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Instructions
 This self assessment module on chest radiography consisting 30
questions related to chest radiographs and explanations for each.

 You can either try all questions first and then check your answers or
check the answer to each question after every attempt.

 Marks allocated to each component is given next to the question within
brackets.

 Your suggestions to improve this module may be emailed to
thilakpw@yahoo.com

Thilak Weerarathna,
Department of Medicine,
Faculty of Medicine, Galle
Question’s

1
This chest radiograph was taken from a
patient after a road traffic accident
a) What is the abnormality

b) Give two other causes
for this radiological
abnormality

Next question Answer

2

a) What abnormality
do you see in this
chest radiograph

b) List two complications
of this condition


3

(a ) List two abnormalities
in this chest
radiograph

(b) What is the most likely
diagnosis based on
your findings in 3 .a


4

a. Describe the abnormality
seen in this chest
radiograph

b) Give two likely causes
for this appearance


5

a) Describe the
abnormality
seen in this
chest radiograph

b) List two likely causes
for the abnormality
noted


This radiograph was taken from a person
6 with hemoptysis

a) Describe two abnormalities

b) Give a likely diagnosis


This chest radiograph was taken from a 35 year old
7 man with 5 days of fever and cough.

a. What is the radiological
diagnosis

b. List two complications
of the condition
mentioned in 7. a

Next Question Answer

8

diagnosis

b. Give one association
of this condition


This chest radiograph was taken from 35 year old
9
man with productive cough of 6 months

a. List two abnormalities

b. What is the likely
diagnosis

c. List two complications


10

a. Describe the radiological
abnormality

b. What segment of the
lung is involved

c. Give reasons for your
answer to ( b)


11

a) Describe the
radiological
abnormality

b) List two investigations
that would provide
etiological diagnosis
of this condition


12 This chest radiograph is taken from a man with
severe haemoptysis

a). What is the radiological
diagnosis


13

a) Describe the
radiological
abnormalities

b) List two therapeutic
measures in the
management of
this condition


This chest radiograph was taken from a 45 year old
14
male with recent onset finger clubbing

a) Describe the
abnormality seen.

b) List two extra pulmonary
complications of this
condition


This chest radiograph was taken from a man with
15 progressive breathlessness over one week

a) What is the radiological
diagnosis?

b) List the most useful
investigation for
arriving at a diagnosis
of the condition you
mentioned in (a)


This chest radiograph was taken from a man with
16
facial puffiness and engorged neck veins

a) What is the likely cause
for above findings
in this patient

b) Give two likely causes for
the condition you
mentioned in (a)


This chest radiograph was taken from a 40 year
17 old man with pyrexia of unknown origin

a) Describe the radiological
abnormality

b) What investigation
would confirm the
diagnosis


This chest radiograph is taken from a 18 year old
18 boy with sudden onset chest pain and breathlessness

a) Right down the complete
radiological diagnosis

b) What is the immediate
therapeutic measure?


19

diagnosis

b) What specific feature
of the condition you
mentioned above
is present in this
radiograph ?


20

diagnosis?

b) Name one specific
physical sign that
can be elicited in this
condition


A patient with following chest radiograph presented
21
with progressive breathlessness over 6 months

a) What condition would account
for the breathlessness in
this patient ?

b) List 3 radiological features
in this radiograph in favor of
the condition you mentioned
in (a)


A 56 year old man presented with 3 weeks of fever.
22 His chest radiograph is shown below.

a. Name the abnormality in this
chest radiograph.

b. What is the next investigation
that would help in arriving
at a specific diagnosis ?


This chest radiograph was taken from a 55 year
23 old male with fever, chest pain and breathlessness
over 2 weeks

diagnosis?

b) What investigation would
confirm your diagnosis
mentioned in ( a ) ?


Following chest radiograph was taken from a
24 60 year old male with chest pain and breathlessness
over 4 hours.
diagnosis?

b. List 4 immediate
measures you take in this
patients if the blood
pressure
is 130/ 85 mm Hg


25

diagnosis ?

b. List 3 radiological features
in favor of the diagnosis
mentioned in (a).


26

a. Name the abnormality in this
chest radiograph

b. List 3 causes for the
abnormality you mentioned
in (a)


27

a) Write down the
radiological
abnormality

b) List two causes
for the abnormality
you mentioned in (a)


This chest radiograph was taken from a previously
28 healthy male presenting with cough and fever of
one week

diagnosis?

b) List two antibiotics you
select to treat this patient


29

a) List two abnormalities in
this chest radiograph

b) Give a likely underlying cause
for the abnormalities
mentioned in (a)


30

a) Name two abnormalities
in this chest radiograph

Introductions Answer

Answer 1
a) air ( gas ) under the diaphragm / ruptured
viscus organ ( 06 marks )
b) following laporoscopy ( 04 marks)

Notes – perforation of bowel or stomach
following trauma or other pathology such as
peptic ulcer can give rise to gas under the
diaphragm sign.
Inflation of air at laporoscopy also can give
rise to this radiological sign.

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Answer 2

a) cystic shadows in right lung field/ pulmonary cysts (
06 marks), Lung abscess (02 marks)

b) infection (02), rupture , pneumothorax (02)

Notes – cysts in lung are characterized by rounded,
thin walled shadows. When are filled with fluid due
to infection, they are called abscess. Abscesses are
characterized by an air – fluid level. Sometimes
these cysts can rupture giving rise to
pneumothorax.

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Answer 3

a) 1. right sided massive pleural effusion (3),
pleural effusion (1),
2. lytic lesions in clavicles and ribs (3)
b) malignancy (4), secondary deposits (4),

Notes – homogenous opacification of a hemithorax is a
sign of pleural effusion. Usually large effusions causes
displacement of trachea and if trachea is central,
possibility of right sided lung collapse with effusion is
more likely. Combination of collapse and large
effusion is amore likely be due to malignancy. lytic
lesions in ribs and clavicles also favor malignancy

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Answer - 4

a) air- fliud level in the left hemithorax (6)
b) hydropneumothorax(2),
pyopneumothorax (2)

Notes- collection of fluid in the pleural space with an air- fluid level
is seen with lung abscess and hydro/ pyo pneumothorax. Lung
abscess is characterized by a such collection with a well
demarcated capsule and when the air fluid level is seen across
the hemi thorax without a capsule it is due to hydro or
pyopneumothorax. These can arise as a rupture of lung abscess
(pyopneumothorax) or following trauma ( hemopneumothorax)

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Answer 5

a) abnormal elevation of the right dome of the
diaphragm(6)
b) paralysis of right phrenic nerve(2)
collection of pus under the diaphragm(2) or
any cause for the above
Notes – abnormal elevation of the right dome of the
diaphragm can occur as a result of phrenic nerve
paralysis due to causes such as malignant infiltration.
The same appearance is seen when there is collection
of pus under the diaphragm following ruptured liver
abscess.
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Answer 6

a) two opacities in the upper zones of the left lung(3),
cavitations with thick walls in the left upper zone(3)
b) malignant lesions with central cavitations(4)

Notes-
Lung opacities with irregular margins are features of
either primary or secondary malignancy. Cavitations
within the lesion also favor this. Cavitations with thick
irregular walls are more in favor of a malignant lesions.
Always look for erosion of ribs, hilar lymh node
enlargement (which are not present in this case) when
there is suspicious malignant lesions in the lung.

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Answer- 9

a) thickened bronchial markings(2), bilateral cystic
shadows(2)
b) Bronchiectasis (4)
c) hemoptysis(1), secondary infection (consolidataion)(1),
fibrosis(1), lung abscesse(1)

Notes- Bronchiectataic changes are often seen in bases of
lung fields, but in this film the whole of the lung is
affected. The characteristic features include thickened
bronchial walls appearing as rail road sign and multiple
small cystic shadows some filled with fluid especially in
bases. Tuberculosis is a more likely etiology in upper
lobe bronchiectais
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Answer 7

a) consolidation of the lingular lobe (6)
consolidation of left middle lobe(5)
left sided pneumonia(4)
b) pleural effusion(2), lung abscess(2), myocarditis(2),
septiciemia(2)

Notes- Diffuse opacification of the left mid zone of the lung
obliterating the left heart border is characteristic of left
lingular consolidation.As the left heart border and the left
middle lobe are in the same plane the former is
obliterated in consolidation of the later. Complication of
pneumonia at any site include pleural effusion, abscess ,
fibrosis, empyema, septicemia and myocarditis and rarely
respiratory and renal failure

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Answer 8

a) situs inversus(8) / dexrocardia (4)
b) Kartergeners syndrome, absent frontal sinuses ,
infertility

Notes- Although the entire lung fields and cardiac shadow
looks normal careful inspection would reveal the mark
of left side on the top right corner. As the gastric air
bubble is also in the same side of the heart this is not
only dextrocardia but situs inversus. Be aware or the
causes for apparent normal chest radiograph (small
pneumothorax, rib notching )

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Answer-10

a) consolidation of left lower lobe/ left sided
pneumonia(4)
b) left lower lobe (2)
c) left heart border is well seen. But, the left hemi
diaphragm is not seen (4).

Notes- consolidation of the left lower zone can occur as a
result of involvement of ;left lingular lobe or left lower
lobe. In the former left heart border is not well seen
and in the later the left hemi diaphragm is obscured.

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Answer-11

a) well demarcated , round, opacities of different sizes in
both lung fields (canon ball appearance) (6).
b) brobchoscopy guided biopsy, brushings or
washings(2), CT guided biopsy(2), Serum PSA level, or
any specific tumor markers (Beta Hcg)

Notes- Canon balls in lung fields are very often due to
secondary deposited from thyroid, renal, testicular or
bony malignancies. The specific etiological diagnosis
can be revealed in bronchoscopical biopsy, or
brushings or elevated specific tumor markers such as
PSA for prostatic and beta hcg for testicular
malignancies etc.
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Answer-12

a) Mycetoma on the left upper lobe (10), fibrosis of left
upper lobe (6), bronchiectaisis of LUL (5). Abscess in
LUL (2)

Notes- Mycetoma comprises of a ball of fungal tissue
entrapped in a cavity surrounded by lung fibrosis and
has a characteristic radiological appearance. A halo of
air at the top giving rise to crescentic air shadow with
an irregular opacity with avrying density within the
fibrosed lung tissue. It differs from a lung abscess by
not having a air fluid level and bronchiectasis may be
an added finding
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Answer-13

a) lung abscesses of different sizes in the right upper, left
middle and left lower zones.
b) Antibiotic therapy comprising anaerobic
(metronidazole) and staphylococal cover (cloxacillin)
for a longer duration (2- 6 weeks) and postural drainage
and chest physiotherapy

Notes- Thin walled cavities with air fluid level are
characteristic of lung abscesses due to non malignant
causes( suppurative pneumonia). Management
protocols should comprise appropriate antibiotic
therapy for a longer duration and chest physiotherapy
including postural drainage.
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Answer-14

a) rounded opacity in the left middle zone/ mass lesion in
the lung (6)
b) hypercalcemia, effects due to secondary deposits
( convulsions, hepatomegaly, obstructive jaundice),
neurological or endocrine para malignant syndromes (2
each)

Notes- rounded lung lesions with the given history is
more likely to be due to a malignant lung lesion.
Primary lung cancer can leads to a variety of extra
pulmonary effects including neurological, endocrine
and other systemic effects.

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Answer-15

a) right sided massive pleural effusion(6)/ pleural
effusion(4)
b) pleural biopsy(4)/ pleural fluid analysis(1)

Notes- homogenous opaccification of the whole lung field
with obliteration of costo phrenic angle and S shaped
curve upward at the rib margin is characteristic of
pleural effusion. As the effusion is massive the later
feature is not obvious in this film. Massive effusion with
no mediastinal displacement is a feature of collapse of
the ipsilateral lung and more likely to be secondary to a
malignant etiology
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Answer-16

a) SVC obstruction due to a seperior mediastinal mass(6),
SVC obstruction(4), Superior mediastinal mass(3),
mediatinal mass(2)
b) retro sternal goiter(2), thymoma (2)

Notes- engorgement of neck veins with facial puffiness
with given findings in chest radiograph confims SVC
obstruction. Any superior mediatinal mass can give rise
to this picture. I life threatning situations urgent
radiotherapy may be reqiuredto relive upper air way
obstruction. Steriod therapy is also used as a measure of
reducing tissue oedema in this condition.

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Answer-17

a) milliary mottling (6)
b) Liver biopsy for typical granulaoma (4)

Notes- Characteristic milliary mottling of this
chest radiograph with given history is more
likely to be due to milliary tuberculosis. Other
causes for milliary mottling include sarcoidosis
and histoplasmosis. Typically less than 2 mm
mottlings are seen in these conditions. Liver
biopsy would show characteristic caseating
granulomas in milliary tuberculosis.

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Answer-18

a) Right sided complete tension pneumothorax (6) /
Pneumothorax (3)
b) intercostal tube drainage(4) / aspiration (2)

Notes – absent lung markings in the right hemithorax
with mediastinal displacement is characteristic of
tension pneumothorax. Urgent IC tube drainage is
indicated to avoid severe hypoxia. Small
pneumothoracies may sometimes be left alone to be
reabsorbed with time if there is no respiratory
embarrassment.

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Answer-19

a) Consolidation of the right upper lobe(6)/
consolidation(3)
b) Airbronchogram (4)

Notes – homogenous opacification of a segment
or a lobe of lung with clear demarcation with
air bronchogram sign is almost
pathognomonic of lung consolidation. Air
bronchogram is due to the air trapped in the
patent airways with consolidation of
surrounding lung tissue.
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Answer-20

a) Subcutaneous emphysema (6)
b) crepitus elicited over chest wall (4)

Notes – rupture of alveoli or airways can cause
leaking of air outside the pleural cavity
through tissue planes in the neck. This will
show thin layers of air trapped along tissue
planes and muscle layers and produce
characteristic physical sign of crepitations on
palpation. Common causes for SC emphysema
are ruptures bulle or in paraquat poisoning.

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Answer-21

a) Emphysema (6)
b) flat diaphragms, horizontal ribs, elongated
heart shadow, bilateral hyper translucent lungs

Notes –Pulmonary emphysema is characterized
by increased radiolucency of lung fiels( due to
more air trapped in distended alveoli) and
features of air trapping such as horizontal ribs,
flat diaphragms. Horizontal elongated heart
shadow is also a radiological feature in this
condition
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Answer-22

a) Encysted pleural effusion(6), pleural based tumor(6),
pleural effusion(3)
b) Ultra sound examination of thorax (4), CT scan of
thorax (4)

Notes- Encysment of fluid between the two layers of
pleura with fibrous adhesions would produce encysted
effusions. Due to holding up of fluid in the closed
cavity general appearance of an effusion is not seen.
Once the nature of the material encysted is determined
by the ultrasound scan and locate the best position to
aspirate , diagnostic aspirations can be done.

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Answer-23

a) Pericardial effusion(6) / cardiomegaly(2)
b) 2-D echocardiogram (4)

Notes- enlarged cardiac silhouette with sharply
demarcated borders with appearance of a water bag is
due to pericardial effusion. There may be features of
cardiac failure. 2-D echocardiogram is the
confirmatory investigation. Etiology could be primary
cardiac pathology ( pericarditis, severe CCF or non
cardiac, infections, such as tuberculosis

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Answer-24

a) Pulmonary oedema (6) / left heart failure(3)
b) Prop-up the patient, Oxygen , intravenous fruesemide,
Intravenous morphine,

Notes - enlarged heart shadow, pulmonary venous
congestion with dilated upper lobar veins, hilar
congestion and appearance of kerlys lines with or
without small pleural effusion are features of
pulmonary oedema. In some cases of pulmonary
oedema heart size can be normal

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Answer-25
a) right upper lobe collapse/ fibrosis (6)
b) elevation of right hilum, displacement of trachea
to right side, elevation of the inter lobar fissure

Notes- fibrosis or collapse of the right upper lobe
would cause pulling up of lung tissue and other
surrounding organs towards it. In fibrosis the
streaky shadows will be seen and in collapse, its
cause such as a foreign body or a tumor/ lymph
node may be evident.

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Answer-26

a) Cardiomegaly with left ventricular type enlargement( 6)
/ cardiomegaly (4)
b) systemic hypertension, aortic stenosis, hypertrophic
cardiomyppathy( 2 each)

Notes - enlargement of cardiac silhopute above the half
of the trans thoracic diameter
( Cardio thoracic ratio >0.5) is seen here. As the cardiac
apex is directed upwards in this film there is a
possibility of left ventricular enlargement although this
is not a very reliable sign.

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Answer-27

a) Bilateral hilar lymph node enlargement( BHL)
(6), Hilar lymphadenopathy (5)
b) Sarcoidosis, Hodgkins lymphoma( 3 each)

Notes- enlargement of hilar lymph nodes in both
sides give rise to this appearance. Sarcoidosis
is the commenest cause in the west and
lymphomas esp Hodgkins is the other case.
Look for other radiological features of
sarcoidosis such as pulmonary fibrosis,
milliary mottling and small pleural effusions in
typical cases.
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Answer-28

a) right middle lobe consolidation(6)
b) Oral Erythromycin (or any macrolide), Oral
amoxycillin.

Notes- consolidation of a segment of the right middle
(RML) lobe is seen here. In complete consolidation of
RML right heart border is not seen. As the patient
involved is said to be previously healthy, Community
acquired pneumonia is the likely diagnosis. Oral
Macrolides with or without Amoxycillin are the
recommended antibiotics for uncomplicated CAP in
immune competent hosts.
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Answer-29

a) opacification of left hemi thorax with tracheal and
mediastinal displacement, hyper translucency
(compensatory emphysema) of the right hemi thorax.
3 each )
b) surgical removal of the left lung (due to a tumor),
collapse of the left lung due to obstruction of left main
bronchus( 6 for any of the two)

Notes- ipsilaterel opacification with contra lateral
emphysema with tracheal displacement towards
opaque side is characteristic of complete removal or
collapse of left lung.
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Answer- 30

a) hydro/pyopneumothorax (5), with IC tube in
situ (5)

Notes- Opacity with air fluid level at top are
features of air and fluid within the thorax. As
there is no clear capsule seen and there is a
intercostal tube in place this film shows a
probable hydro/ pyo or hemo pneumothorax.

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