 2: Which of the following is NOT a chest X-ray feature suggestive of Ventricular Septal Defect (VSD) in a child?
- A. Large aortic knob (Correct Answer)
- B. Increased splaying of the carina
- C. Cardiomegaly
- D. Pulmonary plethora
Explanation: **Explanation:** Ventricular Septal Defect (VSD) is a left-to-right shunt characterized by increased pulmonary blood flow and volume overload of the left heart chambers. **1. Why "Large aortic knob" is the correct answer:** In VSD, blood shunts from the left ventricle directly into the right ventricle and then into the pulmonary circulation. Because the shunt occurs **distal** to the aorta, the aorta does not carry the excess volume. In fact, in large shunts, the systemic output may decrease, leading to a **small or inconspicuous aortic knob**. A large aortic knob is typically seen in Patent Ductus Arteriosus (PDA), where the aorta must carry the extra volume before it shunts into the pulmonary artery. **2. Analysis of incorrect options:** * **Increased splaying of the carina:** Large VSDs lead to left atrial enlargement (due to increased venous return from the lungs). An enlarged left atrium pushes the left main bronchus upward, widening the subcarinal angle. * **Cardiomegaly:** This occurs due to volume overload and subsequent hypertrophy/dilation of the left atrium and left ventricle (and eventually the right ventricle if pulmonary hypertension develops). * **Pulmonary plethora:** Increased pulmonary blood flow (left-to-right shunt) manifests on X-ray as prominent vascular markings extending to the outer third of the lung fields. **Clinical Pearls for NEET-PG:** * **VSD** is the most common congenital heart disease. * **Shunt Rule:** VSD and PDA cause **Left** atrial/ventricular enlargement; ASD causes **Right** atrial/ventricular enlargement. * **Small Aorta:** Common in VSD and ASD. * **Large Aorta:** Characteristic of PDA and Tetralogy of Fallot (compensatory). * **Eisenmenger Syndrome:** Look for "pruning" of peripheral vessels (central pulmonary artery dilation with peripheral tapering).
Question 3: Golden S sign is seen in which of the following conditions?
- A. Bronchogenic carcinoma with collapse of lung (Correct Answer)
- B. Traction bronchiectasis with apical scarring
- C. Emphysema with increased lucency and flattened diaphragm
- D. Pulmonary edema
Explanation: ### Explanation **Golden S Sign (S-sign of Golden)** is a classic radiological sign seen on a chest X-ray. It occurs when a central mass (usually **bronchogenic carcinoma**) obstructs a bronchus, leading to the **collapse of the right upper lobe (RUL)**. 1. **Why Option A is Correct:** The sign is created by two distinct borders: * **The Superior/Lateral portion:** Formed by the upward displacement of the minor fissure due to RUL collapse (concave). * **The Inferior/Medial portion:** Formed by the convexity of the obstructing hilar mass. Together, these create a shape resembling a reverse "S." While most commonly associated with RUL collapse, it can occur in other lobes. 2. **Why Other Options are Incorrect:** * **B. Traction bronchiectasis:** Characterized by irreversible dilation of airways due to surrounding parenchymal fibrosis (e.g., TB or Sarcoidosis), showing "tram-track" or "string-of-pearls" appearances. * **C. Emphysema:** Shows signs of hyperinflation, such as hyperlucent lung fields, flattened diaphragms, and a "saber-sheath" trachea, but not a focal S-shaped collapse. * **D. Pulmonary edema:** Typically presents with bilateral Kerley B lines, Bat-wing opacities, and pleural effusions. **High-Yield Clinical Pearls for NEET-PG:** * **Luftsichel Sign:** A crescent of air seen in Left Upper Lobe collapse (due to hyperinflation of the superior segment of the lower lobe). * **Sail Sign:** Seen in Right Middle Lobe collapse or a normal neonatal thymus. * **Flat Waist Sign:** Seen in Left Lower Lobe collapse. * **Westermark Sign:** Focal oligemia seen in Pulmonary Embolism.
Question 4: All of the following radiologic features are seen in patients with chronic cor pulmonale, except?
- A. Prominence of pulmonary artery segment
- B. Kerley's B lines (Correct Answer)
- C. Dilatation of the main pulmonary arteries
- D. Attenuated pulmonary vessels in lateral one third of the lung fields
Explanation: **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).
Question 5: Minimum pneumothorax is best seen in which of the following views?
- A. Lordotic view
- B. Right lateral view
- C. Left lateral view
- D. Chest x-ray in complete expiration (Correct Answer)
Explanation: **Explanation:** The correct answer is **Chest x-ray in complete expiration**. **Why it is correct:** In a standard inspiratory film, the lungs are fully inflated, which increases the volume of the thoracic cavity and can mask a small (minimum) pneumothorax. During **complete expiration**, two physiological changes occur that make a pneumothorax more visible: 1. **Relative Volume Increase:** The lung volume decreases while the volume of the intrapleural air remains constant. This makes the pneumothorax occupy a larger percentage of the hemithorax, making it easier to spot. 2. **Increased Lung Density:** As air is expelled, the lung parenchyma becomes more radiopaque (whiter). This creates a sharper contrast against the radiolucent (black) air in the pleural space, highlighting the visceral pleural line. **Why the other options are incorrect:** * **Lordotic view:** Primarily used to visualize the lung apices by displacing the clavicles upward. It is used for suspected apical tuberculosis or tumors (Pancoast tumor), not pneumothorax. * **Lateral views (Right/Left):** While lateral views can sometimes show air retrosternally, they are generally less sensitive than frontal views for detecting small amounts of air and are not the "best" initial choice for a minimum pneumothorax. **Clinical Pearls for NEET-PG:** * **Gold Standard:** While expiratory films are a classic exam answer, **CT Chest** is the most sensitive imaging modality for detecting any pneumothorax. * **Lateral Decubitus View:** In a patient who cannot stand, a lateral decubitus film (with the **affected side up**) is the most sensitive plain film for detecting small amounts of pleural air. * **Deep Sulcus Sign:** On a supine CXR (common in ICU/Trauma), look for an abnormally deepened and lucent costophrenic angle; this is a high-yield sign of pneumothorax in the supine position.
Question 6: Non-visualization of the gastric fundic bubble in the retrocardiac region suggests which of the following?
- A. Carcinoma esophagus
- B. Esophageal web
- C. Achalasia cardia (Correct Answer)
- D. Congenital hypertrophic pyloric stenosis
Explanation: ### 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.
Question 7: Dilatation of upper lobe veins is a reliable sign of which condition?
- A. Cardiac decompensation (Correct Answer)
- B. Pulmonary hypertension
- C. Emphysema
- D. Silicosis
Explanation: **Explanation:** Dilatation of the upper lobe veins, also known as **Cephalization** or **Antler’s sign**, is the earliest radiological sign of pulmonary venous hypertension, typically caused by **cardiac decompensation** (Left Heart Failure). In a normal upright individual, gravity causes greater perfusion to the lung bases; thus, lower lobe vessels are larger than upper lobe vessels. When the Left Ventricular End-Diastolic Pressure (LVEDP) rises (12–18 mmHg), it leads to pulmonary venous congestion. This increased pressure causes interstitial edema at the lung bases, which compresses the lower lobe vessels and triggers reactive vasoconstriction. Consequently, blood is shunted to the upper lobes, leading to the characteristic dilatation of upper lobe veins. **Analysis of Incorrect Options:** * **B. Pulmonary Hypertension:** This primarily affects the **arteries**. It is characterized by "pruning" of peripheral vessels and enlargement of the central pulmonary arteries, not specific upper lobe venous dilatation. * **C. Emphysema:** This leads to the destruction of the capillary bed and hyperinflation. Radiologically, it presents with a small vertical heart, flattened diaphragm, and **oligemia** (reduced vascular markings), rather than venous dilatation. * **D. Silicosis:** This is a restrictive lung disease characterized by small, rounded nodular opacities and "eggshell calcification" of hilar lymph nodes. **High-Yield Pearls for NEET-PG:** * **Stages of Pulmonary Edema on CXR:** 1. **Stage I (Cephalization):** PCWP 12–18 mmHg. 2. **Stage II (Interstitial Edema):** PCWP 18–25 mmHg. Features **Kerley B lines**, peribronchial cuffing, and hazy hila. 3. **Stage III (Alveolar Edema):** PCWP >25 mmHg. Features **Bat-wing appearance** (perihilar opacities) and pleural effusion.
Question 8: What is the investigation of choice for the detection and characterization of interstitial lung disease?
- A. MRI
- B. Chest X-ray
- C. High resolution CT scan (Correct Answer)
- D. Ventilation perfusion scan
Explanation: **Explanation:** **High-Resolution Computed Tomography (HRCT)** is the gold standard and investigation of choice for Interstitial Lung Disease (ILD). The underlying medical concept relies on the use of thin collimation (1–2 mm slices) and high-spatial-frequency reconstruction algorithms. This allows for the visualization of the secondary pulmonary lobule—the smallest functional unit of the lung—enabling the detection of subtle patterns like ground-glass opacities, reticulation, honeycombing, and traction bronchiectasis which are essential for diagnosing specific ILD subtypes (e.g., UIP vs. NSIP). **Why other options are incorrect:** * **Chest X-ray:** While often the initial screening tool, it lacks sensitivity. Up to 10–15% of patients with biopsy-proven ILD may have a normal chest radiograph. It cannot characterize the specific pattern of involvement. * **MRI:** Due to low proton density in the lungs and artifacts from respiratory/cardiac motion, MRI has poor spatial resolution for lung parenchyma and is not used for ILD. * **Ventilation-Perfusion (V/Q) Scan:** This is primarily used to evaluate pulmonary embolism or regional lung function, not for parenchymal lung architecture. **High-Yield Clinical Pearls for NEET-PG:** * **HRCT Technique:** Uses thin slices (1-2mm) rather than the 5-10mm slices used in conventional CT. * **Prone HRCT:** Often performed to differentiate early interstitial changes from dependent atelectasis (gravity-related collapse). * **Expiratory HRCT:** Essential for detecting "air trapping," a hallmark of small airway diseases like hypersensitivity pneumonitis. * **Honeycombing:** The diagnostic hallmark of Usual Interstitial Pneumonia (UIP).
Question 9: Which X-ray view is best for detecting minimal pleural effusion?
- A. Anteroposterior view
- B. Posteroanterior view
- C. Lateral view
- D. Lateral decubitus view (Correct Answer)
Explanation: **Explanation:** The detection of pleural effusion on a chest X-ray depends on the sensitivity of the view to gravity-dependent fluid accumulation. **Why Lateral Decubitus is Correct:** The **Lateral Decubitus view** (specifically with the affected side down) is the most sensitive radiographic projection for detecting minimal pleural effusion. In this position, gravity causes even small amounts of free-flowing fluid to layer along the dependent lateral chest wall. It can detect as little as **5–10 mL** of fluid. It is also clinically useful to differentiate free-flowing fluid from loculated effusion or pleural thickening. **Why Other Options are Incorrect:** * **Lateral View:** This is the second most sensitive view. It can detect approximately **25–75 mL** of fluid, typically seen as blunting of the posterior costophrenic angle (the deepest part of the pleura). * **Posteroanterior (PA) View:** This view requires roughly **150–200 mL** of fluid to be present before the lateral costophrenic angles appear blunted (the "meniscus sign"). * **Anteroposterior (AP) View:** Often taken as a supine portable film in ICU settings, this is the least sensitive. Fluid layers posteriorly, causing a non-specific "ground-glass" haziness or veiling opacity over the lung field rather than a distinct meniscus. **High-Yield Clinical Pearls for NEET-PG:** * **Sensitivity Hierarchy:** Lateral Decubitus (5-10 mL) > Lateral (25-75 mL) > PA View (150-200 mL). * **USG Chest:** More sensitive than any X-ray; it can detect as little as **3–5 mL** of fluid and is the gold standard for guiding thoracocentesis. * **Ellis S-shaped curve:** The characteristic upper limit of a large pleural effusion seen on a PA view.
Question 10: Which condition is associated with a 'figure of 8' appearance on a chest X-ray?
- A. Supracardiac Total Anomalous Pulmonary Venous Connection (TAPVC) (Correct Answer)
- B. Tetralogy of Fallot
- C. Transposition of the Great Arteries (TGA)
- D. None of the above
Explanation: The **'Figure of 8' appearance** (also known as the **Snowman sign**) is a classic radiological hallmark of **Supracardiac Total Anomalous Pulmonary Venous Connection (TAPVC)**. ### **Explanation of the Correct Answer** In Supracardiac TAPVC, all four pulmonary veins drain into a common pulmonary vein, which then drains into an **anomalous vertical vein**. This vertical vein ascends and joins the **left innominate (brachiocephalic) vein**, which finally drains into the **Superior Vena Cava (SVC)**. * **The Upper Loop (Head of the Snowman):** Formed by the dilated vertical vein (left), the left innominate vein (top), and the dilated SVC (right). * **The Lower Loop (Body of the Snowman):** Formed by the enlarged right atrium and right ventricle. ### **Why Other Options are Incorrect** * **Tetralogy of Fallot (TOF):** Characterized by a **'Boot-shaped heart' (Coeur en Sabot)** due to right ventricular hypertrophy and a narrow pulmonary artery segment. * **Transposition of the Great Arteries (TGA):** Characterized by an **'Egg-on-a-string' appearance** due to a narrow mediastinum (caused by stress-induced thymic atrophy and the anteroposterior alignment of the great vessels). ### **High-Yield Clinical Pearls for NEET-PG** * **TAPVC Types:** Supracardiac is the most common (Type I). Infracardiac (Type III) often presents with severe pulmonary congestion and a normal-sized heart. * **Box-shaped heart:** Seen in **Ebstein’s Anomaly** (massive right atrial enlargement). * **Sitting Duck sign:** Seen in **Persistent Truncus Arteriosus**. * **Shone’s Complex:** A rare condition involving multiple left-sided obstructive lesions (Parachute mitral valve, supravalvular mitral ring, subaortic stenosis, and coarctation of the aorta).
Practice by Chapter
Normal Chest Radiographic Anatomy
Practice Questions
Radiographic Signs in Chest Imaging
Practice Questions
Pulmonary Infections
Practice Questions
Chronic Obstructive Pulmonary Disease
Practice Questions
Interstitial Lung Diseases
Practice Questions
Pulmonary Neoplasms
Practice Questions
Pleural Diseases
Practice Questions
Mediastinal Pathology
Practice Questions
Congenital and Developmental Chest Anomalies
Practice Questions
Pulmonary Vascular Diseases
Practice Questions
Chest Trauma Imaging
Practice Questions
Post-Surgical Chest Imaging
Practice Questions
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