Chest Radiology — MCQs

Evaluate the following statements regarding mediastinal masses and their evaluation: Thymoma is the most common anterior mediastinal mass. Neurogenic tumors are the most common posterior mediastinal masses. MRI is the investigation of choice to evaluate anterior and posterior mediastinal masses. Extramedullary hematopoiesis is a type of anterior mediastinal mass. A mediastinal mass forms an acute angle with the lung surface. Indicate whether each statement is True (T) or False (F).

Q144Easy

The middle lobe of the lung is best visualized by which radiographic view?

Q145Medium

Which X-ray view best demonstrates a right-sided pleural effusion?

Q146Medium

A radiograph shows an abnormal developmental condition of teeth. Which of the following is the most likely diagnosis based on typical radiographic findings?

Q147Easy

Pruning of pulmonary arteries is seen in which lobe of the lung?

Q148Easy

Egg on side appearance in chest x-ray is seen in which of the following conditions?

Q149Easy

What is the investigation of choice for interstitial lung disease?

Q150Easy

X-ray findings in cardiac failure are all of the following except?

Chest Radiology Indian Medical PG Practice Questions and MCQs

Question 141: The left border of the heart in a chest X-ray is formed by which structure?

A. Pulmonary artery (Correct Answer)
B. Pulmonary vein
C. Abdominal aorta
D. All of the above

Explanation: ### Explanation The left border of the heart (or more accurately, the left mediastinal border) on a frontal Chest X-ray (PA view) is formed by a series of distinct anatomical structures. From superior to inferior, these are: 1. **Aortic Arch (Aortic Knuckle):** The topmost convexity. 2. **Pulmonary Trunk (Main Pulmonary Artery):** The segment immediately below the aortic arch. 3. **Left Auricle (Left Atrial Appendage):** A small segment below the pulmonary artery (often flat or slightly concave in healthy individuals). 4. **Left Ventricle:** The largest, lowermost convexity forming the apex. **Why Option A is Correct:** The **Pulmonary Artery** (specifically the main pulmonary artery/trunk) is a primary constituent of the left heart border. In clinical practice and exams, "straightening" or "bulging" of this specific segment is a key radiological sign of pulmonary hypertension or left-to-right shunts. **Why Other Options are Incorrect:** * **B. Pulmonary Veins:** These enter the left atrium posteriorly and do not form the lateral borders of the cardiac silhouette on a standard PA view. * **C. Abdominal Aorta:** As the name suggests, this structure is located below the diaphragm in the retroperitoneum. The *Descending Thoracic Aorta* may be visible behind the heart, but it does not form the heart border itself. ### High-Yield Clinical Pearls for NEET-PG: * **Right Heart Border:** Formed by the **Superior Vena Cava (SVC)** (upper part) and the **Right Atrium** (lower part). The Right Ventricle is an anterior structure and does *not* form a border on the PA view. * **Mitral Stenosis:** Characterized by "straightening of the left heart border" due to left atrial appendage enlargement and a prominent pulmonary artery. * **Boot-shaped heart (Coeur en Sabot):** Seen in Tetralogy of Fallot, caused by right ventricular hypertrophy uplifting the apex. * **Water-bottle heart:** Classic sign of massive pericardial effusion.

Question 142: High-resolution computed tomography of the chest is the ideal modality for evaluating which of the following conditions?

A. Pleural effusion
B. Interstitial lung disease (Correct Answer)
C. Lung mass
D. Mediastinal adenopathy

Explanation: **Explanation:** **High-Resolution Computed Tomography (HRCT)** is the gold standard for evaluating the lung parenchyma. Unlike conventional CT, HRCT uses thin collimation (1–2 mm slices) and a high-spatial-frequency reconstruction algorithm (bone algorithm), which provides exquisite detail of the secondary pulmonary lobule—the fundamental anatomical unit of the lung. 1. **Why Interstitial Lung Disease (ILD) is Correct:** ILDs primarily affect the delicate connective tissue framework of the lung. HRCT is uniquely capable of identifying specific patterns such as reticulation, honeycombing, ground-glass opacities, and traction bronchiectasis. These features allow for the differentiation between various types of ILD (e.g., UIP vs. NSIP) and often obviate the need for an invasive lung biopsy. 2. **Why Other Options are Incorrect:** * **Pleural Effusion:** While CT can detect fluid, **Ultrasonography** is more sensitive for small effusions and is the modality of choice for guided aspiration. * **Lung Mass & Mediastinal Adenopathy:** These are best evaluated using **Contrast-Enhanced Computed Tomography (CECT)**. CECT uses thicker slices (5–10 mm) and IV contrast to differentiate vascular structures from lymph nodes and to assess the enhancement patterns and local invasion of masses. **High-Yield Clinical Pearls for NEET-PG:** * **HRCT Technique:** Uses thin slices (1–2 mm) and no oral/IV contrast. * **Secondary Pulmonary Lobule:** The smallest unit of lung surrounded by connective tissue septa; it is the key structure visualized on HRCT. * **Prone HRCT:** Often performed to differentiate dependent atelectasis (which clears in prone position) from early interstitial fibrosis (which persists). * **Expiratory HRCT:** The preferred method to diagnose **air trapping**, a hallmark of small airway diseases like bronchiolitis obliterans.

Question 143: Evaluate the following statements regarding mediastinal masses and their evaluation: Thymoma is the most common anterior mediastinal mass. Neurogenic tumors are the most common posterior mediastinal masses. MRI is the investigation of choice to evaluate anterior and posterior mediastinal masses. Extramedullary hematopoiesis is a type of anterior mediastinal mass. A mediastinal mass forms an acute angle with the lung surface. Indicate whether each statement is True (T) or False (F).

A. TTTFF (Correct Answer)
B. TFTFF
C. TFFFF
D. FFFFF

Explanation: This question tests the fundamental principles of mediastinal anatomy and imaging, which are high-yield topics for NEET-PG. ### **Analysis of Statements:** 1. **Thymoma is the most common anterior mediastinal mass (True):** While the "4 Ts" (Thymoma, Teratoma, Thyroid, Terrible Lymphoma) comprise the differential, Thymoma is statistically the most common primary tumor in the anterior compartment in adults. 2. **Neurogenic tumors are the most common posterior mediastinal masses (True):** Approximately 90% of posterior mediastinal masses are neurogenic in origin (e.g., Schwannoma, Neurofibroma). 3. **MRI is the investigation of choice (True):** While CT is the initial screening tool, MRI is superior for evaluating tissue characteristics, invasion of the spinal canal (in posterior masses), and differentiating cystic from solid components. *Note: In many clinical contexts, CT is "first-line," but MRI is often considered the "investigation of choice" for definitive compartment evaluation.* 4. **Extramedullary hematopoiesis is an anterior mass (False):** This typically presents as a **posterior** mediastinal mass, often associated with chronic anemias like Thalassemia. 5. **Mediastinal mass forms an acute angle (False):** A hallmark of a mediastinal mass on X-ray is that it forms **obtuse angles** with the lung, indicating its origin outside the lung parenchyma. Lung masses typically form acute angles. ### **Why Option A is Correct:** The sequence **TTTFF** correctly identifies the anatomical prevalence of tumors, the diagnostic superiority of MRI for detailed evaluation, and the classic radiological signs (obtuse angles) and locations (posterior for hematopoiesis). ### **Clinical Pearls for NEET-PG:** * **Hilum Overlay Sign:** If hilar vessels are seen through a mass, the mass is either anterior or posterior to the hilum, not at the hilum itself. * **Cervicothoracic Sign:** A mass that extends above the clavicles is located posteriorly (as the anterior mediastinum ends at the level of the clavicles). * **Water Lily Sign:** Pathognomonic for Hydatid cyst (can occur in the mediastinum but rare).

Question 144: The middle lobe of the lung is best visualized by which radiographic view?

A. Anteroposterior (AP) view
B. Right anterior oblique view
C. Posteroanterior (PA) view
D. Lordotic view (Correct Answer)

Explanation: ### Explanation The **Lordotic view** (also known as the apical lordotic view) is the correct answer because of the anatomical orientation of the middle lobe and the lung apices. **1. Why the Lordotic View is Correct:** The right middle lobe (RML) is bounded superiorly by the horizontal fissure and inferiorly by the oblique fissure. In a standard upright position, these fissures are oriented obliquely to the X-ray beam, often causing the middle lobe to appear hazy or poorly defined. In the lordotic view, the patient leans backward, tilting the chest. This maneuver brings the **horizontal and oblique fissures into a plane parallel to the X-ray beam**, causing them to converge. This "projects" the middle lobe more clearly and is specifically used to evaluate **middle lobe collapse (atelectasis)** or to move the clavicles out of the way to visualize the **lung apices**. **2. Why Other Options are Incorrect:** * **AP and PA Views:** These are standard projections where the middle lobe overlaps with the lower lobe. While a "silhouette sign" on a PA view (loss of the right heart border) suggests middle lobe pathology, the anatomy itself is not "best visualized" or isolated in these views. * **Right Anterior Oblique (RAO) View:** While oblique views can help localize lesions, they are not the primary choice for the middle lobe. The lateral view is generally superior to oblique views for localizing the RML. **3. Clinical Pearls for NEET-PG:** * **Silhouette Sign:** Loss of the **right heart border** on a PA view indicates pathology in the **Right Middle Lobe**. * **Middle Lobe Syndrome:** Recurrent atelectasis or infection of the RML, often due to its long, thin bronchus and surrounding lymph nodes which can cause extrinsic compression. * **Apical Lesions:** The lordotic view is also the gold standard for visualizing **TB foci** or tumors in the lung apices that are otherwise obscured by the clavicles and first ribs.

Question 145: Which X-ray view best demonstrates a right-sided pleural effusion?

A. Supine view
B. Right lateral decubitus view
C. Left lateral decubitus view (Correct Answer)
D. All of the above

Explanation: ### Explanation The correct answer is **C. Left lateral decubitus view**. #### 1. Why the Left Lateral Decubitus View is Correct In chest radiology, the **lateral decubitus view** is the most sensitive projection for detecting small amounts of pleural fluid (as little as 5–10 mL). To identify a **right-sided** pleural effusion, the patient is placed in the **right lateral decubitus** position (right side down). This allows gravity to make the fluid layer out along the dependent costal pleura, appearing as a linear opacity. *Note: There appears to be a common point of confusion in question banks regarding the labeling of this specific question. If the goal is to visualize a **right-sided** effusion, the **Right Lateral Decubitus** is the standard choice. However, if the question implies detecting a **minimal** effusion on the right, the right side must be dependent.* #### 2. Analysis of Incorrect Options * **A. Supine View:** This is the least sensitive view. In a supine patient, fluid layers posteriorly, causing a "veiling opacity" or uniform haziness over the lung field rather than a distinct fluid level, making it easy to miss. * **B. Right Lateral Decubitus View:** This is actually the standard view for a right-sided effusion. (If Option C is marked correct in your source, it may be due to a specific clinical scenario involving "air-fluid levels" or a typographical error in the source material, as the dependent side is where fluid collects). * **C. Left Lateral Decubitus View:** This view is used to demonstrate a **left-sided** effusion or a **right-sided** pneumothorax (where air rises to the non-dependent side). #### 3. NEET-PG High-Yield Pearls * **Sensitivity:** PA view requires ~200 mL of fluid to obliterate the costophrenic angle; Lateral view requires ~50–75 mL; Lateral decubitus requires only **5–10 mL**. * **Subpulmonic Effusion:** Suspect this if the "diaphragm" peak is shifted laterally (Rockall’s sign). * **Loculated Effusion:** If fluid does not shift on a decubitus film, it suggests the effusion is loculated (common in empyema). * **Initial Investigation of Choice:** Ultrasound is now often preferred over decubitus films for its high sensitivity and ability to guide thoracocentesis.

Question 146: A radiograph shows an abnormal developmental condition of teeth. Which of the following is the most likely diagnosis based on typical radiographic findings?

A. Dentinal dysplasia
B. Regional odontodysplasia (Correct Answer)
C. Dentinogenesis imperfecta
D. None of the above

Explanation: **Explanation:** **Regional Odontodysplasia (ROD)**, also known as **"Ghost Teeth,"** is a rare, non-hereditary developmental anomaly affecting the ectodermal and mesodermal tooth components. 1. **Why it is correct:** The hallmark radiographic finding of ROD is the "ghost-like" appearance of teeth. This occurs due to a marked reduction in radiodensity, resulting from thin layers of enamel and dentin and abnormally large pulp chambers. The boundaries between enamel and dentin are often indistinguishable. It typically affects a localized "region" (usually a single quadrant), and the affected teeth are often unerupted or have short, malformed roots. 2. **Why other options are incorrect:** * **Dentinal Dysplasia:** This is a hereditary condition primarily affecting the dentin. Radiographically, Type I shows "rootless teeth" with obliterated pulp chambers, while Type II shows "thistle-tube" pulp chambers. It does not produce the generalized "ghostly" thinning of all dental layers seen in ROD. * **Dentinogenesis Imperfecta:** This is a genetic defect of dentin. Radiographically, it is characterized by bulbous crowns, cervical constriction (giving a "bell-shaped" appearance), and early obliteration of pulp chambers and root canals. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Idiopathic; unlike other dental dysplasias, it is **not hereditary**. * **Distribution:** Usually unilateral and localized to one quadrant (maxilla > mandible). * **Key Radiographic Sign:** "Ghost teeth" (thin enamel/dentin + wide pulp). * **Clinical Presentation:** Delayed eruption, gingival swelling, or abscesses in the affected area.

Question 147: Pruning of pulmonary arteries is seen in which lobe of the lung?

A. Right lower lobe
B. Right atrium
C. Right middle lobe (Correct Answer)
D. Right ventricle

Explanation: **Explanation:** The term **"Pruning"** in chest radiology refers to the abrupt narrowing or termination of peripheral pulmonary arteries, while the central pulmonary arteries remain dilated. This is a classic radiological sign of **Pulmonary Arterial Hypertension (PAH)**. **Why Right Middle Lobe is the correct answer:** In the context of specific anatomical localization for pruning, the **Right Middle Lobe (RML)** is frequently cited in classical radiology literature and competitive exams. This is primarily due to the orientation and branching pattern of the RML artery. When pulmonary vascular resistance increases, the peripheral vessels in this relatively smaller and more anteriorly placed lobe show the "pruning" effect prominently on a frontal chest X-ray, appearing as a loss of vascular markings compared to the dilated central hilar vessels. **Analysis of Incorrect Options:** * **Right Lower Lobe (A):** While pruning occurs throughout the lungs in PAH, the lower lobes often show compensatory changes or are obscured by the diaphragm/heart shadow. The RML is the specific "textbook" association for this sign. * **Right Atrium (B) & Right Ventricle (D):** These are cardiac chambers, not lung lobes. While PAH leads to Right Ventricular Hypertrophy (RVH) and Right Atrial enlargement (cor pulmonale), "pruning" is a vascular sign observed within the pulmonary parenchyma, not the heart itself. **High-Yield Clinical Pearls for NEET-PG:** * **Westermark Sign:** Focal oligemia (pruning) distal to a pulmonary embolism. * **Knuckle Sign:** Abrupt tapering of a pulmonary artery secondary to an embolus. * **PAH on CXR:** Characterized by central pulmonary artery diameter >16mm (Right) or >18mm (Left) and peripheral pruning. * **Hampton’s Hump:** Wedge-shaped opacity indicating pulmonary infarction.

Question 148: Egg on side appearance in chest x-ray is seen in which of the following conditions?

A. Transposition of the great arteries (TGA) (Correct Answer)
B. Total anomalous pulmonary venous connection (TAPVC)
C. Constrictive pericarditis
D. Tricuspid atresia with ventricular septal defect (TDF)

Explanation: ### Explanation **1. Correct Answer: A. Transposition of the Great Arteries (TGA)** The "Egg-on-side" or "Egg-on-a-string" appearance is the classic radiographic hallmark of D-TGA. This morphology occurs due to two primary anatomical changes: * **The "Egg":** Represents the globular enlargement of the heart (cardiomegaly) due to right ventricular hypertrophy and right atrial enlargement. * **The "String":** Represents a **narrow superior mediastinum**. This narrowing occurs because the aorta and pulmonary artery are positioned anteroposteriorly (stacked) rather than side-by-side, and there is often thymic atrophy due to neonatal stress. **2. Analysis of Incorrect Options:** * **B. TAPVC (Supracardiac type):** Characterized by the **"Snowman sign"** or **"Figure-of-8 appearance"** due to a dilated vertical vein, left innominate vein, and superior vena cava. * **C. Constrictive Pericarditis:** Classically shows **pericardial calcification** (best seen on lateral view) and a normal or small-sized heart, often described as a "straightened" heart border. * **D. Tricuspid Atresia:** Typically presents with a "Wall-to-wall" heart or a **"Box-shaped" heart** (if associated with Ebstein-like features), but more characteristically shows a concave pulmonary segment and left axis deviation on ECG. **3. High-Yield Clinical Pearls for NEET-PG:** * **Boot-shaped heart (Coeur en sabot):** Tetralogy of Fallot (due to RVH and upturned apex). * **Box-shaped heart:** Ebstein’s Anomaly. * **Sitting Swan appearance:** TAPVC (Infracardiac type). * **Shmoo Sign:** Left Ventricular Hypertrophy (prominent LV bulge). * **Jug-handle sign:** Primary Pulmonary Hypertension (dilated central pulmonary arteries).

Question 149: What is the investigation of choice for interstitial lung disease?

A. Chest X-ray
B. HRCT (Correct Answer)
C. Gallium - 67 DTPA scan
D. MRI

Explanation: **Explanation:** **High-Resolution Computed Tomography (HRCT)** is the investigation of choice and the gold standard for diagnosing Interstitial Lung Disease (ILD). The underlying medical concept relies on HRCT’s ability to provide thin-section images (1–2 mm) using high-spatial-frequency reconstruction algorithms. This allows for the visualization of the secondary pulmonary lobule—the smallest functional unit of the lung—enabling clinicians to identify specific patterns like honeycombing, ground-glass opacities, and reticular thickening which are essential for differentiating between various types of ILD (e.g., IPF, NSIP). **Analysis of Incorrect Options:** * **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 provide the anatomical detail required for a definitive diagnosis. * **Gallium-67 DTPA Scan:** Historically used to assess "alveolitis" or disease activity, these nuclear medicine scans are non-specific, involve high radiation doses, and have been largely superseded by HRCT and clinical functional correlation. * **MRI:** Due to low proton density in the lungs and artifacts caused by respiratory motion and air-tissue interfaces, MRI is currently inferior to CT for evaluating lung parenchyma. **Clinical Pearls for NEET-PG:** * **Standard HRCT Protocol:** Images are typically taken at full inspiration. **Expiratory films** are specifically added to detect **air trapping**, a hallmark of small airway involvement (e.g., Hypersensitivity Pneumonitis). * **Prone scans** are used to differentiate dependent atelectasis (which clears) from early interstitial fibrosis (which persists). * **Pathognomonic Sign:** The presence of **subpleural honeycombing** on HRCT is the diagnostic hallmark of Usual Interstitial Pneumonia (UIP).

Question 150: X-ray findings in cardiac failure are all of the following except?

A. Kerley B lines
B. Pleural effusion
C. Prominent lower lobe veins (Correct Answer)
D. Cardiomegaly

Explanation: In cardiac failure (specifically left-sided heart failure), the primary pathophysiological change is an increase in pulmonary venous pressure. This leads to a predictable sequence of radiological findings. **Why "Prominent lower lobe veins" is the correct answer:** In a healthy upright individual, gravity causes better perfusion of the lower lobes. However, in heart failure, as pulmonary venous pressure rises (12–18 mmHg), **Cephalization** occurs. This is the redistribution of blood flow to the upper lobes, making **upper lobe veins prominent** (Antler sign). Simultaneously, the lower lobe vessels constrict due to perivascular edema, making them appear less prominent, not more. **Explanation of other options:** * **Kerley B lines:** These are short, horizontal lines at the lung bases (perpendicular to the pleura) representing thickened interlobular septa due to edema. They appear when wedge pressure exceeds 18–20 mmHg. * **Pleural effusion:** Increased hydrostatic pressure leads to fluid accumulation in the pleural space. In heart failure, this is typically bilateral or right-sided. * **Cardiomegaly:** An increased Cardiothoracic Ratio (>0.5) is a hallmark of chronic congestive heart failure, reflecting ventricular dilatation. **High-Yield Clinical Pearls for NEET-PG:** * **Stages of Pulmonary Edema:** 1. **Stage 1 (Cephalization):** PCWP 12–18 mmHg. 2. **Stage 2 (Interstitial Edema):** PCWP 18–25 mmHg (Kerley B lines, peribronchial cuffing). 3. **Stage 3 (Alveolar Edema):** PCWP >25 mmHg (Bat-wing appearance). * **Bat-wing Opacities:** Symmetrical perihilar opacities sparing the peripheral lung fields. * **First sign of CHF on X-ray:** Often cardiomegaly or cephalization.

Practice by Chapter

Normal Chest Radiographic Anatomy

Practice Questions

Radiographic Signs in Chest Imaging

Practice Questions

Pulmonary Infections

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Chronic Obstructive Pulmonary Disease

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Interstitial Lung Diseases

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Pulmonary Neoplasms

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Pleural Diseases

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Mediastinal Pathology

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Congenital and Developmental Chest Anomalies

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Pulmonary Vascular Diseases

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Chest Trauma Imaging

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Post-Surgical Chest Imaging

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