Chest Radiology Practice Questions

Q: All of the following can cause a miliary shadow on X-ray chest except?

Wegener's granulomatosis. **Explanation:** The term **"miliary shadow"** refers to a pattern of fine, discrete, uniform micronodules (1–3 mm in diameter) distributed throughout both lung fields. This pattern typically represents the hematogenous spread of an infection or a systemic process. **Why Wegener’s Granulomatosis is the correct answer:** Wegener’s Granulomatosis (now known as **Granulomatosis with Polyangiitis or GPA**) typically presents on a chest X-ray as **large nodules (often >1 cm), masses, and cavitary lesions**. While it is a granulomatous disease, it does not typically present with a diffuse miliary (micronodular) pattern. Instead, it is a classic cause of multiple cavitating pulmonary nodules. **Analysis of Incorrect Options:** * **Tuberculosis (TB):** The most common cause of a miliary pattern. It occurs due to the hematogenous dissemination of *Mycobacterium tuberculosis*. * **Histoplasmosis & Coccidioidomycosis:** These are fungal infections that can disseminate hematogenously, especially in immunocompromised hosts, leading to a miliary appearance indistinguishable from TB. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic for Miliary Shadows:** **"MIST"** * **M:** Miliary TB, Metastasis (Thyroid-medullary/papillary, Renal Cell Carcinoma, Melanoma, Trophoblastic disease). * **I:** Infections (Fungal: Histoplasmosis, Coccidioidomycosis; Viral: Varicella). * **S:** Sarcoidosis, Silicosis (usually upper zone predominance). * **T:** Tropical Eosinophilia, Talcosis. * **Key Distinction:** If the nodules are larger and "fluffy," consider **"Cannon-ball metastases"** (typically from RCC, Choriocarcinoma, or Prostate cancer). * **GPA (Wegener's) Triad:** Necrotizing granulomas of the respiratory tract, vasculitis, and glomerulonephritis (c-ANCA positive).

Q: The provided chest X-ray demonstrates findings suggestive of which of the following conditions?

Metastasis to the lungs. ***Metastasis to the lungs*** - Chest X-ray shows **multiple bilateral rounded nodules** creating a characteristic **"cannonball" pattern**, which is pathognomonic for pulmonary metastases. - The nodules are typically **well-defined**, **varying in size**, and distributed throughout both lung fields, indicating hematogenous spread. *Pneumothorax* - Would present as **lucency** (blackness) in the pleural space with **absence of lung markings** and a visible **pleural line**. - The lung would appear **collapsed** away from the chest wall, not as multiple nodular opacities. *Pneumatocele* - Appears as **thin-walled air-filled cavities** that are typically **single or few in number**, not multiple solid nodules. - Usually develops after **pneumonia** or **trauma**, presenting as cystic lesions rather than solid masses. *Bronchial adenoma* - Typically presents as a **single well-defined mass** near the **hilum** or within a **bronchus**, not multiple bilateral nodules. - Often causes **post-obstructive pneumonia** or **atelectasis** downstream from the obstruction, which is not seen in this pattern.

Q: A CT scan of the lung bases shows cavitary lesions. What is the most likely diagnosis?

Bronchiectasis. **Explanation:** **Bronchiectasis** is defined as the permanent, abnormal dilation of the bronchi due to chronic inflammation and infection. On a CT scan, these dilated bronchi often appear as **cavitary or cystic lesions**, especially when viewed in cross-section. A classic radiological sign is the **"Signet Ring Sign,"** where the internal diameter of the bronchus is larger than its accompanying pulmonary artery. When these dilated airways are filled with air and occur in clusters at the lung bases, they mimic multiple thin-walled cavities. **Analysis of Incorrect Options:** * **Asbestosis:** Characterized by subpleural reticular opacities, pleural plaques, and interstitial fibrosis. It does not typically present with cavitary lesions. * **Silicosis:** Presents with small, well-defined nodules (predominantly in upper lobes) and "Eggshell calcification" of hilar lymph nodes. Cavitation only occurs if complicated by progressive massive fibrosis (PMF) or tuberculosis. * **Emphysema:** Characterized by hyperlucency and destruction of alveolar walls (bullae), but these are not true "cavitary lesions" of the bronchial tree. Centrilobular emphysema lacks the distinct walls seen in bronchiectasis. **NEET-PG High-Yield Pearls:** * **HRCT** is the gold standard investigation for Bronchiectasis. * **Tram-track sign:** Parallel opacities representing thickened bronchial walls. * **Finger-in-glove sign:** Seen when dilated bronchi are impacted with mucus (common in ABPA). * **Kartagener Syndrome:** Triad of Bronchiectasis, Sinusitis, and Situs Inversus. * **Most common cause in India:** Post-tubercular bronchiectasis (usually involving upper lobes).

Q: What is the most reliable sign of injury to the intrathoracic aorta?

Obliteration of the aortic knob contour. **Explanation:** Traumatic aortic injury (TAI) most commonly occurs at the **aortic isthmus** (just distal to the origin of the left subclavian artery) due to deceleration forces. **1. Why "Obliteration of the aortic knob contour" is correct:** While mediastinal widening is the most common finding, it is highly non-specific. The **loss of the sharp, distinct contour of the aortic knob** is considered the **most reliable and specific plain film sign** of aortic rupture. This occurs because an intramural or periaortic hematoma obscures the interface between the air-filled lung and the aortic wall. **2. Analysis of Incorrect Options:** * **Mediastinal Widening (>8 cm):** This is the most sensitive screening sign (seen in ~85% of cases) but has poor specificity, as it can be caused by venous bleeding, technical factors (supine AP films), or sternal fractures. * **Depression of the left main stem bronchus:** This occurs when a large hematoma pushes the bronchus downward (usually >40° from the horizontal). It is a secondary sign indicating a significant volume of blood in the superior mediastinum. * **Apical cap (Pleural fluid):** This refers to blood tracking along the extrapleural space over the apex of the lung (usually the left). It is a suggestive but late and non-specific sign. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** CT Angiography (CTA) is the investigation of choice in stable patients. * **Most common site of injury:** Aortic Isthmus (fixation point by Ligamentum Arteriosum). * **Other specific signs:** Deviation of the nasogastric tube to the right, deviation of the trachea to the right, and widening of the right paratracheal stripe.

Q: In X-ray, loops of bowel are seen on the left side of the hemithorax with a shift of the heart shadow. What is the likely diagnosis?

Any of the above. **Explanation:** The presence of bowel loops within the thoracic cavity on an X-ray, accompanied by a mediastinal shift (displacement of the heart shadow), indicates a **diaphragmatic defect** allowing abdominal contents to herniate into the chest. 1. **Why "Any of the above" is correct:** All three conditions listed involve the displacement of abdominal viscera into the hemithorax, which can radiologically present as air-filled bowel loops and a contralateral shift of the heart. * **Bochdalek Hernia:** The most common congenital diaphragmatic hernia (CDH). It occurs due to the failure of the pleuroperitoneal canal to close. It is characteristically located **posterolaterally** and occurs on the **left side** in 85% of cases. * **Morgagni’s Hernia:** A rarer defect occurring through the **anteromedial** (retrosternal) space. While more common on the right, it can occur on the left and present with bowel herniation. * **Eventration of Diaphragm:** This is not a true hernia but a condition where the diaphragm is thin and weak (due to incomplete muscularization) but remains intact. The weakened leaf of the diaphragm elevates high into the thorax, carrying the bowel loops with it and causing a similar mass effect and heart shift. **Clinical Pearls for NEET-PG:** * **Bochdalek = Back and Left:** (Posterolateral). This is the one most associated with neonatal respiratory distress and pulmonary hypoplasia. * **Morgagni = Midline/Anterior:** (Retrosternal). Often asymptomatic until later in life. * **Scaphoid Abdomen:** A classic clinical sign of CDH where the abdomen appears sunken because the viscera have moved into the chest. * **Management:** Initial stabilization involves **nasogastric decompression** and avoiding bag-mask ventilation (to prevent bowel distension); definitive treatment is surgical repair.

Q: Unilateral elevation of the diaphragm is commonly due to which of the following?

Large liver. **Explanation:** Unilateral elevation of the diaphragm occurs when the diaphragm is pushed upward by an abdominal process or pulled upward by a thoracic process. **Why "Large Liver" is correct:** Hepatomegaly (a large liver) is a classic cause of **unilateral (right-sided) elevation**. Because the liver is situated immediately beneath the right hemidiaphragm, any significant increase in its volume or the presence of a space-occupying lesion (like a liver abscess or tumor) will physically displace the diaphragm superiorly. This is a common radiological finding on a Chest X-ray (CXR). **Analysis of Incorrect Options:** * **Obesity:** This typically causes **bilateral** elevation of the diaphragm due to increased intra-abdominal pressure and adipose tissue pushing both sides upward simultaneously. * **Scoliosis:** While severe spinal curvature can distort the appearance of the chest cavity and make the diaphragm appear asymmetric, it is a structural skeletal deformity rather than a primary cause of diaphragmatic displacement. * **Congenital causes:** While conditions like Eventration (congenital muscular deficiency) can cause unilateral elevation, they are statistically less common than acquired causes like hepatomegaly or phrenic nerve palsy in clinical practice. **High-Yield Clinical Pearls for NEET-PG:** * **Phrenic Nerve Palsy:** The most common cause of a "paralyzed" elevated hemidiaphragm. Diagnosis is confirmed via the **Sniff Test** (Fluoroscopy), where the affected side shows **paradoxical movement** (moves up during inspiration). * **Normal Variation:** The right hemidiaphragm is normally **1–2 cm higher** than the left due to the liver. * **Differential Diagnosis:** Always rule out **infrapulmonary effusion** (pseudodiaphragmatic contour) and **lower lobe collapse** (which pulls the diaphragm up).

Q: 'Batwing' appearance on X-ray chest is seen in:

Cardiogenic pulmonary edema. **Explanation:** The **'Batwing' (or Butterfly) appearance** is a classic radiological sign characterized by bilateral, symmetric perihilar opacities that spare the peripheral lung zones (the outer 2–3 cm of the lung parenchyma). **Why Cardiogenic Pulmonary Edema is correct:** In acute heart failure, increased pulmonary venous pressure leads to the leakage of fluid into the alveolar spaces. This fluid accumulation occurs preferentially in the large-vessel-rich perihilar regions due to better lymphatic drainage at the periphery and the effects of gravity. This results in the dense central opacification resembling the wings of a bat or butterfly. **Analysis of Incorrect Options:** * **Bronchial Asthma:** Typically presents with a normal chest X-ray or signs of hyperinflation (flattened diaphragm, increased retrosternal space). It does not cause alveolar filling patterns. * **Mitral Stenosis:** While it can lead to pulmonary edema, its primary early findings include left atrial enlargement (straightening of the left heart border, double atrial shadow) and Cephalization (upper lobe diversion/Antler sign). * **Pulmonary Embolism:** Usually presents with a normal X-ray. Specific signs include **Hampton’s Hump** (wedge-shaped opacity) or **Westermark sign** (focal oligemia), not bilateral perihilar opacities. **High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis for Batwing Appearance:** Apart from cardiogenic edema, it can be seen in Alveolar proteinosis, Pneumocystis jirovecii pneumonia (PJP), and pulmonary hemorrhage. * **Stages of Heart Failure on CXR:** 1. **Stage 1 (Redistribution):** PCWP 13–18 mmHg; Cephalization (Antler sign). 2. **Stage 2 (Interstitial Edema):** PCWP 18–25 mmHg; **Kerley B lines**, peribronchial cuffing. 3. **Stage 3 (Alveolar Edema):** PCWP >25 mmHg; **Batwing appearance**, pleural effusion.

Question 1

All of the following can cause a miliary shadow on X-ray chest except?

Accepted Answer

Wegener's granulomatosis

Answer

Tuberculosis

Answer

Histoplasmosis

Answer

Coccidioidomycosis

Question 2

The provided chest X-ray demonstrates findings suggestive of which of the following conditions?

Accepted Answer

Metastasis to the lungs

Answer

Pneumothorax

Answer

Pneumatocele

Answer

Bronchial adenoma

Question 3

A lesion with sharp outlines extending above the clavicles suggests?

Accepted Answer

Posterior mediastinal lesion

Answer

Anterior mediastinal lesion

Answer

Cardiac lesion

Answer

All of the above

Question 4

A CT scan of the lung bases shows cavitary lesions. What is the most likely diagnosis?

Accepted Answer

Bronchiectasis

Answer

Asbestosis

Answer

Silicosis

Answer

Emphysema

Question 5

What is the most reliable sign of injury to the intrathoracic aorta?

Accepted Answer

Obliteration of the aortic knob contour

Answer

Presence of apical cap of pleural fluid

Answer

Depression of the left main stem bronchus

Answer

Mediastinal widening

Question 6

In X-ray, loops of bowel are seen on the left side of the hemithorax with a shift of the heart shadow. What is the likely diagnosis?

Accepted Answer

Any of the above

Answer

Eventration of diaphragm

Answer

Foramen of Bochdalek hernia

Answer

Morgagni's hernia

Question 7

Unilateral elevation of the diaphragm is commonly due to which of the following?

Accepted Answer

Large liver

Answer

Obesity

Answer

Scoliosis

Answer

Congenital causes

Question 8

Which of the following can cause rib notching, except?

Accepted Answer

Waterston Cooley's shunt

Answer

Blalock Taussig shunt

Answer

Pulmonary atresia with large VSD

Answer

All

Question 9

'Batwing' appearance on X-ray chest is seen in:

Accepted Answer

Cardiogenic pulmonary edema

Answer

Bronchial asthma

Answer

Mitral stenosis

Answer

Pulmonary embolism

Question 10

A 30-year-old male presents with a 3-week history of right-sided chest pain and cough. Examination reveals decreased breath sounds in the right lower lung. Chest X-ray shows blunting of the costophrenic angles. A contrast-enhanced CT scan of the chest is performed. What is the most probable diagnosis?

Accepted Answer

Empyema

Answer

Loculated pleural effusion

Answer

Pulmonary abscess

Answer

Mesothelioma

Chest Radiology — MCQs

Chest Radiology — MCQs

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