Question 1

In this AP projection the arrow indicates:

Accepted Answer

This question involves basic pattern recognition. Students should be able to recognize that a convex edge very high on the left heart border is the aortic arch. The pulmonary artery is seen as a convexity of the upper left heart border, below the aortic arch, and is usually much smaller than the aortic arch. (In the case we picked a patient who does not have a large arch.) A dilated pulmonary artery (trunk) would be a much larger convexity than the one in this case. An enlarged tracheobronchial lymph node is not a recognized finding on a chest radiograph. This image does not show shifting of the trachea or any abnormal positive mass effect.

Question 2

This portable AP chest radiograph shows a patient with:

Accepted Answer

A left pleural effusion is shown because of the characteristic meniscus along the superior margin of a fluid density that fills the left costophrenic sulcus. There are no signs of acute pulmonary edema in this image. Pneumonias do not have sharp, curved upper margins as shown in this image. There is no rounded opacity that looks like a mass to suggest a carcinoma.

Question 3

What condition does the image depict?

Accepted Answer

Bacterial pneumonia is a good explanation for the obscuration of the left cardiac margin (silhouette sign). There is no pleural white line indicating pneumothorax and no fluid density filling a costophrenic sulcus (angle) to suggest pleural effusion. No pulmonary venous congestion or cardiac dilatation is present to suggest congestive heart failure.

Question 4

This image includes a classic radiographic finding. What is the name of this radiologic sign, and what is the most likely disease?

Accepted Answer

The silhouette sign is a basic radiographic finding, explained in the book, that classically indicates the presence of pneumonia. No reticulonodular pattern is shown. The pulmonary veins in upper lobes are not bigger than in lower lobes, so congestive heart failure is not indicated. Although a single metastatic lesion abutting a pleural surface of the lingula at the heart margin could obscure a section of the cardiac border, option (D) is incorrect because to jump to that diagnosis one should see multiple lesions in the lungs.

Question 5

This frontal radiograph suggests an increase in lung density associated with an apparent silhouette sign along the right border of the heart. However, after a lateral view was also examined, the radiologist concluded that the patient's lungs were normal. Why?

Accepted Answer

A pitfall in the interpretation of a PA chest radiograph is that a pectus excavatum can create an appearance of a silhouette sign of right heart border, and pectus deformities are readily apparent on lateral views.

Question 6

Based on the image, what does this patient likely have?

Accepted Answer

Wedge-shaped densities, like the one seen "through" the heart, should always make one think of atelectasis. Masses are usually round in contour, not wedges or triangles.

Question 7

This patient is suffering from which symptoms?

Accepted Answer

Several rib fractures appear on the left, including some that are found in more than one place within a rib-flail chest by definition.

Question 8

This image shows a child with:

Accepted Answer

In this image the epiglottis looks more like a fat thumb than a slender pinkie finger. Acute epiglottitis, evident on the lateral soft tissue neck radiograph, is the first, second, and third thing to look for and be suspicious of in a young patient with dyspnea and sore throat. This finding requires urgent action.

Question 9

The axial CT shown depicts that this patient has which disease?

Accepted Answer

The large areas of absent lung tissue and large sacs of air (bullae) indicate emphysema. There are no nodules or extra lines to indicate interstitial lung disease or nodular lung disease. Although there is air density up against the pleural surface, there is no thin pleural white line; the visceral pleura is not separated from the parietal pleura by a pneumothorax.

Question 10

Based on the image, what treatment will the patient likely receive?

Accepted Answer

The patient will likely receive antibiotics to address the alveolar right lower lobe pneumonia that is causing loss of sharpness of the right hemidiaphragm. Cardiac transplant is not indicated by this image even though the heart is big and pulmonary veins are a bit distended because there is no "batwing" pattern of pulmonary edema secondary to severe congestive heart failure. No tumors are shown, making chemotherapy and surgery inappropriate treatments.

Question 11

The red arrows in this image highlight a finding that is associated with:

Accepted Answer

The image shows classic Kerley-B lines, seen with interstitial pulmonary edema secondary to congestive heart failure.

Question 12

The maximum transverse diameter of the heart in a PA view should be no more than what percentage of the transverse diameter of the inner margin of the rib cage at the level of the highest point of the diaphragm to be considered normal in size?

Accepted Answer

The maximum transverse diameter of the heart in a PA view should be no more than 50% of the transverse diameter of the inner margin of the rib cage at the level of the highest point of the diaphragm to be considered normal in size.

Question 13

In examining a PA chest radiograph:

Accepted Answer

There is no "right way" to look for everything that one should look for on any radiograph. Any search pattern or system will do as long as you look at everything. The book emphasizes the importance of looking for specific things on radiographs in a systematic way, rather than just looking at radiographs.

Question 14

A blunted costophrenic (costodiaphragmatic) sulcus on a PA view is most commonly associated with:

Accepted Answer

Blunting of a costophrenic sulcus is characteristic of most pleural effusions. It occurs less commonly in extremely advanced fibrotic interstitial disease. This is not a radiographic feature of pneumothorax. When the diaphragm is flattened by pulmonary hyperinflation in emphysema, the costophrenic angle (sulcus) becomes less acute but does not have the appearance of fluid filling that sulcus.

Question 15

Which of the following statements about evaluating rib fractures is NOT true?

Accepted Answer

Uncomplicated rib fractures require no further imaging.

Question 16

The key finding on a chest radiograph leading to the diagnosis of a pneumothorax is:

Accepted Answer

The white line of the visceral pleura is the hallmark sign of a pneumothorax, not just black density in the lung periphery adjacent to the chest wall.

Question 17

Which of the following statements regarding pneumonia is CORRECT?

Accepted Answer

Viral pneumonia is more likely to have reticulonodular pattern than the fluffy airspace "alveolar" opacification seen with bacterial pneumonia. The other statements are not true.

Question 18

Croup is associated with which radiological sign?

Accepted Answer

The steeple sign is the classic description of subglottic edema seen on an AP soft-tissue neck radiograph. The other options are pulmonary signs and are not related to croup.

Question 19

High-resolution computed tomography (HRCT) is fundamental in evaluating and diagnosing:

Accepted Answer

As described in the text, HRCT is used to evaluate and diagnose interstitial lung disease. For adenopathy, the usual protocol is a contrast-enhanced chest CT, usually with significantly thicker slice collimation and slice reconstruction than used with HRCT. Additionally, HRCT does not use IV contrast enhancement. Congestive heart failure is diagnosed clinically and with radiographs. Bronchogenic carcinoma is incorrect for essentially the same reasons as for adenopathy.

Question 20

Which of the following statements is NOT true for the imaging of rib metastases?

Accepted Answer

A radionuclide bone scan is a standard procedure recommended for evaluation of suspected skeletal metastatic disease. The density shown on radiographs depends upon whether or not a metastatic rib lesion is a lytic or blastic lesion, usually depending upon site of origin. MRI would be too expensive and inefficient and too difficult for the patient to consider. Radiographs and radionuclide bone scans are usually sufficient. Also because MRI is a cross-sectional imaging modality (and a bone scan is not), there are difficulties with viewing curved structures such as ribs; only short segments are seen as a rib curves into and out of an image plane.

Quiz 6: Chest