Chest Radiology Practice Questions

Q: A 44-year-old man presents with dyspnea, cough, and mild pyrexia. Which lobe of the lung is most likely involved?

Right middle lobe. ***Right middle lobe*** - The **right middle lobe** is most commonly affected in pneumonia presenting with dyspnea, cough, and pyrexia, often showing **silhouette sign** with obliteration of the **right heart border** on chest X-ray. - On **lateral chest X-ray**, right middle lobe consolidation appears as opacity in the **anterior-inferior portion** of the thorax, helping differentiate from other lobes. *Right upper lobe* - Right upper lobe pneumonia typically shows consolidation **above the horizontal fissure** and would obliterate the **right paratracheal stripe**, not the heart border. - On lateral view, opacity would be located in the **anterior-superior** portion, distinctly different from middle lobe involvement. *Left lower lobe* - Left lower lobe consolidation would obliterate the **left hemidiaphragm** and **descending aorta** silhouette, not affecting the right heart border. - Symptoms would be similar, but radiological findings show **retrocardiac opacity** on PA view and **posterior-inferior** opacity on lateral view. *Left upper lobe* - Left upper lobe pneumonia would cause loss of the **left heart border** and **aortic knob** silhouette, with opacity in the **upper left thorax**. - On lateral chest X-ray, consolidation appears in the **anterior-superior** region, similar to right upper lobe but on the opposite side.

Q: The 'tree in bud' sign on HRCT is suggestive of which condition?

Endobronchial spread in tuberculosis. ### Explanation The **'Tree-in-bud' appearance** on High-Resolution Computed Tomography (HRCT) represents an **impaction of the small airways** (bronchioles) with mucus, pus, or fluid, combined with peribronchial inflammation. This creates a pattern resembling a budding tree: the "stalk" is the fluid-filled terminal bronchiole, and the "buds" are the opacified centrilobular nodules. #### Why Option C is Correct: * **Endobronchial spread of Tuberculosis (TB):** This is the classic cause. When a TB cavity ruptures into the bronchial tree, infected material spreads distally into the bronchioles, causing an inflammatory response and impaction. It signifies **active disease**. #### Why Other Options are Incorrect: * **A. Sarcoidosis:** Characteristically shows a **perilymphatic distribution** of nodules. These nodules are typically found along the pleura, interlobular septa, and bronchovascular bundles, rather than a centrilobular tree-in-bud pattern. * **B. Miliary Tuberculosis:** This represents **hematogenous spread** (via blood). It presents as tiny, uniform (1–3 mm) nodules distributed randomly throughout both lungs, lacking the branching "budding" appearance of airway-related spread. #### High-Yield Clinical Pearls for NEET-PG: * **Differential Diagnosis for Tree-in-bud:** While TB is the most common cause in India, it is also seen in **Bronchiectasis** (especially Cystic Fibrosis), **Bacterial pneumonia** (Staphylococcus), and **Diffuse Panbronchiolitis**. * **Key Distinction:** Tree-in-bud = **Centrilobular** nodules. * **Golden Rule:** If you see "Tree-in-bud" in a clinical vignette involving fever, weight loss, and cough, it almost always points to **Active PTB**.

Q: What is the best radiographic view for demonstrating an interlobar pleural effusion?

Lateral view. **Explanation:** **1. Why the Lateral View is Correct:** Interlobar pleural effusions (also known as "vanishing tumors" or "pseudotumors") occur when fluid collects within the pleural fissures (major or minor). On a standard frontal (PA) view, these collections often appear as ill-defined masses. However, the **Lateral View** is the gold standard for demonstration because it aligns the X-ray beam parallel to the orientation of the major and minor fissures. This allows the fluid to be clearly visualized as a characteristic **biconvex or spindle-shaped (lenticular) opacity** with well-defined margins, confirming its location within the fissure rather than the lung parenchyma. **2. Why Other Options are Incorrect:** * **PA and AP Views:** These are frontal projections. Because the fissures are oriented obliquely or horizontally in three-dimensional space, fluid within them appears "en face," leading to a hazy, rounded appearance that can be easily mistaken for a lung abscess or malignancy. * **Oblique View:** While sometimes used to clear overlying structures (like ribs or the heart), it does not consistently align with the anatomical plane of the fissures as effectively as the lateral view. **3. NEET-PG High-Yield Pearls:** * **Vanishing Tumor:** Interlobar effusions are most commonly associated with **Congestive Heart Failure (CHF)**. They are called "vanishing tumors" because they disappear rapidly with diuretic therapy. * **Shape:** Look for the "spindle shape" or "lemon shape" on the lateral film. * **Fissure Anatomy:** The minor (horizontal) fissure is only seen on the right side, while major (oblique) fissures are bilateral. * **Lateral Decubitus View:** This is the most sensitive view for detecting **small, free-flowing** pleural effusions (as little as 5-10ml), but it is not the best for *loculated* interlobar fluid.

Q: The "1-2-3 sign" or "Pawnbroker's sign" is typically seen in which of the following conditions?

Sarcoidosis. The **1-2-3 sign**, also known as the **Garland triad** or **Pawnbroker’s sign**, is a classic radiological finding in **Sarcoidosis**. It refers to a specific pattern of symmetrical lymphadenopathy involving three distinct nodal groups: 1. **Right paratracheal nodes** 2. **Right hilar nodes** 3. **Left hilar nodes** The term "Pawnbroker’s sign" originates from the historical symbol of a pawnbroker’s shop, which features three hanging golden balls. In Sarcoidosis, these nodes are typically discrete, non-matted, and may later develop "eggshell calcification." **Analysis of Incorrect Options:** * **Kaposi Sarcoma:** Typically presents with a "flame-shaped" or "spiculated" peribronchovascular interstitial pattern and hemorrhagic pleural effusions, rather than isolated symmetrical triad lymphadenopathy. * **Castleman’s Disease:** Characterized by massive, localized lymphadenopathy (often a single large mass) that shows intense contrast enhancement on CT. It is usually unicentric. * **Wegener’s Granulomatosis (GPA):** Characterized by multiple pulmonary nodules that frequently undergo cavitation. While lymphadenopathy can occur, it is not the primary or diagnostic feature. **High-Yield Clinical Pearls for NEET-PG:** * **Löfgren Syndrome:** A clinical triad of Sarcoidosis consisting of Erythema nodosum, bilateral hilar lymphadenopathy, and arthralgia (excellent prognosis). * **Eggshell Calcification:** While classic for Silicosis, it is also frequently seen in the later stages of Sarcoidosis. * **Panda Sign:** Seen on Gallium-67 scan due to uptake in lacrimal and parotid glands. * **Staging:** Stage I Sarcoidosis is defined by bilateral hilar lymphadenopathy alone on a chest X-ray.

Q: Pulmonary mycetomas on radiographs most commonly show as?

Lucent crescent. **Explanation:** A **pulmonary mycetoma** (fungal ball), most commonly caused by *Aspergillus fumigatus*, occurs when fungal hyphae colonize a pre-existing lung cavity (e.g., from old Tuberculosis, sarcoidosis, or bronchiectasis). **1. Why "Lucent Crescent" is correct:** The characteristic radiographic finding is the **Monod Sign**. As the fungal ball grows within a cavity, air is trapped between the mass and the cavity wall, creating a crescent-shaped radiolucency. This is known as the **Air-Crescent sign** or **Lucent Crescent**. A key clinical feature is that the fungal ball is mobile; its position changes when the patient moves from a supine to a prone position during imaging. **2. Why other options are incorrect:** * **Air-fluid level:** This is typical of a lung abscess or an infected cyst, where liquid (pus) and gas coexist. Mycetomas are solid masses of hyphae, not fluid. * **Eccentric nodule:** While a mycetoma is a nodular mass, it is usually central within the cavity. Eccentric nodules are more characteristic of certain malignancies or granulomas. * **Rim calcification:** This is often seen in "eggshell calcification" (silicosis/sarcoidosis) or hydatid cysts, but it is not a primary feature of a mycetoma. **3. NEET-PG High-Yield Pearls:** * **Monod Sign:** Air surrounding a mycetoma in a pre-existing cavity. * **Air-Crescent Sign:** Also seen in **Angioinvasive Aspergillosis**, but there it signifies the *recovery* phase (necrosed lung tissue separating from healthy parenchyma). * **Clinical Presentation:** The most common symptom is **hemoptysis**, which can sometimes be life-threatening. * **Treatment:** Surgical resection is the definitive treatment for symptomatic cases; systemic antifungals have poor penetration into the cavity.

Q: The 'thumb print' sign is seen in which of the following conditions?

Epiglottitis. **Explanation:** The **'Thumb print' sign** is a classic radiologic finding seen on a **lateral neck X-ray** in patients with **Acute Epiglottitis**. It represents the severe edema and enlargement of the epiglottis, which normally appears thin and leaf-like but becomes rounded and thickened, resembling the distal tip of a thumb. **Why Epiglottitis is Correct:** Acute Epiglottitis (most commonly caused by *Haemophilus influenzae* type b) is a medical emergency. The inflammation causes the epiglottis to swell and protrude into the airway. On a lateral soft tissue neck X-ray, this thickened epiglottis narrows the valleculla and appears as a blunt, thumb-like projection. **Why Other Options are Incorrect:** * **Candida & Aspergillus:** These are fungal infections. While they can cause laryngitis or tracheobronchitis in immunocompromised patients, they do not typically present with the localized, massive epiglottic swelling required to produce the thumb print sign. * **Rhinosporidium:** Caused by *Rhinosporidium seeberi*, this typically presents as friable, strawberry-like vascular polyps in the nasal cavity or nasopharynx, not as acute epiglottic edema. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Triad:** Dysphagia, Drooling, and Distress (the 3 D's). * **Positioning:** Patients often assume the **'Tripod position'** to maintain airway patency. * **Management:** Never examine the throat with a tongue depressor if epiglottitis is suspected, as it can trigger fatal laryngospasm. Secure the airway first. * **Differential Diagnosis:** Contrast this with **Croup (Laryngotracheobronchitis)**, which shows the **'Steeple sign'** (subglottic narrowing) on an Anteroposterior (AP) view.

Q: What imaging technique is best for demonstrating a small pneumothorax?

Chest X-ray in inspiration and expiration. **Explanation:** The diagnosis of a small pneumothorax relies on visualizing the visceral pleural line. The correct answer is **Chest X-ray in inspiration and expiration** because of the physiological changes that occur during the respiratory cycle. During **expiration**, the lung volume decreases while the volume of the intrapleural air remains constant. This makes the pneumothorax appear relatively larger and more radiopaque compared to the deflated lung, enhancing the visibility of the thin visceral pleural line. **Analysis of Options:** * **A. Supine chest X-ray:** This is the least sensitive method. In a supine patient, air collects anteromedially and at the lung bases. This may only manifest as the **"Deep Sulcus Sign"** (a deep, lucent costophrenic angle), making small pneumothoraces easy to miss. * **C. Lateral decubitus view:** While sensitive (air rises to the highest point, i.e., the lateral chest wall), it is typically reserved for patients who cannot stand or when pleural effusion is suspected. It is not the standard "best" technique compared to expiratory films for routine screening. * **D. Prone oblique view:** This is not a standard or recommended view for detecting pneumothorax. **Clinical Pearls for NEET-PG:** * **Gold Standard:** Non-contrast CT (NCCT) Chest is the most sensitive imaging modality overall. * **Erect PA View:** The standard initial film; air typically collects at the **apex**. * **Tension Pneumothorax:** A clinical diagnosis. Radiographic signs include mediastinal shift to the contralateral side and flattening/inversion of the diaphragm. * **Deep Sulcus Sign:** A high-yield radiological sign of pneumothorax in **supine** trauma patients.

Q: Which of the following features suggests a benign nature in the evaluation of a solitary pulmonary nodule on CT scan?

Fat density within the lesion. ### Explanation A **Solitary Pulmonary Nodule (SPN)** is defined as a single, well-circumscribed opacity ≤3 cm in diameter. Determining whether a nodule is benign or malignant is a critical skill in radiology. **Why Option C is Correct:** The presence of **fat density** (typically -40 to -120 Hounsfield Units) within a pulmonary nodule is a highly specific indicator of a **Hamartoma**, which is the most common benign lung tumor. Another benign lesion containing fat is a lipoma. Identifying fat or characteristic "popcorn calcification" on a CT scan virtually confirms a benign etiology. **Analysis of Incorrect Options:** * **A. Air bronchogram:** While sometimes seen in benign conditions like pneumonia, in the context of a chronic nodule, an air bronchogram is more frequently associated with **malignancy**, specifically Adenocarcinoma (formerly BAC) or lymphoma. * **B. Amorphous calcification:** Calcification patterns matter. **Amorphous, eccentric, or stippled** calcifications are suspicious for malignancy. Benign calcification patterns include diffuse, central, laminated (seen in granulomas), or popcorn (seen in hamartomas). * **D. Spiculated outline:** Also known as the "corona radiata" sign, a spiculated or jagged border is highly suggestive of **malignancy** due to local infiltration of the lung parenchyma. **High-Yield Clinical Pearls for NEET-PG:** * **Size:** Nodules >2 cm have an 80% risk of malignancy. * **Stability:** A nodule that remains unchanged in size for **2 years** is generally considered benign. * **Doubling Time:** Malignant nodules typically have a volume doubling time between **20 and 400 days**. * **Contrast Enhancement:** Enhancement of **<15 HU** on dynamic CT suggests a benign lesion.

Question 1

A 44-year-old man presents with dyspnea, cough, and mild pyrexia. Which lobe of the lung is most likely involved?

Accepted Answer

Right middle lobe

Answer

Right upper lobe

Answer

Left lower lobe

Answer

Left upper lobe

Question 2

Which of the following is FALSE about Kerley's A lines?

Accepted Answer

Transverse lines at the lung base perpendicular to the pleura

Answer

Lines are 2-6 cm in length

Answer

These are found in mid and upper zones

Answer

These are due to thickened interlobar septa

Question 3

The 'tree in bud' sign on HRCT is suggestive of which condition?

Accepted Answer

Endobronchial spread in tuberculosis

Answer

Sarcoidosis

Answer

Miliary tuberculosis

Answer

All the above

Question 4

What is the best radiographic view for demonstrating an interlobar pleural effusion?

Accepted Answer

Lateral view

Answer

Anteroposterior (AP) view

Answer

Posteroanterior (PA) view

Answer

Oblique view

Question 5

The "1-2-3 sign" or "Pawnbroker's sign" is typically seen in which of the following conditions?

Accepted Answer

Sarcoidosis

Answer

Kaposi sarcoma

Answer

Castleman's disease

Answer

Wegener's granulomatosis

Question 6

Pulmonary mycetomas on radiographs most commonly show as?

Accepted Answer

Lucent crescent

Answer

Air fluid level

Answer

Eccentric nodule

Answer

Rim calcification

Question 7

The 'thumb print' sign is seen in which of the following conditions?

Accepted Answer

Epiglottitis

Answer

Candida

Answer

Aspergillus

Answer

Rhinosporidium

Question 8

What imaging technique is best for demonstrating a small pneumothorax?

Accepted Answer

Chest X-ray in inspiration and expiration

Answer

Supine chest X-ray

Answer

Lateral decubitus view

Answer

Prone oblique view

Question 9

Which of the following features suggests a benign nature in the evaluation of a solitary pulmonary nodule on CT scan?

Accepted Answer

Fat density within the lesion

Answer

Air bronchogram within the nodule

Answer

Presence of amorphous calcification

Answer

Spiculated outline

Question 10

Sequestration lung is best diagnosed by?

Accepted Answer

Angiography

Answer

CT Scan

Answer

MRI

Answer

Barium swallow

Chest Radiology — MCQs

Chest Radiology — MCQs

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