Chest Radiology — MCQs

Chest Radiology Indian Medical PG Practice Questions and MCQs

Question 331: Which of the following statements is NOT true regarding Pectus excavatum?

A. Heart shifted towards the left side
B. May present with features suggestive of right middle lobe consolidation
C. Anterior ribs are more vertically oriented, resulting in a '7-shaped' appearance
D. Heart shifted towards the right side (Correct Answer)

Explanation: **Explanation:** **Pectus excavatum** (funnel chest) is the most common congenital chest wall deformity, characterized by a concave depression of the sternum. This structural abnormality reduces the anteroposterior (AP) diameter of the chest, leading to specific radiological findings. 1. **Why Option D is the Correct Answer (The False Statement):** In Pectus excavatum, the depressed sternum physically compresses the heart against the spine. Because the heart cannot move posteriorly, it is typically **displaced to the left** and rotated. Displacement to the right is not a feature of this condition; therefore, Option D is the false statement. 2. **Analysis of Other Options:** * **Option A:** As explained above, the heart is characteristically shifted to the **left**, which can sometimes mimic cardiomegaly on a PA view. * **Option B:** The depressed sternum and overlying soft tissues can cause an area of increased opacity over the right heart border. This often obscures the right heart border, mimicking **Right Middle Lobe (RML) consolidation** (the "pseudo-silhouette sign"). * **Option C:** Due to the sternal depression, the **anterior ribs** take on a more **vertical/steep orientation**, often described as a **"7-shaped"** or "verticalized" appearance on a frontal chest X-ray. **Clinical Pearls for NEET-PG:** * **Haller Index:** Used on CT to quantify severity (Lateral diameter / AP diameter). A value **>3.25** is usually considered severe and may require surgical correction (e.g., Nuss procedure). * **Lateral X-ray:** This is the definitive view to confirm the diagnosis, showing the posterior displacement of the lower sternum. * **Associations:** Often associated with Marfan syndrome, Ehlers-Danlos syndrome, and scoliosis.

Question 332: Superior rib notching is not associated with which of the enlisted conditions?

A. Hyperparathyroidism
B. Marfan syndrome
C. Blalock-Taussig shunt (Correct Answer)
D. Systemic lupus erythematosus

Explanation: **Explanation:** Rib notching is a high-yield topic in chest radiology. To answer this question, one must distinguish between **inferior** and **superior** rib notching. **Why Blalock-Taussig (BT) Shunt is the correct answer:** A BT shunt (specifically the classic version) involves anastomosing the subclavian artery to the pulmonary artery. This reduces blood flow to the intercostal arteries on the ipsilateral side. Consequently, it causes **inferior rib notching** (due to collateral retrograde flow through dilated intercostal arteries), not superior. Inferior notching is typically associated with vascular pressure/dilatation (e.g., Coarctation of the aorta), whereas superior notching is associated with disturbances in osteoblastic/osteoclastic activity or connective tissue pressure. **Analysis of Incorrect Options (Causes of Superior Rib Notching):** * **Hyperparathyroidism (A):** This is the most common cause of superior rib notching due to subperiosteal bone resorption along the upper margin of the ribs. * **Marfan Syndrome (B):** Connective tissue disorders lead to a deficiency in the supportive matrix of the bone, making the superior aspect of the ribs susceptible to pressure erosion. * **Systemic Lupus Erythematosus (D):** Chronic inflammation and corticosteroid use in SLE can lead to localized bone resorption and superior rib thinning/notching. **NEET-PG High-Yield Pearls:** 1. **Inferior Rib Notching (Roesler’s Sign):** Most commonly seen in **Coarctation of the Aorta** (3rd to 8th ribs; spares 1st and 2nd). 2. **Superior Rib Notching:** Think "Mnemonic: **SHAM**" — **S**cleroderma/SLE, **H**yperparathyroidism, **A**lkaptonuria, **M**arfan syndrome/Melorheostosis. 3. **Unilateral Inferior Notching:** Seen in classic BT shunt or subclavian artery stenosis.

Question 333: Which of the following statements regarding the right anterior oblique (RAO) view of a chest X-ray are true?

A. The cassette is placed near the right shoulder, and the aortic arch is best seen. (Correct Answer)
B. The aortic arch is best seen.
C. The cassette is placed near the right shoulder, and left atrial enlargement can be diagnosed.
D. The cassette is placed near the right shoulder, and the cassette is placed near the left shoulder.

Explanation: ### Explanation In chest radiography, the **Right Anterior Oblique (RAO)** view is obtained by rotating the patient approximately 45 degrees so that the **right anterior chest (right shoulder)** is in contact with the film/cassette. **1. Why Option A is Correct:** In the RAO position, the heart and mediastinal structures are projected in a specific orientation. This view provides an excellent profile of the **aortic arch**, the ascending aorta, and the pulmonary artery. Historically, this view was also used during barium swallows to assess the esophagus, as it displaces the heart away from the spine. **2. Analysis of Incorrect Options:** * **Option B:** While the aortic arch is indeed seen well, this option is incomplete compared to Option A, which correctly identifies the patient's positioning (cassette near the right shoulder). * **Option C:** Left atrial enlargement (LAE) is best evaluated in the **Left Anterior Oblique (LAO)** view or a lateral view with barium swallow (where the enlarged atrium causes posterior indentation of the esophagus). In RAO, the left atrium is not the primary focus for diagnostic enlargement. * **Option D:** This option is logically inconsistent and contains a repetitive error regarding the placement of the cassette. **3. High-Yield Clinical Pearls for NEET-PG:** * **RAO View:** Think "Right shoulder to film." Best for the **aortic arch**, esophagus, and right lung fields. * **LAO View:** Think "Left shoulder to film." Best for the **"Aortic Window"** (space under the arch), **left atrium**, and evaluating the size of the left ventricle. * **Mnemonic:** **R**AO = **R**ight side/Aortic arch; **L**AO = **L**eft Atrium/Ventricle. * **Barium Swallow:** In RAO, an enlarged left atrium will displace the barium-filled esophagus posteriorly and to the right.

Question 334: Pulmonary plethora is seen in which of the following conditions?

A. Total anomalous pulmonary venous connection (TAPVC) (Correct Answer)
B. Tetralogy of Fallot (TOF)
C. Ebstein anomaly
D. Tricuspid atresia

Explanation: **Explanation:** **Pulmonary Plethora** (increased pulmonary vascularity) occurs when there is a **Left-to-Right shunt**, leading to an increased volume of blood flowing through the pulmonary arteries. On a chest X-ray, this is characterized by prominent pulmonary markings extending to the outer third of the lung fields and enlargement of the main pulmonary artery. **Why TAPVC is correct:** Total Anomalous Pulmonary Venous Connection (TAPVC) is a cyanotic congenital heart disease characterized by a **Left-to-Right shunt**. Since all pulmonary veins drain into the right atrium (instead of the left), the pulmonary circulation receives a massive excess of blood volume, leading to classic pulmonary plethora. In the supracardiac type, this produces the characteristic **"Snowman" or "Figure-of-8" appearance** on X-ray. **Why the other options are incorrect:** * **Tetralogy of Fallot (TOF):** Characterized by pulmonary stenosis, which restricts blood flow to the lungs, resulting in **pulmonary oligemia** (decreased vascularity) and a "boot-shaped" heart (Coeur en sabot). * **Ebstein Anomaly:** Involves tricuspid regurgitation and a "wall-to-wall" globular heart. The right-to-left shunt at the atrial level leads to **pulmonary oligemia**. * **Tricuspid Atresia:** Due to the lack of a tricuspid valve, blood flow to the right ventricle and pulmonary artery is severely diminished, resulting in **pulmonary oligemia**. **High-Yield Clinical Pearls for NEET-PG:** * **Plethora (L $\to$ R Shunt):** ASD, VSD, PDA, TAPVC, Transposition of Great Arteries (TGA), Truncus Arteriosus. * **Oligemia (Decreased Flow):** TOF, Ebstein anomaly, Tricuspid atresia, Pulmonary stenosis. * **TAPVC X-ray Sign:** "Snowman sign" (Supracardiac type). * **TGA X-ray Sign:** "Egg-on-side" appearance.

Question 335: Westermark's sign is seen in which of the following conditions?

A. Pulmonary embolism (Correct Answer)
B. Pulmonary sequestration
C. Pulmonary alveolar proteinosis
D. Allergic bronchopulmonary aspergillosis

Explanation: **Explanation:** **Westermark’s sign** is a classic, though infrequent, radiographic finding in **Pulmonary Embolism (PE)**. It refers to a focal area of **oligemia** (reduced vascular markings) distal to an occluded pulmonary artery. This occurs because the thrombus obstructs blood flow, leading to a "lucent" or darker appearance of the lung parenchyma in that specific segment. While highly specific for PE, its sensitivity is low. **Analysis of Options:** * **Pulmonary Sequestration:** Characterized by non-functioning lung tissue with an anomalous systemic arterial supply. On imaging, it typically appears as a solid mass or cystic lesion, often in the left lower lobe. * **Pulmonary Alveolar Proteinosis (PAP):** Classically presents with a **"Crazy Paving" pattern** (ground-glass opacities with superimposed interlobular septal thickening) on HRCT, not focal oligemia. * **Allergic Bronchopulmonary Aspergillosis (ABPA):** Key radiographic features include **"Finger-in-glove" opacities** due to mucoid impaction and central bronchiectasis. **High-Yield Clinical Pearls for NEET-PG:** * **Hampton’s Hump:** A wedge-shaped, pleural-based opacity representing pulmonary infarction (also seen in PE). * **Palla’s Sign:** Enlargement of the right descending pulmonary artery in PE. * **Fleischner Sign:** Prominent central pulmonary artery due to a large embolus. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) is the investigation of choice for PE. * **Knuckle Sign:** Abrupt tapering of a pulmonary artery secondary to an embolus.

Question 336: A chest X-ray shows an opacity in the lung with irregular calcification. What is this suggestive of?

A. Lung carcinoma
B. Hamartoma (Correct Answer)
C. Hydatid cyst
D. Adenoma

Explanation: **Explanation:** **Hamartoma** is the most common benign tumor of the lung. The classic radiological hallmark of a pulmonary hamartoma is **"Popcorn Calcification"** (irregular, coarse, or speckled calcification). These lesions are typically small (<3 cm), peripheral, well-circumscribed, and slow-growing. The presence of fat density on a CT scan (Hounsfield units -40 to -120) combined with popcorn calcification is pathognomonic for hamartoma. **Analysis of Incorrect Options:** * **Lung Carcinoma:** While malignancies can show calcification (eccentric or stippled), it is rare. Malignant lesions usually present with "spiculated" margins, rapid doubling time, and a lack of organized calcification. * **Hydatid Cyst:** Typically presents as a well-defined, water-density fluid-filled cyst. Classic signs include the **"Water Lily sign"** (Camasalotte sign) or **"Crescent sign."** Calcification, if present, is usually curvilinear or peripheral (wall calcification), not irregular/popcorn-like. * **Adenoma:** Bronchial adenomas (like Carcinoid tumors) are usually central/endobronchial. While they can occasionally calcify, they typically present with signs of airway obstruction like distal collapse or obstructive pneumonitis. **NEET-PG High-Yield Pearls:** * **Popcorn Calcification:** Seen in Pulmonary Hamartoma and Fibroadenoma of the breast. * **Benign Calcification Patterns:** Diffuse, central, laminated (target), and popcorn. * **Malignant Calcification Patterns:** Eccentric, stippled, or fine/punctate. * **Fleischner Society Guidelines:** Used for the management of incidental pulmonary nodules. * **Feeding Vessel Sign:** Classically associated with Septic Emboli or Metastasis.

Question 337: Which of the following is NOT a posterior mediastinal tumor?

A. Neurofibroma
B. Lymphoma
C. Thymoma (Correct Answer)
D. Gastroenteric cyst

Explanation: To master mediastinal masses for NEET-PG, it is essential to understand the anatomical compartmentalization of the mediastinum (Felson’s or Shields’ classification). **Explanation of the Correct Answer:** **C. Thymoma:** This is the most common primary tumor of the **anterior mediastinum**. The anterior mediastinum is defined as the space between the sternum and the anterior border of the heart and great vessels. Thymomas are frequently associated with Myasthenia Gravis (30-50% of patients) and are never found in the posterior mediastinum unless they are ectopic, which is extremely rare. **Analysis of Incorrect Options:** * **A. Neurofibroma:** Neurogenic tumors are the **most common** cause of a posterior mediastinal mass. They arise from the spinal nerve roots or the sympathetic chain. * **B. Lymphoma:** While lymphoma most commonly involves the anterior and middle mediastinal lymph nodes, it can occur in **any** compartment. In the posterior mediastinum, it typically presents as paravertebral lymphadenopathy. * **C. Gastroenteric cyst:** These are congenital foregut duplication cysts. Because they are embryologically related to the esophagus and spine, they are characteristically located in the posterior mediastinum. **High-Yield Clinical Pearls for NEET-PG:** * **The "4 Ts" of Anterior Mediastinal Masses:** Thymoma, Teratoma (Germ cell tumors), Thyroid (Retrosternal goiter), and "Terrible" Lymphoma. * **Posterior Mediastinum (The 3 Ns):** Neurogenic tumors (most common), Neurenteric cysts, and Not-so-common Extramedullary Hematopoiesis. * **Cervicothoracic Sign:** If a mass extends above the clavicles on a CXR, it is located in the posterior mediastinum (as the anterior mediastinum ends at the level of the clavicles).

Question 338: Sequestration lung is best diagnosed by which imaging modality?

A. CT scan
B. MRI
C. Barium swallow
D. Angiography (Correct Answer)

Explanation: **Explanation:** **Pulmonary sequestration** is a congenital anomaly characterized by a non-functioning mass of lung tissue that lacks normal communication with the tracheobronchial tree and, most importantly, receives its **systemic arterial blood supply** (usually from the abdominal or thoracic aorta) rather than the pulmonary arteries. 1. **Why Angiography is the Correct Answer:** The definitive diagnosis of pulmonary sequestration depends on the identification of this **aberrant systemic arterial supply**. Historically and classically, **Angiography** is considered the "gold standard" because it precisely maps the origin and course of the anomalous artery, which is crucial for surgical planning to prevent fatal intraoperative hemorrhage. 2. **Why Other Options are Incorrect:** * **CT Scan:** While Multidetector CT (MDCT) angiography is now the practical first-line investigation in modern clinical practice, traditional "CT scan" (without specific vascular focus) is less definitive than angiography for identifying the aberrant vessel. * **MRI:** MR Angiography is a non-invasive alternative but is generally not the primary diagnostic standard compared to conventional or CT angiography. * **Barium Swallow:** This is used to rule out associated gastrointestinal communications (bronchopulmonary foregut malformations) but cannot diagnose the vascular anomaly itself. **High-Yield Clinical Pearls for NEET-PG:** * **Intralobar Sequestration (75%):** Located within the normal visceral pleura; usually presents in adulthood with recurrent infections; venous drainage is typically via pulmonary veins. * **Extralobar Sequestration (25%):** Has its own pleural investment; usually presents in neonates with respiratory distress or associated anomalies (e.g., diaphragmatic hernia); venous drainage is via systemic veins (azygos/hemi-azygos). * **Most common location:** Posterior basal segment of the Left Lower Lobe.

Question 339: A 75-year-old male presented with chief complaint of pain in the right shoulder. Which of the following could be the cause of pain in this patient?

A. Pancoast tumor (Correct Answer)
B. Sarcoidosis
C. Subclavian artery aneurysm
D. Mesothelioma

Explanation: ### **Explanation** **Correct Option: A. Pancoast Tumor** A **Pancoast tumor** (Superior Sulcus Tumor) is typically a non-small cell lung carcinoma (most commonly squamous cell or adenocarcinoma) arising at the apex of the lung. The pain in the right shoulder is caused by the local invasion of the **brachial plexus** (specifically the lower roots, C8–T2) and the **stellate ganglion**. This presentation is known as **Pancoast Syndrome**, which classically includes: 1. **Shoulder/Arm Pain:** Radiating along the ulnar distribution. 2. **Horner’s Syndrome:** Due to involvement of the sympathetic chain (ptosis, miosis, anhidrosis). 3. **Atrophy:** Wasting of the small muscles of the hand. **Why Incorrect Options are Wrong:** * **B. Sarcoidosis:** Typically presents with bilateral hilar lymphadenopathy and interstitial lung disease. While it can cause systemic symptoms, it does not characteristically invade the brachial plexus to cause isolated shoulder pain. * **C. Subclavian Artery Aneurysm:** While located in the superior sulcus, it is a rare cause of shoulder pain compared to malignancy. It more commonly presents with a pulsatile mass or distal embolic phenomena (blue toe syndrome). * **D. Mesothelioma:** This is a tumor of the pleura, usually associated with asbestos exposure. It typically presents with diffuse pleural thickening, chest wall pain, and pleural effusion, rather than focal apical invasion of the brachial plexus. **Clinical Pearls for NEET-PG:** * **Radiology Sign:** Look for an **apical soft tissue opacity** with or without destruction of the 1st and 2nd ribs. * **MRI** is the investigation of choice to evaluate the extent of brachial plexus and vertebral body invasion. * **Most common histology:** Adenocarcinoma (previously Squamous cell carcinoma). * **Differential Diagnosis:** Always rule out cervical spondylosis in elderly patients presenting with similar radicular pain.

Question 340: Nipple shadows in a chest X-ray characteristically have a sharp:

A. Medial margin
B. Lateral margin (Correct Answer)
C. Superior margin
D. Inferior margin

Explanation: **Explanation:** Nipple shadows are a common mimic of pulmonary nodules on a chest X-ray. The characteristic appearance of a nipple shadow is defined by the **Mach band effect** and the tangential orientation of the X-ray beam. **Why the Lateral Margin is correct:** The lateral margin of the nipple is typically surrounded by air, creating a sharp interface with the skin. Because the X-ray beam strikes this interface tangentially, it produces a **well-defined, sharp lateral border**. Conversely, the medial aspect of the nipple gradually blends into the soft tissue of the breast or chest wall, resulting in an ill-defined or "fuzzy" medial margin. This "sharp-lateral, blurred-medial" appearance is a classic radiological sign used to differentiate a nipple shadow from an intrapulmonary lesion. **Analysis of Incorrect Options:** * **Medial Margin:** As noted, the medial side lacks a sharp air-tissue interface, making it appear hazy. * **Superior/Inferior Margins:** While these may occasionally appear somewhat defined, they do not consistently exhibit the characteristic sharpness seen on the lateral edge due to the anatomical contour of the nipple. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Nipple shadows are typically located in the 4th or 5th intercostal spaces, usually lateral to the midclavicular line. * **Symmetry:** They are often bilateral and symmetric, which helps rule out pathology. * **Confirmatory Step:** If a nipple shadow is suspected to be a lung nodule, the next best step is a **repeat X-ray with nipple markers** (e.g., small metallic pellets taped over the nipples). * **Differential Diagnosis:** Always differentiate from "Coin lesions" (e.g., granulomas, hamartomas, or malignancy). A true pulmonary nodule usually has sharp borders all around (360 degrees).

Practice by Chapter

Normal Chest Radiographic Anatomy

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Radiographic Signs in Chest Imaging

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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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