Chest Radiology Practice Questions

Q: A boot-shaped heart on a chest X-ray is characteristic of which congenital heart defect?

Tetralogy of Fallot. **Explanation:** The **boot-shaped heart** (also known as **"Coeur en Sabot"**) is the classic radiological sign for **Tetralogy of Fallot (TOF)**. This specific morphology occurs due to two primary anatomical changes: 1. **Right Ventricular Hypertrophy (RVH):** The pressure overload causes the right ventricle to enlarge, which lifts the cardiac apex upward and outward. 2. **Pulmonary Hypoplasia:** The narrow right ventricular outflow tract (pulmonary stenosis) results in a small, concave pulmonary artery segment (the "waist" of the heart), accentuating the boot appearance. **Analysis of Incorrect Options:** * **Transposition of the Great Arteries (TGA):** Characterized by an **"Egg-on-a-string"** appearance. The narrow mediastinum (due to stress-induced thymic atrophy and the parallel orientation of the great vessels) makes the heart look like an egg hanging by a string. * **Total Anomalous Pulmonary Venous Connection (TAPVC):** Specifically the supracardiac type, it presents with a **"Snowman sign"** or **"Figure-of-8"** appearance due to a dilated vertical vein and superior vena cava. * **Partial Anomalous Pulmonary Venous Connection (PAPVC):** Often associated with **Scimitar Syndrome**, where a curved anomalous vein drains into the IVC, resembling a Turkish sword (Scimitar sign). **High-Yield Clinical Pearls for NEET-PG:** * **TOF Components:** VSD, Overriding of Aorta, Pulmonary Stenosis, and RVH. * **Lung Fields in TOF:** Usually show **oligemia** (decreased vascular markings) due to reduced pulmonary blood flow. * **Box-shaped heart:** Seen in **Ebstein’s Anomaly** (massive right atrial enlargement). * **Sitting Duck sign:** Seen in **Persistent Truncus Arteriosus**.

Q: In a lung X-ray, what causes a heterogenous shadow?

Tuberculosis. ### Explanation **Correct Answer: D. Tuberculosis** In chest radiology, a **heterogenous shadow** refers to an opacity with varying densities within the same lesion. **Tuberculosis (TB)** is the classic cause because it is a complex pathological process. A single TB lesion often contains a mix of different stages: **caseous necrosis, cavitation, fibrosis, calcification, and exudative inflammation**. On an X-ray, the air within a cavity appears radiolucent (dark), while fibrosis and calcification appear radiopaque (white), resulting in a "patchy" or non-uniform appearance. **Why the other options are incorrect:** * **A. Haemangioma:** These are vascular malformations that typically present as well-defined, smooth, **homogenous** soft tissue masses. * **B. Pulmonary Infarction:** This usually presents as a **homogenous** wedge-shaped opacity (Hampton’s Hump) located at the periphery/pleural base. * **C. Metastatic Lesion:** Pulmonary metastases (e.g., "cannonball" secondaries) are typically well-circumscribed, discrete, and **homogenous** nodules or masses. **High-Yield Clinical Pearls for NEET-PG:** * **Homogenous shadows** are typically seen in pleural effusion, lobar pneumonia (consolidation), and collapse. * **Heterogenous shadows** are characteristic of TB, bronchopneumonia, and lung abscesses (due to the air-fluid level). * **Ghon’s Complex:** A combination of a parenchymal lesion (Ghon focus) + lymphangitis + hilar lymphadenopathy; it is a hallmark of primary TB. * **Ranke Complex:** A healed Ghon’s complex that has undergone calcification.

Q: Which of the following is NOT a chest X-ray sign of pulmonary embolism?

Monod sign. **Explanation** In the context of Pulmonary Embolism (PE), the chest X-ray is often normal (the most common finding), but specific signs can point toward the diagnosis. **Why Monod Sign is the Correct Answer:** The **Monod sign** is not associated with pulmonary embolism. It refers to a radiolucent crescent of air surrounding a mobile intracavitary mass, typically a **mycetoma (aspergilloma)**, within a pre-existing lung cavity. It is a hallmark of fungal colonization rather than vascular pathology. **Analysis of Incorrect Options (Signs of PE):** * **Westermark’s Sign:** Represents focal oligemia (decreased vascular markings) distal to the occluded pulmonary artery. It occurs due to the redirection of blood flow away from the embolized segment. * **Palla’s Sign:** Refers to an enlarged, "sausage-shaped" right descending pulmonary artery caused by the physical presence of a large thrombus distending the vessel. * **Hampton’s Hump (Not listed but related):** A wedge-shaped, pleural-based opacity representing pulmonary infarction. **Clinical Pearls for NEET-PG:** 1. **Most common CXR finding in PE:** A normal chest X-ray. 2. **Most common ECG finding in PE:** Sinus tachycardia (S1Q3T3 is specific but less common). 3. **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA). 4. **Air Crescent Sign vs. Monod Sign:** While often used interchangeably, the "Air Crescent Sign" specifically refers to the crescent seen during the recovery phase of invasive pulmonary aspergillosis as necrotic tissue separates from healthy lung.

Q: The "sniff test" is used to assess for which of the following conditions?

Phrenic nerve palsy. ### Explanation **Correct Option: C. Phrenic Nerve Palsy** The "sniff test," also known as **diaphragmatic fluoroscopy**, is the gold standard radiological investigation for assessing diaphragmatic paralysis (Phrenic nerve palsy). * **Mechanism:** Under fluoroscopic guidance, the patient is asked to perform a quick, sharp inspiration through the nose (a "sniff"). * **Normal Response:** Both hemidiaphragms should move downwards (caudally) as the diaphragm contracts. * **Positive Result (Palsy):** The paralyzed side shows **paradoxical movement**, where it moves upwards (cephalad) during inspiration. This occurs because the negative intrathoracic pressure generated by the healthy side sucks the flaccid, paralyzed hemidiaphragm into the chest. **Analysis of Incorrect Options:** * **A & B (Facial and Vestibular Nerve Palsy):** These are cranial nerve (CN VII and VIII) deficits. Assessment involves clinical neurological examination (e.g., facial symmetry, caloric reflex testing, or audiometry), not dynamic respiratory maneuvers. * **D (Oculomotor Nerve Palsy):** CN III palsy is assessed via extraocular movement examination and pupillary light reflex testing. **High-Yield Clinical Pearls for NEET-PG:** * **Chest X-ray finding:** Phrenic nerve palsy typically presents as an **elevated hemidiaphragm** on the affected side. * **Differential Diagnosis:** An elevated hemidiaphragm can also be caused by **Eventration** (congenital thinning of the muscular portion). The sniff test helps differentiate true paralysis from eventration (where movement is usually sluggish but not paradoxical). * **Nerve Root:** Remember the phrenic nerve originates from **C3, C4, and C5** ("keeps the diaphragm alive"). * **Causes:** Most common causes include malignancy (bronchogenic carcinoma invading the nerve), trauma, or idiopathic.

Q: Deep sulcus sign is seen in which of the following conditions?

Pneumothorax. **Explanation:** The **Deep Sulcus Sign** is a classic radiological indicator of **pneumothorax** in a supine patient (e.g., trauma patients or those in the ICU). In a standing position, air rises to the apex; however, in a supine position, air collects anteriorly and laterally in the pleural space. This causes the costophrenic angle to appear abnormally deepened, lucent (darker), and sharp, sometimes extending below the level of the diaphragm. **Analysis of Options:** * **A. Pneumothorax (Correct):** As explained, the displacement of air into the lateral costophrenic sulcus creates the "deep" appearance. It is often the only sign of pneumothorax on a supine chest X-ray. * **B. Pleural Effusion:** This typically causes **blunting** or "obliteration" of the costophrenic angle due to fluid accumulation, which is the opposite of the deep sulcus sign. * **C. Tuberculosis:** Common findings include apical infiltrates, cavitation, or Ghon complexes, but not a deep sulcus unless complicated by a secondary pneumothorax. * **D. Pneumonia:** Characterized by consolidation (air bronchograms and increased opacity), not the lucent deepening of the sulcus. **Clinical Pearls for NEET-PG:** * **Supine X-ray:** Always look for the deep sulcus sign when a pneumothorax is suspected in a bedbound patient. * **Companion Sign:** The **"Double Diaphragm Sign"** is another indicator of supine pneumothorax, where air outlines the anterior diaphragmatic surface separately from the posterior domes. * **Gold Standard:** While X-ray is the initial screening tool, **NCCT Chest** is the most sensitive imaging modality for detecting a small pneumothorax.

Q: Popcorn calcification on chest X-ray is seen in:

Hamartoma. **Explanation:** **1. Why Hamartoma is correct:** A pulmonary hamartoma is the most common benign lung tumor. It is a disorganized growth of tissues normally found in the lung, predominantly cartilage, fat, and connective tissue. The characteristic **"popcorn calcification"** occurs due to the irregular, lobulated patterns of calcification within the cartilaginous component of the tumor. On a chest X-ray or CT, this appears as coarse, scattered, or tufted calcified clumps resembling a popcorn kernel. **2. Why the other options are incorrect:** * **Granuloma:** These typically show solid, central, or laminated ("target") calcification patterns. They are usually the result of healed infections like Tuberculosis or Histoplasmosis. * **Metastasis:** Most pulmonary metastases do not calcify. When they do (e.g., osteosarcoma or chondrosarcoma), the pattern is usually dense or osteoid rather than "popcorn-like." * **Sarcoidosis:** This typically presents with bilateral hilar lymphadenopathy (Stage I) and parenchymal infiltrates. While lymph nodes may show "eggshell calcification," the lung parenchyma itself does not typically exhibit popcorn calcification. **3. High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Triad for Hamartoma on CT:** A well-circumscribed solitary pulmonary nodule containing **fat** (low Hounsfield units: -40 to -120 HU) and **popcorn calcification**. * **Eggshell Calcification:** Classically seen in the hilar lymph nodes of patients with **Silicosis** and sometimes Sarcoidosis. * **Phleboliths:** Calcifications seen in pulmonary hemangiomas. * **Fleischner Society Guidelines:** Remember that a stable size for 2 years and benign calcification patterns (popcorn, laminated, central, or diffuse) generally indicate a benign lesion.

Q: What is the characteristic radiological feature of sarcoidosis?

All of the above. **Explanation:** The correct answer is **D. All of the above** because sarcoidosis is a multisystem granulomatous disease that progresses through distinct radiological stages. The Scadding Staging System is used to categorize these findings on a chest X-ray, and all the options provided represent different stages of the disease. * **Option A (Stage I):** Characterized by **Bilateral Hilar Lymphadenopathy (BHL)**. This is the most common initial presentation and is often asymptomatic. * **Option B (Stage II):** Characterized by **BHL plus Parenchymal Infiltration**. The lung changes typically present as a reticulonodular pattern, often in the mid-to-upper zones. * **Option C (Stage III):** Characterized by **Parenchymal Infiltration without BHL**. At this stage, the lymphadenopathy has regressed, but the lung disease persists. **Why "All of the above" is correct:** Since sarcoidosis is a progressive disease, a patient may present with isolated lymphadenopathy, a combination of nodes and lung changes, or isolated lung changes depending on the stage at which they are imaged. **High-Yield Clinical Pearls for NEET-PG:** * **Scadding Stages:** * Stage 0: Normal CXR. * Stage I: BHL only. * Stage II: BHL + Parenchymal changes. * Stage III: Parenchymal changes only. * Stage IV: End-stage pulmonary fibrosis (honeycombing). * **Garland’s Triad (1-2-3 Sign):** Right paratracheal, right hilar, and left hilar lymphadenopathy. * **Eggshell Calcification:** Occasionally seen in hilar nodes (though more common in silicosis). * **Galaxy Sign:** On CT, a large nodule surrounded by many tiny satellite nodules. * **Panda Sign & Gallium-67 Scan:** Increased uptake in lacrimal and parotid glands.

Q: A well-defined lesion in the lung with popcorn calcification on X-ray is suggestive of which of the following?

Hamartoma. ### Explanation **Correct Answer: C. Hamartoma** **Why it is correct:** A **Pulmonary Hamartoma** is the most common benign tumor of the lung. It is a disorganized growth of tissues normally found in the lung (cartilage, fat, and connective tissue). The characteristic **"Popcorn Calcification"** seen on a Chest X-ray or CT scan is a classic radiological sign representing irregular, tufted calcification of the cartilaginous component within the lesion. On CT, the presence of **fat density** (-40 to -120 HU) alongside this calcification is virtually pathognomonic for a hamartoma. **Why the other options are incorrect:** * **A. Carcinoma of the lung:** Malignant lesions typically present with eccentric, stippled, or amorphous calcifications (if any). They often have irregular, spiculated margins rather than the well-defined borders seen in hamartomas. * **B. Bronchial adenoma:** These are slow-growing neuroendocrine tumors (like Carcinoid). While they can calcify, they typically present as endobronchial masses causing obstructive symptoms like collapse or post-obstructive pneumonia. * **C. Hydatid cyst:** Classically presents as a well-defined fluid-filled density. Key radiological signs include the **"Water-lily sign"** (Camasalotta sign) or **"Air crescent sign,"** but not popcorn calcification. **NEET-PG High-Yield Pearls:** 1. **Popcorn Calcification** is also seen in **Fibroadenoma of the breast** (involuting type). 2. **Benign Calcification Patterns in Lung Nodules:** Central, diffuse (solid), laminated (bull’s eye), and popcorn. 3. **Malignant Calcification Patterns:** Eccentric or dystrophic. 4. **Coin Lesion:** A solitary pulmonary nodule (SPN) <3 cm; Hamartoma is a common benign cause of a coin lesion.

Question 1

A boot-shaped heart on a chest X-ray is characteristic of which congenital heart defect?

Accepted Answer

Tetralogy of Fallot

Answer

Transposition of the great arteries (TGA)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Partial anomalous pulmonary venous connection (PAPVC)

Question 2

In a lung X-ray, what causes a heterogenous shadow?

Accepted Answer

Tuberculosis

Answer

Haemangioma

Answer

Pulmonary infarction

Answer

Metastatic lesion

Question 3

Which of the following is NOT a chest X-ray sign of pulmonary embolism?

Accepted Answer

Monod sign

Answer

Westermark's sign

Answer

Felson's sign

Answer

Palla's sign

Question 4

The "sniff test" is used to assess for which of the following conditions?

Accepted Answer

Phrenic nerve palsy

Answer

Facial nerve palsy

Answer

Vestibular nerve palsy

Answer

Oculomotor nerve palsy

Question 5

Deep sulcus sign is seen in which of the following conditions?

Accepted Answer

Pneumothorax

Answer

Pleural effusion

Answer

Tuberculosis

Answer

Pneumonia

Question 6

Popcorn calcification on chest X-ray is seen in:

Accepted Answer

Hamartoma

Answer

Granuloma

Answer

Metastasis

Answer

Sarcoidosis

Question 7

What is the characteristic radiological feature of sarcoidosis?

Accepted Answer

All of the above

Answer

Hilar lymphadenopathy

Answer

Hilar lymphadenopathy with parenchymal lung changes

Answer

No hilar lymphadenopathy with parenchymal lung changes

Question 8

Honeycomb appearance on X-ray is seen in all except?

Accepted Answer

Wegener's granulomatosis

Answer

Histiocytosis-X

Answer

Tuberous sclerosis

Answer

Rheumatoid arthritis

Question 9

Which of the following is a feature of pulmonary venous hypertension?

Accepted Answer

Pulmonary ossicles and fine nodular pattern

Answer

Peribroncheal cuffing

Answer

Upper lobar diversion

Answer

Uniformly branching lines parallel to pleura

Question 10

A well-defined lesion in the lung with popcorn calcification on X-ray is suggestive of which of the following?

Accepted Answer

Hamartoma

Answer

Carcinoma of the lung

Answer

Bronchial adenoma

Answer

Hydatid cyst

Chest Radiology — MCQs

Chest Radiology — MCQs

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