Chest Radiology Practice Questions

Q: What is the most common feature of sarcoidosis on chest X-ray?

Bilateral hilar lymphadenopathy. ***Bilateral hilar lymphadenopathy*** - **Bilateral hilar lymphadenopathy** is the hallmark radiological feature of sarcoidosis, seen in over 75% of cases. - This finding, often symmetrical, represents the accumulation of **non-caseating granulomas** in the lymph nodes. - Classic presentation in **Stage I and Stage II** sarcoidosis. *Pleural effusion* - **Pleural effusions** are uncommon in sarcoidosis, occurring in less than 5% of cases. - When present, they are usually small and unilateral, and their presence should prompt consideration of alternative diagnoses. *Cavitation* - **Cavitation** is a rare manifestation of sarcoidosis and is more characteristic of infectious processes like **tuberculosis** or certain fungal infections. - If seen, it usually suggests severe parenchymal involvement or superimposed infection. *Reticular opacities* - While **reticular opacities** (interstitial changes) can be seen in later stages of sarcoidosis, representing **pulmonary fibrosis**, they are not the *most common* initial finding. - These opacities indicate chronic disease progression (Stage III/IV) rather than the initial presentation.

Q: Which view is best for visualizing the collapse of the middle lobe of the lung?

Lateral. ***Lateral*** - A **lateral chest X-ray** is crucial for localizing abnormalities to specific lung lobes because it allows for a clear visualization of the **fissures** which define the lung lobes. - Collapse of the right middle lobe is particularly well-visualized on a lateral view as a **triangular opacity** that points towards the hilum, often obliterating the right heart border. *Anteroposterior (AP)* - While an AP or PA view can show collapse, it often appears as a **non-specific wedge or triangular opacity** and struggles with precise lobar localization due to superimposed structures. - The **heart shadow and mediastinum** can obscure parts of the middle lobe, making definitive diagnosis challenging from this view alone. *Oblique* - Oblique views are typically used for specific purposes, such as evaluating the **pleura** or **ribs**, and are not a standard view for initial assessment of lobar collapse. - They introduce **distortion and superimposition** that can make the identification and characterization of lobar collapse more difficult than a standard lateral projection. *Lordotic* - A lordotic view is primarily used to visualize the **lung apices** and to differentiate apical lesions from superimposed clavicular shadows. - It is not effective for visualizing the middle lobe, which is located more inferiorly, and would introduce significant distortion, making assessment of its collapse unreliable.

Q: Which of the following is NOT a typical differential diagnosis for a solitary pulmonary nodule?

Mycetoma. ***Mycetoma*** - A mycetoma is a **fungal infection** that typically affects subcutaneous tissues, skin, and bone, forming granulomas and sinuses. It is not typically seen as a solitary pulmonary nodule. - While pulmonary fungal infections can occur, a mycetoma in the lung typically presents as a **fungus ball (aspergilloma)** within a pre-existing cavity, rather than a solitary, solid nodule. *Tuberculoma* - A tuberculoma is a **granuloma** caused by Mycobacterium tuberculosis, which can present as a well-defined, solitary pulmonary nodule or mass on imaging. - It represents a contained form of tuberculosis and is a common differential for a solitary pulmonary nodule, especially in endemic areas. *Hamartoma* - A hamartoma is a **benign tumor-like malformation** composed of normal tissues (like cartilage, fat, and muscle) that are disorganized. - It is one of the most common benign causes of a solitary pulmonary nodule. *Bronchogenic carcinoma* - Bronchogenic carcinoma, including adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, is the most significant concern when evaluating a solitary pulmonary nodule. - It is a primary **malignant lung tumor** and represents a crucial differential diagnosis due to its poor prognosis if not detected and treated early.

Q: In a patient with high clinical suspicion of pulmonary thromboembolism, best investigation would be?

CT angiography. ***CT angiography*** - In a patient with **high clinical suspicion** of pulmonary embolism (PE), CT angiography of the pulmonary arteries is the preferred and often definitive diagnostic test. - It allows for direct visualization of thrombi within the pulmonary arterial tree with high sensitivity and specificity. *D-dimer* - While useful for **ruling out PE** in patients with low or intermediate pre-test probability, a positive D-dimer is non-specific and requires further investigation in high-suspicion cases. - It has a high **negative predictive value** but a low positive predictive value, meaning a normal D-dimer makes PE unlikely, but an elevated one does not confirm it. *Catheter angiography* - This is an **invasive procedure** that is typically reserved for cases where CT angiography is inconclusive or contraindicated, or when interventional treatment is contemplated. - It carries risks such as **bleeding** and **contrast-induced nephropathy**, making it less appropriate as a first-line diagnostic in most situations. *Color Doppler* - Color Doppler ultrasound is primarily used to diagnose **deep vein thrombosis (DVT)** in the lower extremities, which is a common source of PE. - It is **not used to directly diagnose PE** in the pulmonary arteries; however, finding a DVT can support the diagnosis of PE indirectly.

Q: Air bronchogram on chest X-ray denotes -

Intrapulmonary lesion. ***Intrapulmonary lesion*** - An **air bronchogram** indicates that the air-filled bronchi are surrounded by consolidated or fluid-filled alveoli, making the bronchi visible against the opacified lung parenchyma. - This pattern is a strong sign of a process **within the lung tissue itself**, such as pneumonia, pulmonary edema, or malignancy. *Extrapulmonary lesion* - **Extrapulmonary lesions**, such as pleural effusions or masses originating from the chest wall, typically displace or compress the lung and bronchi, rather than filling the alveoli around them. - They usually do **not produce an air bronchogram** because the air in the bronchi is not juxtaposed against diseased lung parenchyma. *Intrathoracic lesion* - This is a broad term that includes all lesions within the thoracic cavity, both intrapulmonary and extrapulmonary. - While an air bronchogram is an intrathoracic finding, it specifically points to an **intrapulmonary process**, not just any intrathoracic lesion. *Extrathoracic lesion* - **Extrathoracic lesions** are located outside the chest cavity and would not manifest as an air bronchogram on a chest X-ray. - This option is **completely unrelated** to the interpretation of an air bronchogram.

Q: A chest X-ray shows bilateral lung infiltrates. What is the next best investigation?

CT. ***CT*** - A **CT scan (preferably HRCT)** provides a more detailed view of the lung parenchyma, allowing for better characterization of the infiltrates (e.g., location, pattern, presence of nodules, ground-glass opacities, or consolidation). - This detailed imagery is crucial for narrowing down the differential diagnosis and guiding further diagnostic or therapeutic interventions. - **CT is the best next investigation** for characterizing bilateral lung infiltrates seen on chest X-ray. *Sputum examination* - While important for identifying infectious causes, **sputum examination** is often only productive in certain types of pneumonia or infections and might not directly clarify the morphology or distribution of the infiltrates as a CT scan would. - It might be a subsequent step once the nature of the infiltrate is better understood through imaging. *Bronchoscopy* - **Bronchoscopy** is an invasive procedure generally reserved for cases where less invasive methods have failed to yield a diagnosis or when specific findings from imaging (like a CT scan) suggest the need for direct visualization, lavage, or biopsy. - It's not typically the immediate next step after identifying bilateral infiltrates on a chest X-ray. *Echocardiography* - **Echocardiography** is useful for evaluating cardiac causes of bilateral infiltrates (such as pulmonary edema from heart failure). - However, it does not directly visualize or characterize the lung parenchymal infiltrates themselves, making CT more valuable as the next investigation.

Q: Retrocardiac lucency with air fluid level is seen in

Hiatus hernia. ***Hiatus hernia*** - A **hiatus hernia** occurs when part of the stomach protrudes into the chest through the **esophageal hiatus** of the diaphragm. - This can lead to a **retrocardiac lucency** (gas-filled stomach) with an **air-fluid level** visible on chest X-rays due to gastric contents. - The herniated gastric fundus appears as a characteristic gas bubble behind the heart, particularly well-seen on lateral chest radiographs. *Distal esophageal obstruction* - While distal esophageal obstruction can cause esophageal dilation and sometimes an **air-fluid level** within the esophagus, it generally presents as a tubular structure *behind* the heart rather than a distinct retrocardiac lucency representing a portion of the stomach. - The appearance would be more suggestive of a dilated esophagus filled with contents, not a herniated stomach. *Diaphragmatic eventration* - **Diaphragmatic eventration** is an abnormal elevation of a portion of the diaphragm, often due to congenital weakness or phrenic nerve paralysis. - It does not typically cause a **retrocardiac lucency** with an **air-fluid level**, as it involves the diaphragm itself rather than the herniation of an abdominal organ. - It may show elevation of the hemidiaphragm but without the characteristic gas-filled viscus appearance. *None of the options* - Hiatus hernia is a well-established radiological diagnosis for retrocardiac lucency with an **air-fluid level**, making this option clearly incorrect.

Q: Which of the following is not typically seen on a chest X-ray in pulmonary artery hypertension?

Narrowing of central arteries. ***Narrowing of central arteries*** - **Pulmonary artery hypertension** is characterized by the **enlargement of the central pulmonary arteries** due to increased pressure. - **Narrowing of central arteries** would contradict the hemodynamic changes seen in pulmonary hypertension. - This is the finding that is **NOT typically seen**, making this the correct answer. *Enlargement of central arteries* - This is a **hallmark radiographic finding** in pulmonary hypertension, reflecting the **dilatation of the main and proximal pulmonary arteries** due to increased pressure. - The **pulmonary artery segment becomes prominent**, often appearing convex on the left heart border. *Peripheral pruning* - This refers to the **abrupt tapering and loss of peripheral pulmonary vascular markings**, indicating reduced blood flow to the distal lung parenchyma. - It is a **common finding in advanced pulmonary hypertension**, as the distal vessels constrict and become obliterated. *None of the options* - This is incorrect since **narrowing of central arteries** is clearly not a typical finding in pulmonary hypertension.

Q: Which of the following conditions characteristically causes bilateral hypertranslucency of lung fields on chest X-ray?

Emphysema. ***Correct: Emphysema*** - **Emphysema** causes destruction of alveolar walls, leading to enlarged air spaces and **air trapping**, making both lungs appear hypertranslucent on X-ray - This **bilateral hypertranslucency** is due to reduced lung tissue density, decreased vascular markings, and increased air volume - Classic radiographic features include flattened diaphragms, increased retrosternal space, and hyperlucent lung fields *Incorrect: Mcleod syndrome* - Also known as **Swyer–James–MacLeod syndrome**, this condition causes **unilateral** lung or lobe hyperlucency due to post-infectious obliterative bronchiolitis - The key differentiating feature is that it's **unilateral**, whereas the question asks for bilateral hypertranslucency - Affected lung shows air trapping on expiratory films *Incorrect: Pneumothorax* - A **pneumothorax** presents as a **unilateral** or focal hypertranslucent area due to air in the pleural space - Characterized by **absence of lung markings** beyond the visceral pleural line and associated lung collapse - This is a pleural space abnormality, not a bilateral parenchymal lung disease *Incorrect: Poland syndrome* - **Poland syndrome** is a congenital condition with absence or underdevelopment of the pectoralis major muscle - Can lead to **unilateral** apparent hyperlucency on the affected side due to missing chest wall muscle - This is a **chest wall anomaly**, not a parenchymal lung disease causing bilateral hypertranslucency

Question 1

What is the most common feature of sarcoidosis on chest X-ray?

Accepted Answer

Bilateral hilar lymphadenopathy

Answer

Cavitation

Answer

Pleural effusion

Answer

Reticular opacities

Question 2

Which view is best for visualizing the collapse of the middle lobe of the lung?

Accepted Answer

Lateral

Answer

Anteroposterior (AP)

Answer

Oblique

Answer

Lordotic

Question 3

Inferior rib notching is seen in

Accepted Answer

Coarctation of the aorta

Answer

Rickets (Vitamin D deficiency)

Answer

Atrial Septal Defect (ASD)

Answer

Multiple Myeloma

Question 4

Which of the following is NOT a typical differential diagnosis for a solitary pulmonary nodule?

Accepted Answer

Mycetoma

Answer

Tuberculoma

Answer

Hamartoma

Answer

Bronchogenic carcinoma

Question 5

In a patient with high clinical suspicion of pulmonary thromboembolism, best investigation would be?

Accepted Answer

CT angiography

Answer

D-dimer

Answer

Catheter angiography

Answer

Color Doppler

Question 6

Air bronchogram on chest X-ray denotes -

Accepted Answer

Intrapulmonary lesion

Answer

Extrapulmonary lesion

Answer

Intrathoracic lesion

Answer

Extrathoracic lesion

Question 7

A chest X-ray shows bilateral lung infiltrates. What is the next best investigation?

Accepted Answer

CT

Answer

Sputum examination

Answer

Bronchoscopy

Answer

Echocardiography

Question 8

Retrocardiac lucency with air fluid level is seen in

Accepted Answer

Hiatus hernia

Answer

Distal esophageal obstruction

Answer

Diaphragmatic eventration

Answer

None of the options

Question 9

Which of the following is not typically seen on a chest X-ray in pulmonary artery hypertension?

Accepted Answer

Narrowing of central arteries

Answer

Enlargement of central arteries

Answer

Peripheral pruning

Answer

None of the options

Question 10

Which of the following conditions characteristically causes bilateral hypertranslucency of lung fields on chest X-ray?

Accepted Answer

Emphysema

Answer

Mcleod syndrome

Answer

Poland syndrome

Answer

Pneumothorax

Chest Radiology — MCQs

Chest Radiology — MCQs

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