Chest Radiology Practice Questions

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

Metastatic lesion. **Explanation:** In chest radiology, a **heterogeneous shadow** refers to an opacity that is not uniform in density, often containing areas of varying lucency or calcification. **1. Why Metastatic Lesion is correct:** Pulmonary metastases (especially from primary tumors like osteosarcoma, thyroid cancer, or mucinous adenocarcinomas) often present as multiple nodules of varying sizes. These lesions can undergo **central necrosis, cavitation, or internal calcification**, leading to a non-uniform or heterogeneous appearance on an X-ray. While "cannonball" metastases are typically well-defined, the internal architecture of metastatic deposits is frequently inconsistent compared to simple fluid or solid consolidation. **2. Analysis of Incorrect Options:** * **Hemangioma:** These are vascular malformations that typically appear as well-circumscribed, smooth, and **homogeneous** soft tissue densities. * **Pulmonary Infarction:** Usually presents as a wedge-shaped, **homogeneous** opacity (Hampton’s Hump) located at the periphery/pleural base. * **Tuberculosis:** While TB can be complex, primary TB typically presents with homogeneous consolidation or Ghon complexes. (Note: While chronic fibro-cavitary TB can look heterogeneous, in the context of standard MCQ patterns, metastatic disease is the classic association for varying densities due to the processes mentioned above). **High-Yield Clinical Pearls for NEET-PG:** * **Cannonball Metastases:** Classically seen in Renal Cell Carcinoma (RCC), Choriocarcinoma, and Testicular tumors. * **Calcified Metastases:** Suggests Osteosarcoma or Chondrosarcoma. * **Cavitating Metastases:** Most commonly associated with Squamous Cell Carcinoma (SCC). * **Hampton’s Hump:** A sign of pulmonary infarction; a pleural-based, wedge-shaped opacity with the apex pointing toward the hilum.

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 55-year-old man, who has been on bed rest for the past 10 days, complains of breathlessness and chest pain. The chest X-ray is normal. What is the next step in investigation?

Lung ventilation-perfusion scan. **Explanation:** The clinical presentation of sudden onset breathlessness and chest pain in a patient with prolonged immobilization (10 days of bed rest) is highly suggestive of **Pulmonary Embolism (PE)**. **Why Option A is correct:** In a patient suspected of PE where the **Chest X-ray (CXR) is normal**, the next diagnostic step is a **Lung Ventilation-Perfusion (V/Q) scan**. A normal CXR is a classic finding in PE (though non-specific), and the V/Q scan identifies the "mismatch"—areas of the lung that are ventilated but not perfused due to an arterial clot. While CT Pulmonary Angiography (CTPA) is now the gold standard in many centers, the V/Q scan remains the preferred traditional answer in the context of a normal CXR and is highly sensitive for excluding PE. **Why other options are incorrect:** * **B. Pulmonary Angiography:** This is the **Gold Standard** (most accurate) investigation but is invasive and reserved for cases where non-invasive tests are inconclusive. It is not the immediate "next step." * **C. Pulmonary Venous Wedge Angiography:** This is used to measure pulmonary capillary wedge pressure or visualize pulmonary veins; it has no role in diagnosing acute PE. * **D. Echocardiography:** While useful to see right heart strain or bedside assessment in unstable patients, it is not the definitive diagnostic step for PE. **High-Yield Clinical Pearls for NEET-PG:** * **Most common CXR finding in PE:** Normal (or non-specific atelectasis/effusion). * **Classic CXR signs (Rare):** Westermark sign (focal oligemia) and Hampton’s hump (wedge-shaped opacity). * **ECG finding:** Most common is Sinus Tachycardia; most specific is S1Q3T3. * **Gold Standard:** Invasive Pulmonary Angiography. * **Investigation of choice (Modern):** CT Pulmonary Angiography (CTPA).

Q: Which feature indicates the benign nature of a solitary pulmonary nodule?

Small specks of calcification. **Explanation:** The radiological assessment of a Solitary Pulmonary Nodule (SPN) focuses on differentiating benign lesions from potential malignancies. **Calcification patterns** are the most reliable indicators of stability. **Why Option C is Correct:** While "popcorn" calcification is a classic sign of a benign hamartoma, the presence of **diffuse, central, laminated, or small specks of organized calcification** generally indicates a benign process, often representing a healed granuloma (e.g., Tuberculosis or Histoplasmosis). These patterns suggest the lesion has been stable over a long period. **Analysis of Incorrect Options:** * **Option A (6cm size):** Any lesion >3 cm is technically termed a "mass" rather than a nodule. Size is a strong predictor of malignancy; lesions larger than 2 cm have a >75% risk of being cancerous. * **Option B (Acute onset):** Rapid growth (doubling time 2 years is a hallmark of benignity. * **Option D (Popcorn calcification):** While popcorn calcification is indeed benign (pathognomonic for Hamartoma), in the context of standard radiology MCQ hierarchy, "small specks" or "diffuse" patterns are often used to describe the most common benign presentation (granulomas). *Note: In many clinical scenarios, both C and D indicate benignity, but granulomatous specks are statistically more frequent.* **NEET-PG High-Yield Pearls:** 1. **Benign Calcification Patterns:** Diffuse, Central, Laminated (Bull’s eye), and Popcorn. 2. **Malignant Calcification Patterns:** Stippled, Eccentric, or Punctate. 3. **Corona Radiata Sign:** Spiculated margins highly suggestive of bronchogenic carcinoma. 4. **Doubling Time:** Malignant nodules typically double in volume between 20 to 400 days.

Q: Pruning of pulmonary arteries is seen in which condition?

Pulmonary hypertension. ### Explanation **Correct Answer: A. Pulmonary hypertension** **Mechanism:** "Pruning" of pulmonary arteries is a classic radiological sign of **Pulmonary Arterial Hypertension (PAH)**. It refers to the rapid tapering of peripheral pulmonary vessels. In PAH, there is high pressure in the pulmonary circuit, leading to compensatory **dilation of the central pulmonary arteries** (hilar vessels). However, due to increased vascular resistance and obliterative changes in the distal arterioles, the peripheral vessels appear narrow, sparse, or absent. This contrast between large central arteries and "cut-off" peripheral vessels mimics the appearance of a tree with its outer branches pruned away. **Analysis of Incorrect Options:** * **B. Chronic bronchitis:** While this can lead to Cor Pulmonale and secondary PAH, the primary radiological features are "dirty lungs" (increased bronchovascular markings) and cardiomegaly, rather than isolated pruning. * **C. Pulmonary infections:** These typically present with opacities, consolidations, or infiltrates. While infections can cause local hypervascularity, they do not cause the systemic vascular tapering seen in PAH. * **D. Pulmonary transplant:** Post-transplant imaging focuses on complications like rejection (ground-glass opacities), anastomotic strictures, or infections, not the pruning of the arterial tree. **NEET-PG High-Yield Pearls:** * **Westermark Sign:** Focal oligemia (pruning) distal to a pulmonary embolism; a specific but insensitive sign. * **Knuckle Sign:** Abrupt tapering of a pulmonary artery secondary to an embolus. * **Measurement:** On a PA chest X-ray, a right descending pulmonary artery diameter **>16 mm** (males) or **>15 mm** (females) is suggestive of pulmonary hypertension. * **Egg-on-a-string appearance:** Seen in TGA, not to be confused with vascular pruning.

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

Rib notching of 4
–9th ribs with double bulging is seen in?

Accepted Answer

Coarctation of aorta

Answer

Aortic aneurysm

Answer

Aortic dissection

Answer

Diaphragmatic hernia

Question 2

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

Accepted Answer

Metastatic lesion

Answer

Hemangioma

Answer

Pulmonary infarction

Answer

Tuberculosis

Question 3

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 4

A 55-year-old man, who has been on bed rest for the past 10 days, complains of breathlessness and chest pain. The chest X-ray is normal. What is the next step in investigation?

Accepted Answer

Lung ventilation-perfusion scan

Answer

Pulmonary angiography

Answer

Pulmonary venous wedge angiography

Answer

Echocardiography

Question 5

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 6

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 7

Miliary shadow in chest X-ray is typically seen in which of the following conditions?

Accepted Answer

Klebsiella pneumoniae infection

Answer

Tuberculosis

Answer

Loeffler's pneumonia

Answer

Varicella pneumonia

Question 8

Which feature indicates the benign nature of a solitary pulmonary nodule?

Accepted Answer

Small specks of calcification

Answer

6cm size

Answer

Acute onset

Answer

Popcorn calcification

Question 9

Pruning of pulmonary arteries is seen in which condition?

Accepted Answer

Pulmonary hypertension

Answer

Chronic bronchitis

Answer

Pulmonary infections

Answer

Pulmonary transplant

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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