Chest Radiology Practice Questions

Q: A 25-year-old man presented with fever, cough, expectoration, and breathlessness of 2 months' duration. Contrast-enhanced computed tomography of the chest showed bilateral upper lobe fibrotic lesions and mediastinal enlarged necrotic nodes with peripheral rim enhancement. Which one of the following is the most probable diagnosis?

Tuberculosis. ### Explanation The clinical and radiological presentation is classic for **Post-primary (Reactivation) Tuberculosis**. **Why Tuberculosis is correct:** In a young patient with a chronic history (2 months) of constitutional symptoms (fever, cough, expectoration), the presence of **bilateral upper lobe fibrotic lesions** is highly suggestive of TB, as the organism (*Mycobacterium tuberculosis*) prefers the high oxygen tension found in the lung apices. The pathognomonic CT finding here is **mediastinal lymphadenopathy with peripheral rim enhancement and central necrosis**. This "rim sign" represents granulomatous inflammation with central caseous necrosis, which is the hallmark of tubercular lymphadenitis. **Why other options are incorrect:** * **Sarcoidosis:** Typically presents with bilateral symmetrical hilar lymphadenopathy and perilymphatic nodules. While it can cause upper lobe fibrosis in Stage IV, the nodes are usually "potato-like" (well-defined, non-matted) and **homogeneously enhancing**, not necrotic. * **Lymphoma:** Usually presents with a large anterior mediastinal mass. While nodes can be bulky, they typically show **homogeneous enhancement**. Necrosis is rare unless the tumor is very large or post-treatment. * **Silicosis:** Characterized by multiple small, well-defined nodules in the upper lobes and "eggshell calcification" of hilar nodes. It does not typically present with necrotic nodes or acute febrile illness. **NEET-PG High-Yield Pearls:** * **Rim-enhancing necrotic nodes:** Think Tuberculosis first (especially in the Indian context). * **Eggshell calcification:** Classic for Silicosis; also seen in Sarcoidosis (rarely). * **1-2-3 Sign (Garland’s Triad):** Right paratracheal, right hilar, and left hilar lymphadenopathy—characteristic of Sarcoidosis. * **Tree-in-bud appearance:** On CT, this signifies endobronchial spread of infection (highly suggestive of active TB).

Q: Which of the following is NOT typically seen in congestive cardiac failure?

Prominent lower lobe vessels. In Congestive Cardiac Failure (CCF), the hallmark finding on a chest X-ray is **Cephalization** (also known as the Antler sign). This refers to the redistribution of blood flow to the upper lobes. **Explanation of the Correct Answer:** * **Prominent lower lobe vessels (Option B):** In a normal upright chest X-ray, gravity causes the lower lobe vessels to be more prominent than the upper lobe vessels. However, in CCF, increased pulmonary venous pressure leads to perivascular edema, which compresses the lower lobe vessels. This causes a redistribution of blood flow to the upper lobes. Therefore, **prominent lower lobe vessels are a normal finding**, while their absence (cephalization) is a sign of heart failure. **Explanation of Incorrect Options:** * **Kerley B lines (Option A):** These are short (1-2 cm), horizontal peripheral lines seen at the lung bases. They represent thickened interlobular septa due to fluid accumulation and are a classic sign of pulmonary edema. * **Pleural effusions (Option C):** Increased hydrostatic pressure leads to fluid transudation into the pleural space. In CCF, effusions are typically bilateral; if unilateral, they are more common on the right side. * **Cardiomegaly (Option D):** Defined as a cardiothoracic ratio >0.5 on a PA view, this is a common finding in chronic heart failure, indicating ventricular enlargement. **High-Yield Clinical Pearls for NEET-PG:** * **Stages of Pulmonary Edema on CXR:** 1. **Stage 1 (PCWP 13-18 mmHg):** Cephalization (Upper lobe diversion). 2. **Stage 2 (PCWP 18-25 mmHg):** Interstitial edema (Kerley B lines, peribronchial cuffing). 3. **Stage 3 (PCWP >25 mmHg):** Alveolar edema (Bat-wing appearance). * **Vanishing Tumor:** A localized pleural effusion in the interlobar fissures (usually the minor fissure) that disappears with diuretic therapy is called a "pseudotumor" or "phantom tumor."

Q: Pruned tree appearance of pulmonary circulation is a feature of which condition?

Pulmonary artery hypertension. **Explanation:** The **"Pruned Tree Appearance"** is a classic radiological sign of **Pulmonary Artery Hypertension (PAH)**. It occurs due to the marked dilation of the central pulmonary arteries (the "trunk") followed by a rapid, abrupt narrowing (tapering) of the peripheral pulmonary vessels. This peripheral tapering is caused by increased pulmonary vascular resistance and obliterative changes in the small distal vessels, making the lungs look like a tree with its outer branches cut off. **Analysis of Options:** * **Pulmonary Artery Hypertension (Correct):** High pressure leads to proximal vessel distension and distal vasoconstriction/obliteration, creating the characteristic "pruned" look on a chest X-ray or CT. * **Pulmonary Stenosis:** Typically results in **post-stenotic dilation** of the main pulmonary artery (especially the left branch) and *decreased* pulmonary vascular markings (oligemia), but not the specific pruned-tree pattern. * **Pulmonary Regurgitation:** Usually leads to right ventricular enlargement and potentially dilated central arteries due to volume overload, but it lacks the abrupt peripheral tapering seen in PAH. * **Pulmonary Embolism:** Acute PE may show **Westermark’s sign** (focal oligemia) or **Fleischner sign** (distended central artery), but "pruning" is a chronic feature of vascular remodeling. **High-Yield Clinical Pearls for NEET-PG:** * **Westermark Sign:** Focal area of lucency (oligemia) distal to an embolus in Pulmonary Embolism. * **Hampton’s Hump:** Wedge-shaped opacity at the periphery indicating pulmonary infarction. * **Knuckle Sign:** Abrupt tapering of a pulmonary artery branch due to an embolus. * **PAH on X-ray:** Right descending pulmonary artery diameter **>16 mm** in males or **>15 mm** in females is a strong indicator of PAH.

Q: Which of the following conditions is best investigated with a non-contrast CT scan?

Interstitial lung disease. **Explanation:** The primary goal of a CT scan in **Interstitial Lung Disease (ILD)** is to visualize the fine structural details of the lung parenchyma, such as reticulations, ground-glass opacities, and honeycombing. This is achieved through **High-Resolution Computed Tomography (HRCT)**, which uses thin slices (1–2 mm) and a high-spatial-frequency reconstruction algorithm. Since the natural contrast between air-filled alveoli and the lung interstitium is high, intravenous contrast is unnecessary and may even obscure subtle parenchymal details. **Analysis of Incorrect Options:** * **A. Mediastinal mass:** Contrast (CECT) is essential to differentiate the mass from adjacent vascular structures, identify the degree of vascularity, and check for invasion into the heart or great vessels. * **B. Lung mass:** CECT is required to evaluate the vascularity of the lesion, its relationship with the hilum, and to identify mediastinal lymphadenopathy (staging). * **C. Nodular thickening of pleura:** Contrast helps distinguish between simple pleural fluid and pleural thickening/masses. It also highlights "pleural enhancement," which is a key sign of inflammation or malignancy (e.g., Mesothelioma). **Clinical Pearls for NEET-PG:** * **HRCT** is the "Gold Standard" for diagnosing ILD and Bronchiectasis. * **Non-Contrast CT (NCCT)** is also the investigation of choice for **Ureteric Calculi** (KUB) and **Acute Head Injury** (to rule out hemorrhage). * **Contrast (CECT)** is generally mandatory for evaluating **malignancies, infections (abscesses), and vascular pathologies** (Aortic dissection/PE).

Q: Hampton hump is a feature of which of the following conditions?

Pulmonary embolism. **Explanation:** **Hampton Hump** is a classic radiographic sign of **Pulmonary Embolism (PE)**, specifically representing **pulmonary infarction**. It appears as a shallow, wedge-shaped, pleural-based opacification with a rounded (convex) apex pointing toward the hilum. It is most commonly found in the lower lobes at the costophrenic angles. The "hump" represents distal hemorrhage and necrosis resulting from the occlusion of a peripheral pulmonary artery. **Analysis of Options:** * **Pulmonary Embolism (Correct):** While PE often presents with a normal chest X-ray, Hampton Hump is a specific (though insensitive) sign of infarction. * **Pulmonary Tuberculosis:** Typically presents with apical infiltrates, cavitary lesions, or Ghon complexes, rather than peripheral wedge-shaped opacities. * **Pulmonary Hemorrhage:** Usually manifests as diffuse, patchy alveolar opacities or ground-glass shadows, lacking the distinct wedge-shaped pleural base characteristic of the hump. * **Bronchogenic Carcinoma:** Generally presents as a central or peripheral mass, often with irregular or spiculated margins, and may be associated with lobar collapse or hilar lymphadenopathy. **High-Yield Clinical Pearls for NEET-PG:** * **Westermark Sign:** Focal oligemia (translucency) distal to the embolus; another specific sign of PE. * **Fleischner Sign:** Prominent central pulmonary artery due to a large clot (often seen in saddle embolism). * **Knuckle Sign:** Abrupt tapering of a pulmonary artery. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) is the investigation of choice for PE. * **Palla’s Sign:** Enlargement of the right descending pulmonary artery.

Q: Left atrial enlargement is best seen with which imaging view?

Barium swallow right anterior oblique view. ### Explanation **1. Why the Correct Answer is Right:** The **Left Atrium (LA)** is the most posterior chamber of the heart. In the mediastinum, it lies in direct contact with the anterior wall of the mid-esophagus. When the left atrium enlarges, it displaces the esophagus posteriorly and to the right. In a **Barium swallow Right Anterior Oblique (RAO) view**, the esophagus is projected between the heart and the spine. This specific orientation provides the highest sensitivity for detecting early LA enlargement, as the opacified esophagus will show a characteristic **posterior indentation or displacement**. **2. Why the Other Options are Wrong:** * **Chest X-ray AP View:** While LA enlargement can be seen here (e.g., double atrial shadow, splaying of the carina), it is less sensitive than barium studies for early detection because the heart is a 3D structure projected onto a 2D plane, leading to overlap. * **Chest X-ray Left Lateral View:** This view can show posterior displacement of the esophagus or the left main bronchus (walking-man sign), but the RAO view with barium provides better anatomical separation and visualization of the esophageal-atrial interface. * **Barium Swallow LAO View:** In the Left Anterior Oblique view, the left atrium is not the primary structure indenting the esophagus; this view is better suited for evaluating the aortic arch and the right ventricle. **3. High-Yield Clinical Pearls for NEET-PG:** * **Earliest sign of LA enlargement on CXR PA view:** Straightening of the left cardiac border. * **Most specific sign on CXR PA view:** Double atrial shadow (Double density sign). * **Carinal Angle:** LA enlargement causes widening of the subcarinal angle (>90 degrees) and elevation of the left main bronchus (**"Walking Man Sign"** on lateral view). * **Mitral Stenosis:** The most common cause of isolated left atrial enlargement.

Question 1

What is the most common cause of an air bronchogram?

Accepted Answer

Consolidation

Answer

Pulmonary edema

Answer

Hyaline membrane disease

Answer

Alveolar cell carcinoma

Question 2

Consolidation of which part of the lung is likely to obliterate the aortic knuckle on a chest X-ray?

Accepted Answer

Left upper lobe (posterior segment)

Answer

Left Lingula

Answer

Right Upper lobe

Answer

Apex of the lower lobe

Question 3

Egg shell calcification is seen in which of the following conditions?

Accepted Answer

Sarcoidosis

Answer

Silicosis

Answer

Lung cancer

Answer

Pneumoconiosis

Question 4

A 25-year-old man presented with fever, cough, expectoration, and breathlessness of 2 months' duration. Contrast-enhanced computed tomography of the chest showed bilateral upper lobe fibrotic lesions and mediastinal enlarged necrotic nodes with peripheral rim enhancement. Which one of the following is the most probable diagnosis?

Accepted Answer

Tuberculosis

Answer

Sarcoidosis

Answer

Lymphoma

Answer

Silicosis

Question 5

Which of the following is NOT typically seen in congestive cardiac failure?

Accepted Answer

Prominent lower lobe vessels

Answer

Kerley B lines

Answer

Pleural effusions

Answer

Cardiomegaly

Question 6

Pruned tree appearance of pulmonary circulation is a feature of which condition?

Accepted Answer

Pulmonary artery hypertension

Answer

Pulmonary stenosis

Answer

Pulmonary regurgitation

Answer

Pulmonary embolism

Question 7

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

Accepted Answer

Tuberculosis, Rheumatoid arthritis, COP D, Metastasis

Answer

Tuberculosis, Rheumatoid arthritis, Pneumoconiosis, COP D

Answer

Tuberculosis, Rheumatoid arthritis, Pneumoconiosis, Metastasis

Answer

Tuberculosis, Pneumoconiosis, COP D, Metastasis

Question 8

Which of the following conditions is best investigated with a non-contrast CT scan?

Accepted Answer

Interstitial lung disease

Answer

Mediastinal mass

Answer

Lung mass

Answer

Nodular thickening of pleura

Question 9

Hampton hump is a feature of which of the following conditions?

Accepted Answer

Pulmonary embolism

Answer

Pulmonary tuberculosis

Answer

Pulmonary hemorrhage

Answer

Bronchogenic carcinoma

Question 10

Left atrial enlargement is best seen with which imaging view?

Accepted Answer

Barium swallow right anterior oblique view

Answer

Chest X-ray AP view

Answer

Chest X-ray left lateral view

Answer

Barium swallow left anterior oblique view

Chest Radiology — MCQs

Chest Radiology — MCQs

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