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246 Cards in this Set

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What structure is anterior to RUL bronchus?
• Superior pulmonary vein
• Right pulmonary artery
• Innominate pulmonary vein
• Azygous vein
• Superior vena cava
. Right pulmonary artery, some recalls say pulm vein. Hard to tell.
Which one of the following is the least likely to have calcifications?
• Silicosis
• TB
• Histoplasma
• Sarcoidosis
• Langerhan’s cell histiocytosis
E. Langerhan’s cell histiocytosis?
 In Fraser, no mention of calcifications in discussion of Langerhan’s cell histiocytosis. 2001, p. 339 – 342.
 Silicosis a 10-20% calcifications on x-ray. Fraser, 2001, p. 528.
 Many tuberculomas calcify. Fraser, 2001, p. 163.
 Calcification of lymph nodes is common in histoplasmosis and is associated with broncholithiasis. CT scan reveals parabronchial calcification. Fraser, 2001, p. 171.
 Sarcoidosis is considered to be the most common cause of circumferential or eggshell calcification in patients not exposed to silica. Fraser, 2001, p. 318.
sarcoid granulomas deposit where in lungs?
• a) in bronchovascular lymphatics
• b) interstitium
• c) alveoli
• Ans: A. The granulomas are deposited along the center and periphery of the secondary lobule, along the lymphatics (Dr. Galvin, AFIP notes pg 6).
Which of the following lymph nodes cannot easily be reached by mediastinoscopy?
• Anterior subcarinal
• Prevascular
• Superior mediastinal
• Tracheobronchial angle
B. Prevascular
 “Cervical mediastinoscopy is performed under general anesthesia and involves making an incision in the suprasternal sternal notch and placing a rigid scope into the mediastinum.
 “There is access to lymph nodes at the tracheobronchial angle (10L and 10R). Dissection is needed to reach the upper (2Land 2R) and lower (4L and 4R) lymph nodes. Access to subcarinal lymph nodes also requires dissection. Nodes in the aorticopulmonary window can be reached with difficulty.
 “It should be noted that mediastinoscopy does not access all mediastinal lymph nodes. The nodes around the aortopulmonary window and aortic arch are difficult to reach, and the prevascular, retrotracheal, paraesophageal, and inferior pulmonary ligament areas are inaccessible.”
Surgical Choices: Controversies in the Surgical Treatment of Lung Cancer, Harry J. D'Agostino, Jr., MD, FACS
Patient without treatment, calcified mediastinal mass, which is not likely?
• a) lymphoma
• b) teratoma
• c) TB
• d) bronchogenic cyst
• Ans: A (Repeat). Lymphoma
• Regarding lymphoma in general, according to Fraser and Pare’s Chest textbook, “After treatment, particularly radiotherapy, dystrophic calcification may occur, most commonly in the anterior mediastinum. Rarely, nodal calcification is present at the time of diagnosis.” A literature search demonstrates case reports of calcified, untreated nodes in non-Hodgkin’s lymphoma, but no actual numbers are given.
• Again, according to Fraser and Pare’s Chest textbook, 21% of teratomas present with calcifications (in a series of 66 patients).
• Once again, according to Fraser and Pare’s Chest textbook, thyroid carcinomas commonly calcify, but this is a rare pediatric disease.
• Another issue, I suppose, is the overall frequency of these diseases. Lymphoma (Hodgkin's and non-Hodgkin's) is the third most common childhood malignancy, and non-Hodgkin's lymphoma (NHL) accounts for approximately 7% of cancers in children less than 20 years of age.[2,3] In the United States, there are about 800 new cases of NHL diagnosed each year. Incidence is approximately 10 per 1,000,000. (ed. …but this doesn’t present with calcification)
• http://cancerweb.ncl.ac.uk/cancernet/100915.html
• For pediatric teratomas, I could only find that they represent 8% of mediastinal masses, but I haven’t been able to pin down the incidence of mediastinal masses in pediatric patients.
• As far as thyroid cancer in children, according to emedicine (my new favorite website): Thyroid neoplasms represent 1-1.5% of all pediatric malignancies and 5-5.7% of malignancies in the head and neck. Thyroid nodules occur in 4-7% of the general adult population and in only 1-2% of the pediatric population. The incidence of malignancy is much higher in pediatric nodules. Five percent of nodules in adults are malignant; in the pediatric population, the percentage of malignant nodules is 33%. These numbers are estimated using a compilation of data from multiple reports (Garcia, 1992; Khurana, 1999; Lugo-Vicente, 1998).
• Answer: A
A patient has isolated RUL pulmonary edema on CXR. Most consistent with?
• Aortic stenosis
• Aortic regurgitation
• Pulmonic stenosis
• Mitral regurgitation / insufficiency
• Mitral stenosis
D. Mitral regurgitation
 “Edema localized to the right upper lobe sometimes is seen inpatients in whom mitral regurgitation is the cause of the edema; in one study of 131 patients who had severe regurgitation, 12 (9%) showed this pattern.
 “The mechanism underlying this distribution has been shown to be a predominant orientation of the regurgitant jet toward the right superior pulmonary vein.”
—Radiologic Diagnosis of Disease of the Chest, Muller, Fraser, Colman and Pare, 2001, p. 440
In a patient with chronic eosinophilic pneumonia, which of the following statements is false?
• More common in females
• Peripheral blood shows eosinophilia
• Slowly responds to therapy
C. Slowly respond to therapy
 The mainstay of CEP treatment consists of systemic steroids, with dramatic response occurring within 2 days. CEP rarely resolves spontaneously.
 CEP has a reported female-to-male ratio of 2:1.
 A CBC may show increased eosinophils and/or thrombocytosis; however, the absence of peripheral eosinophilia does not exclude a diagnosis of EP.
Where is the thoracic duct?
• With azygous
• Anterior to esophagus
• Right of IVC
• Left of aorta
A. With azygous
 The thoracic duct begins in the abdomen as the cysterna chyli.
 The duct parallels the azygous vein through the abdomen and chest.
 It terminates at the junction of the left jugular and left subclavian veins.
Acquired bronchectasis is associated with all of the following except?
• Cystic fibrosis
• Poor ciliary motion
• Immunodeficiency states
• Pulmonary hemosiderosis
D. Pulmonary hemosiderosis
 Conditions commonly leading to bronchiectasis are
 Severe pneumonia (especially when complicating measles, pertussis, or certain adenovirus infections in children); necrotizing pulmonary infections due to Klebsiella sp, staphylococci, influenza virus, fungi, mycobacteria, and, rarely, mycoplasmas;
 Bronchial obstruction from any cause (eg, foreign body, enlarged lymph nodes, mucus inspissation, lung cancer, or other lung tumor).
 Miscellaneous chronic fibrosing lung diseases (eg, those following aspiration pneumonia or inhalation of injurious gases or particles--eg, silica, talc, or bakelite) also predispose to bronchiectasis.
 Immunologic deficiencies, including AIDS, and various other acquired, congenital, and hereditary abnormalities that increase host susceptibility to infection or impair respiratory defenses are less common but important predisposing factors.
 Although incidence and mortality have decreased with the widespread use of antibiotics and immunizations in children, bronchiectasis as a manifestation of cystic fibrosis is still common (see Ch. 267).
Merck Manual, Section 6, Ch 70
Pt undergoes a right lung biopsy, and soon after develops hemoptysis. Your best option is to:
• Place patient on left side
• Place patient on right side
• Sit patient up
• Place pt in Trendelenberg
• Hold plastic bag over pt’s head until hemoptysis stops.
Ans: B.
What is characteristic for sarcoidosis on CXR?
• Centrilobular nodules
• Subpleural nodules
B. Subpleural nodules Distribution of nodules in sarcoidosis
 Frequently in relationship to:
 Perihilar peribronchovascular interstitium
 Subpleural interstitium
 Near small vessels
 Major fissures
 Central bronchi and vessels
 Less frequently in:
 Centrilobular or septal in location
Characteristic for lymphangetic spread
• Centrilobular nodule
• Interlobular septal thickening
• Diffuse ground glass opacity
B. Interlobular septal thickening
 Specific HRCT findings in lymphangetic spread include:
 Smooth or nodular thickening of the peribronchovascular interstitium surrounding vessels and bronchi in the perihilar lung
 Smooth or nodular interlobular septal thickening
 Smooth or nodular subpleural interstitial thickening
 Thickening of the peribronhovascular axial interstitium in the centrilobular regions
 Preservation of normal lung architecture at the lobular level.
In a patient with upper extremity weakness, pleural lesions are due to what?
• Pleural fibrosis
• Thymoma
• mesothelioma
• fibrous tumor of pleura
• adenocarcinoma
B. Thymoma

 Most patients [with thymoma] manifest symptoms related to local compression or invasion of thoracic structures.
 Myasthenia is the most common paraneoplastic disease associated with thymoma.
 The most common sites of metastases are the lung, pleura, thoracic skeleton, and mediastinal, supraclavicular and cervical lymph nodes.
 , invasive thymoma with drop mets and myasthenia gravis. Remember relationship b/w myasthenia gravis and thymoma: 15% of pts with myasthenia have thymoma, and 30% of thymomas assoc with myasthenia.
Bilateral upper lobe opacities with AMS and Cheyene-Stokes
• Neurogenic edema
• Aspiration
• Contusion
• Alveolar proteinosis
• Asbestosis
A. Neurogenic edema
 “The radiographic manifestations [of neurogenic edema] consist of homogenous or, less commonly, inhomogeneous bilateral airspace consolidation.
 “The edema usually is generalized; however, an atypical pattern (e.g., predominantly upper zonal or unilateral) is seen in some patients.”
Radiographic Diagnosis of Diseases of the Chest, Muller, Fraser, Colman and Pare, 2001,
Quantitative measurement of measure LV function quantitatively by MRI
• Sagittal
• Coronal
• Horizontal and vertical long axis
• Short axis
D. Short Axis
Which are the following are characteristics of a hepatic hydrothorax ?
• Treat with pleurodesis
• Can occur with small amount of ascites
• Can occur with non-cirrhotic patient
• Left effusion
B. Can occur with small amount of ascites
 The frequency of hepatic hydrothorax in cirrhotic patients is reported to be approximately 5%. The pleural effusion is predominantly right-sided (85% of cases) but may be bilateral. Although most often accompanied by significant ascites, it can occur in its absence.—Serrat J. Roza JJ. Planella T. Hepatic hydrothorax in the absence of ascites: respiratory failure in a cirrhotic patient. Anesthesia & Analgesia. 99(6):1803-4, table of contents, 2004 Dec.
In an untreated adult with calcified mediastinal mass, which is least likely?
• Thyroid tumor Fraser 708 calc
• Thymoma Fraser 699 20% calc Primer
• Lymphoma
• Teratoma Fraser 705 30-50% calc
C. Lymphoma
Lung biopsy in a 30-year-old male reveals small vessel vasculitis and alveolar hemorrhage
• Goodpasture syndrome
• Wegener’s granulomatosis
• Idiopathic pulmonary hemosiderosis
Wegeners.
 Goodpasture syndrome is a cytotoxic antibody-mediated disease (Type II hypersensitivity).
 IgG & IgM antibody with complement activation causes alveolar basement membrane & cell destruction with pulmonary hemorrhage.
 Although Wegener granulomatosis is a vasculitis, it does rarely causes pulmonary hemorrhage.
Dahnert
Which of the following diseases is most likely to increase the residual capacity of the lungs?
• Fibrosis
• Emphysema
B. Emphysema
 Although I could not find a definitive reference to answer the question, I discussed the question with Dr. Malcolm who felt that emphysema and other obstructive diseases would increase residual capacity; whereas fibrosis would decrease it. I did find the following:
 “Emphysema is defined anatomically by abnormal enlargement of airspaces beyond the terminal bronchioles and destruction of their walls.”
 “At present, high-resolution computed tomography of the chest (HRCT) is the only noninvasive method available for reliable detection of pulmonary emphysema in vivo.
 “Patients with chronic bronchitis and macroscopic emphysema showed considerably increased peripheral effective airspace dimensions (EAD) and increased aerosol bolus dispersion (D), whereas in the absence of macroscopic emphysema EAD and D were within normal limits. Of all the lung function parameters under consideration, EAD and D had the highest sensitivity and specificity for the discrimination of patients with COB from those also suffering from macroscopic pulmonary emphysema (COB-E).”
Kohlhaufl M etal., “Diagnosis of emphysema in patients with chronic bronchitis: a new approach.” European Respiratory Journal. 12(4):793-8, 1998 Oct
What is the most likely manifestation of thymic carcinoid?
• Carcinoid syndrome
• SIADH
• Conn’s syndrome
• Hyperinsulinism
• Cushing’s syndrome
E. Cushing Syndrome
 Bronchial + thymic carcinoids are often <1 cm at the time they produce Cushing syndrome!
Danhert CD
Which of the following would be least likely to present with nodular metastases in the chest?
• Breast cancer
• Osteosarcoma
• Prostate cancer
• Renal cell carcinoma
• Testicular cancer
C. Prostate
 5% of all solitary nodules are metastatic with the most likely origin: colon carcinoma (30 - 40%), osteosarcoma, renal cell carcinoma, testicular tumor, and breast carcinoma
 Osteosarcoma causes metastases after interval of 1 month to 4 years to the lungs (81 - 100%)
Adenosine contraindicated in
• Exercise induced angina
• Previous CABG
• Heart block
• Claudication
C. Heart Block
• Alveoli develop fully by which age?
a. Birth
b. 2 years
c. 4 years
d. 8 years
. 8 years
• Which of the following findings is characteristic of interstitial lung disase?
– Segmental distribution
– Air bronchograms
– Honeycombing
– Bat wing appearance
• Honeycombing?
• What is the most likely manifestation of thymic carcinoid?
a. Carcinoid syndrome
b. SIADH
c. Conn’s syndrome
d. hyperinsulinism
e. Cushing’s syndrome
E. Cushing’s syndrome…according to AmershamHealth. SIADH also possible.new
• Which one of the following is the least likely to have calcifications?
a. silicosis
b. TB
c. histoplasma
d. sarcoid
e. Langerhan’s cell histiocytosis
• E.
• On a chest X-Ray, what is the best example of sternal dehiscence?
a. new vertical lucency
b. new broken wire
c. lateral displacement of the sternal wire
d. hematoma
• C. ?According to AuntMinnie, displacement of sternal wires on CXR can be seen in 85% of cases of sternal dehiscence; but other findings are seen, as well.new
• Complete tracheal rings are most likely associated with:
• a) left pulmonary artery coming off the right pulmonary artery
• b) left aortic arch with aberrant right subclavian artery
• c) right aortic arch with aberrant left subclavian artery
• d) double aortic arch
• Answer: A. Choice A is describing a pulmonary sling, which is associated with tracheal rings.
• In patients diagnosed with complete tracheal rings, pulmonary artery sling is present in 30% and intracardiac defects in 15%, and these should be ruled out with echocardiography
• In the chest, which of the following is not an indication for FDG PET?
a. breast mets
b. small cell lung CA
c. esophageal CA
• Small cell lung ca
The location of the pulmonary valve relative to the aortic valve is:
• Left, superior, anterior
• Left, superior, posterior
• Left, inferior, anterior
• Right, superior, anterior
• Right, superior, anterior
• A. Left, superior, anterior
• Source: Dahnert 5th ed. p. 591,592** From 2001 (among other years) **
On a pulmonary function test, the volume expelled from maximum inspiration to maximum expiration is:
• Functional residual capacity FRC
• Tidal volume
• Vital capacity
• Residual volume
• Total lung capacity
Vital Capacity
– There are four volume and three capacity measurements:
– Tidal volume - normal inspiration to normal expiration
– Inspiratory reserve volume- normal inspiration to full
– inspiration
– Expiratory reserve volume - normal expiration to full
– expiration
– Residual volume - volume left in lungs after full
– expiration. Cannot be directly measured.
– Vital capacity - full inspiration to full expiration
– (IRV + TV + ERV)
– Functional residual capacity - volume left in lungs
– after normal expiration (ERV + RV). Cannot be directly measured.
– Total lung capacity- vital capacity + residual volume
– (Andreoli TE, Carpenter CC, Bennett JC, Plum F; Cecil
– Essentials of Medicine 4th ed, W.B. Saunders, 1997, p.
Which of the following is a reason that digital radiography is superior to film for portable imaging?
• Wider density latitude
• Resolution
• Lower patient radiation exposure
A. Wider density latitude
 For radiography of the chest, digital imaging offers numerous advantages over conventional, film-based techniques. Advantages include a linear response to x-ray exposure over a wide dynamic range, the ability to perform image processing to optimize image appearance, and the opportunity to transmit images rapidly to remote locations.
 Computed radiography (CR) systems based on photostimulable storage phosphor detectors have been in use for over 15 years and have gained wide acceptance for both bedside and in department examinations.
 More recently, a selenium-based digital chest radiography system has been introduced, and a new generation of large-area, flat-panel x-ray detectors with integrated readout mechanisms is now emerging.
In a 34 yo asymptomatic construction worker a routine CXR reveals unilateral pleural effusion which resolves on its own in 6 weeks. Six months later the patient presents with a focal upper lobe opacity. What is the most likely cause?
• lung cancer
• PE
• TB
• Lymphoma
• Viral infection
• Asbestosis
• Sarcoid
• PCP
C. TB
 TB pleural effusions in 23-38% adults and 10% children; usually with mediastinal LAD and one or more homogenous area of ill defined airspace consolidation of 1-7cm; atelectasis is seen in 8-18% especially in right anterior segment of the upper lung. Primer pgs. 12-15; Dähnert pgs. 444-445. Fraser 2nd p. 320.
What is the most common appearance of Legionella at the peak of the disease?
• Bilateral airspace consolidation
• Unilateral airspace disease
• Cavitary lesion
A. Bilateral airspace consolidation
 Common radiographic features include bilateral severe disease, rapidly progressive, pleural effusions and lower lobe predilection. Associated hyponatremia. Seroconversion for dx takes 2 weeks. Starts as peripheral patchy consolidation. Source: Primer 3rd ed. p.11
A 35 year-old male develops sudden onset flu-like illness with extrinsic bulbous mediastinal lymphadenopathy (AIDS was not a choice). Which is the most likely diagnosis?
• Ecoli
• Silicosis
• Burkitt's lymphoma
• Bacterial pneumonitis
• Mycoplasma
• Silicoproteinosis
• Kleisbella
• Inhalational anthrax
H. Inhalation anthrax
An elderly lady with shortness of breath and cough has bronchiectasis in the right middle lobe and lingula. Scattered, sub-centimeter nodules in the lung bases. Most likely organism?
• staph. Aureus
• Klebsiella
• Aspergillus
• mycobacterium avium-intracellulare (MAC)
• legionella pneumophilia
D. mycobacterium avium-intracellulare (MAC)
• A patient has a 4 cm mass in the periphery of the lungs with ipsilateral mediastinal lymphadenopathy. No distant mets. Stage?
a. T0N1M0
b. T1N1M0
c. T1N2M0
d. T2N1M0
e. T2N2M0
• E. T2N2M0
• Primary Tumor:
• TX – malignant cells in secretions, T0 – No tumor, T1S – ca in situ, T1 – 3 cm or less without invasion, T2 - 3cm or more or local invasion, associated atelectasis, or pneumonitis, T3 – direct extension to chest wall, T4 – invasion of mediastinum
• Nodal Involvement:
N0 – no mets to nodes,
• N1 – Mets to peribronchial or ipsihilar nodes,
• N2 – Mets to ipsilateral mediastinal and carinal,
• N3 – Mets to contralateral mediastinal or hilar nodes**
• similar to ’02 question; pretty sure ‘N3’ was not in the choices, and/or it said ipsilateral mediastinal LAD **
The most common mediastinal mass in a child between the ages of 6 and 12 years old is which disease?
• Teratoma
• Neuroblastoma
• Ganglioneuroma
• Lymphoma
• Bronchogenic cyst
• Metastatic Wilms tumor
D. Lymphoma
 According to Swischuck, mediastinal masses in young infants are within the posterior mediastinum 50-60% of the time, with neuroblastoma as the most common (*this age group is too old for neuroblastoma). In older children, mediastinal lymphadenopathy is most commonly due to lymphoma.
 Mediastinal masses in children are broken down as follows: anterior = 30%, middle = 30%, posterior = 40%. Greater than 90% of posterior mediastinal masses are neurogenic in origin, with neuroblastoma by far more common than ganglioneuroblastoma or ganglioneuroma. After leukemia and CNS tumors, lymphoma is the third most common neoplasm of childhood. It is the most common anterior mediastinal mass, accounting for 1/4 of all mediastinal masses. [Pediatric Radiology Requisites. p. 44, 5]
A patient undergoes biopsy for a pulmonary mass. Which of the following is the least likely complication?
• Pneumothorax
• Hemoptysis
• air embolization
• seeding of biopsy tract
• infection (?)
D. Seeding of biopsy tract (probably)
 Complication Rates
– Pneumothorax: 20% – 30 %
– Hemoptysis: 1% - 10%
– Air embolism: “rare”
– Seeding of biopsy tract: “very rare”
– Infection: not discussed in Requisites, Muller, Kazerooni, nor found by Ovid search
Requisites, 1998, p. 519-520
Which native structure is preserved during an orthotopic heart transplant?
• Pulmonic valve
• Posterior wall of left atrium
• Right atrial appendage
• Coronary sinus
• Non coronary sinus of Valsalva
B. Left atrial wall
 Most heart transplant surgeries are done with a method called "orthotopic." Your heart is removed but the back half of both upper chambers (atriums) are left in place. The front half of the donor heart's atrium is sewed to the back half of yours, which was left in place. Then the donor heart's right atrium is sewed to the still-in-place back half of your original atrium. Once the heart is in place, the donor's main arteries - the aorta and pulmonary arteries - are sewn to yours. http://www.chfpatients.com/tx/txsurgery.htm
Which of the following is NOT associated with left atrial enlargement?
• Mitral stenosis
• Left atrial myxoma
• Atrial fibrillation
• Decreased compliance of the left ventricle
• VSD
• ASD
• Aortic stenosis
F. ASD
 ASD does not show left atrial enlargement because any additional blood in the left ventricle is “decompressed” into the RV through the defect. Primary pulmonary hyptertension (if it were presented as a choice) would not cause LV enlargement.
 Common acquired causes of left atrial enlargement are mitral stenosis or regurgitation, left ventricular failure, and left atrial myxoma. Congenital causes include ventricular septal defects, patent ductus arteriosus, and the hypoplastic left heart complex. When atrial fibrillation occurs, the left atrial volumes may increase to 20%.
 Aortic stenosis can also cause left atrial enlargement. Dähnert 5th p. 612.
 Atrial fibrillation is most associated with left atrial enlargement. (That was the 1994 question.) In VSD, LA becomes enlarged b/c it receives an increased volume. The LV remains normal in size b/c the blood it receives is "decompressed into the RV. [Cardiac Req p. 10]
• Which of the following is most associated with left atrial enlargement?
a. ASD
b. atrial fibrillation
• Answer: B. Atrial fibrillation
• results in poor atrial contraction, with enlarged atria over time. Rheumatic mitral valve disease was the most common cause of LA enlargement prior to antibiotics. Now myocardiopathies are more common. Other causes include VSD, PDA and LV failure. Most cardiac atrial myxomas are left sided 75%-80%. Answers A, C, and D would all cause the downstream LA to see less pressure and volume, so should not cause LA enlargement. (Paul and Juhl p. 1203 and Brant and Helms p. 565)
A patient has isolated RUL pulmonary edema on CXR. Most consistent with?
• aortic stenosis
• aortic regurgitation
• pulmonic stenosis
• mitral regurgitation / insufficiency
• mitral stenosis
D. Mitral regurgitation
Which of the following entities does NOT cause pulmonary hypertension?
• Asthma
• COPD
• Pulmonary AVM
• Mitral stenosis
• Chronic hypoxia
• Eisenmenger's syndrome
• Cystic fibrosis
• Emphysema
• Pulmonary embolism
• Left heart failure
C. Pulmonary AVM
Which of the following is the most sensitive finding for aortic transection on chest X-Ray?
• apical pleural capping
• deviation of NG tube
• mediastinal widening
• fractures of the 1st and 2nd ribs
• depression of left mainstem bronchus
C. Mediastinal widening
Which can be seen with a small pneumothorax on supine CXR?
• Deep lateral costophrenic sulcus
• Lucency over the lung base.
• Elevation of the hemidiaphragm
A and B
• Which of the following is most characteristic of a supine pneumothorax?
• a. Deep sulcus sign
• b. Eventration of the hemidiaphragm
• c. Hilum overlay sign
• d. Westermark’s sign
• Answer: A
Which is the most accurate regarding endotracheal intubation?
• Mainstem bronchus intubation occurs most often on the left
• Cuff inflation prevents aspiration
• Neck flexion causes the tube tip to move caudally
• Granuloma formation secondary to intubation most often involves the posterior wall of the trachea
• An LPO CXR is the best way to evaluate for esophageal intubation
C. neck flexion causes the tube tip to move caudally.
• Which is least likely to occur in the upper lobes?
• Silicosis
• Alpha-1-antitrypsin deficiency
• Centrilobular emphysema
• Cystic fibrosis
• Histiocytosis, adult-onset
• B. Alpha-1-antitrypsin deficiency
Which of the following is seen in RUL collapse?
• Bronchus intermedius medially displaced
• Posterior aspect of the middle lobe is hyperexpanded
• Left upper lobe herniation
• Elevation of the right hemidiaphragm (juxtaphrenic peak )
B. the posterior middle lobe is hyperexpanded or
D. Juxtaphrenic peak.
 Tenting of the diaphragmatic pleura, called juxtaphrenic peak sign, is another helpful sign of RUL atelectasis
 Right upper lobe (RUL) atelectasis results in overinflation of the right middle lobe (RML) and shift of the minor fissure superiorly and medially. It also results in compensatory overinflation of the right lower lobe (RLL) with a shift of the major fissure anteriorly, superiorly, and medially. Source: Felson p.133.137
• Which is associated with RUL collapse?
• a) Posterior herniation of the RML
• b) Elevation of the left main stem bronchus
• c) rotation of some bronchus
• d) juxtaphrenic peak
• Answer: D. Some chest book says tht choice D is associated with almost all cases of RUL collapse. Apparently caused by either inferior pulmonary ligament or vein.
Which would be most helpful to determine the etiology of a mosaic pattern seen on high resolution CT?
• Lateral decubitus film
• MRI
• Routine chest CT
• High resolution CT in expiration
D. High resolution CT in expiration
• Which extrathoracic malignancy is LEAST likely to manifest as multiple pulmonary nodules? (2001 repeat)
• Thyroid carcinoma
• Testicular carcinoma
• Prostate carcinoma
• Renal cell carcinoma
• Choriocarcinoma
• C. prostate
• At which wedge pressure do you begin to see pulmonary interstitial edema?
a. 0-5
b. 10-12
c. 15-25
d. 25-50
• C. 15 - 25 mm
• Verified in Aunt Minnie article.
• What is the normal pulmonary artery pressure:
• a) 5/0
• b) 20/8
• c) 25/10
• Answer: B. This is a variation of an old question which asked what the mean pulmonary artery pressure is. The mean PA pressure is 15 mm. You’ll have to learn the mean pressures as well as systolic/diastolic pressures for the RA, PA and LA. There’s a chart in Primer.
• A patient has a chronic eosinophilic pneumonia. Which of the following statements is false?
a. more common in females
b. peripheral blood eosinophilia
c. slowly responds to therapy
d. recurs quickly after stopping therapy
• C. slowly responds to therapy
• Which of the following lymph nodes cannot easily be reached by mediastinoscopy?
a. anterior subcarinal
b. prevascular
c. superior mediastinal
d. tracheobronchial angle
e. right paratracheal
f. left paratracheal
• B. Prevascular
• Which of the following diseases is most likely to increase the residual capacity of the lungs?
a. fibrosis
b. emphysema
c. sarcoidosis
d. silicosis
• B. emphysema
child who has had a bone marrow transplant has a 3 cm upper lobe nodule. Most likely diagnosis:
a. CMV
b. Invasive Aspergillus
c. TB
d. lymphoma
e. mycoplasma
• B. Invasive Aspergillus
• Given the Hx of bone marrow transplant (BMT), the child is presumably imminocompromised. Invasive Aspergillosis is then a concern, and findings include single / multiple ill-defined peripheral opacities 1-3cm in size (possibly with a halo of ground glass on CT). Time course is 2-3 weeks (neutropenic phase)—high mortality (70-90%) Dähnert 5th p. 458, 462.CMV pneumonia would certainly be a possibility, given the Hx, however it is characterized by multiple small nodules. Time course is 1st 100 days post transplantation.Late phase pulmonary complications include BOOP, chronic GVHD, and infections (in patients > 100 days post BMT).Mycoplasma favors the lower lobes and is typically not nodular.Radiology Review Manual, 1999. p.385
• A female has leg pain, glucose of 20, fatigue and a well-defined chest mass. Most likely diagnosis:
a. bronchogenic carcinoma
b. lymphoma
c. localized fibrous tumor of pleura
d. Large cell lung CA
e. Pulmonary blastoma
• C. localized fibrous tumor of pleura.
• Localized fibrous tumor of the pleura (LFTP) is a benign mesothelioma (no association with asbestos exposure). It is largely resectable, even when the size is large, and has a favorable prognosis. Episodic hypoglycemia is seen in 4%; hypertrophic pulmonary osteoarthropathy [pain / swelling of limbs, especially tibia / fibula] in 20-35%. Other Sx include dyspnea and cough. Dähnert 5th p. 504, 104
• Bronchogenic CA is more common than LFTP, and causes 88% of cases of hypertrophic pulmonary osteoarthropathy. However, it typically does not cause hypoglycemia (other paraneoplastic syndromes, e.g. SIADH, however), and the well-defined chest mass favors a benign tumor. www.emedicine.com
• For which of the following is CT densitometry most useful?
a. PCP
b. asbestosis
c. silicosis
d. lipoid pneumonia
e. alveolar proteinosis
• D. Lipoid Pneumonia
• Lipoid pneumonia may show a mass of low-attenuation approaching that of subcutaneous fat (-150 to 50 HU). When seen, this is very specific.
Acute Exogenous lipoid pneumonia – “fire-eater pneumonia”
- ingestion of liquid paraffin or petroleum [poisoning in children or
accidental ingestion by “fire eaters”]
Chronic Exogenous lipoid pneumonia:
- aspiration or inhalation of fatlike material (vegetable oil, cod
liver oil, mineral oil)
- in elderly, debilitated, those with neuromuscular disease
- predilection for RML and lower lobes
• Endogenous phospholipoidosis induced by amiodarone is an important cause of pulmonary toxicity.
• Thoracic Radiology the Requisites page 274-5; Dähnert 5th p. 400, 499
• Which of the following is false regarding pulmonary embolism?
a. infarcts not very common with PE
b. distal emboli are more likely to cause infarcts
c. rare from upper extremity
d. the clinical triad of cough, chest pain, and hemoptysis is present in
a majority of patients with angiographically proven emboli
• D. the clinical triad of cough, chest pain, and hemoptysis is present in a majority of patients with angiographically proven emboli * Common Repeater *
• PTE Sx: cough (53%), pleuritic chest pain (88%), hemoptysis (30%). So obviously, patients who have all three of these symptoms will be < 30% [14% if these are independent variables]. Other Sx—dyspnea (84%), apprehension (59%), ↑ RR (92%).
• Infarcts occur in 10-60%; source is DVT of lower extremity / pelvis in > 90%; distal emboli produce infarcts mainly due to the lack of collateral flow Dähnert 5th p. 516
• Which of the following is true regarding lateral chest x-rays?
a. the anterior wall of the bronchus intermedius is usually seen
b. the confluence of the pulmonary venous system is lower than both the right and left upper lobe bronchi
c. the right upper lobe bronchus is more often seen than the left upper bronchus
d. left PA is inferior to the left mainstem bronchus
• B. Confluence of the pulmonary venous system is lower than both the right and left upper lobe bronchi.
• This is a true statement (therefore the answer); Netter 194 shows the relationship clearly. If you’re less visual, you can read about it in Fraser & Pare Synopsis 2nd p. 35-39. Other choices are False--
• The posterior (not anterior) wall of the bronchus intermedius is usually seen in 95% of individuals—this is the intermediate stem line. F&P 2nd p. 33; Primer 3rd p. 3
• The left (not right) upper lobe bronchus is more commonly seen. LUL bronchus seen in 75%, RUL in only 50%. because--
”The orifice of the RUL bronchus is seldom as well circumscribed as that of the left… [because] the latter is completely surrounded by vessels (left PA above, interlobar artery behind, pulmonary vein in front). Fraser & Pare synopsis 2nd p. 33.
• The left mainstem bronchus enters the lung below (not above) the left pulmonary artery (hyparterial). Felson p. 187.
• Patient has right upper lobe mass with ipsilateral paratracheal node mets. Proper staging includes:
a. NX
b. N0
c. N1
d. N2
e. M1
• D. N2
• Which of the following is not typical chest finding of Rheumatoid arthritis?
a. honeycombing
b. pleural effusion
c. lower lobe interstitial disease
d. nodules
e. hilar adenopathy
• E. Hilar adenopathy
• There are five pleuropulmonary abnormalities associated with rheumatoid disease:
1. pleurisy with or without effusion
2. diffuse interstitial pneumonitis or fibrosis (lower lobe predominance)
3. pumonary (necrobiotic) nodules, often cavitate
4. Caplan’s syndrome (pneumoconiotic nodules)
5. Pulmonary hypertension secondary to vasculitis
Thoracic Requisites 252; Dähnert 5th p. 434.
• An elderly lady with shortness of breath and cough has bronchiectasis in the right middle lobe and lingula. Most likely cause:
a. drug adverse effect
b. cancer
c. pulmonary fibrosis
d. mycobacterium avium-intracellulare (MAC)
e. pulmonary embolism
f. missed diagnosis of cystic fibrosis
• D. mycobacterium avium-intracellulare (MAC)
• An elderly man has facial and upper extremity swelling with a widened mediastinum on chest x-ray. Most likely diagnosis:
a. teratoma
b. bronchogenic ca
c. mediastinitis
d. lymphoma
• B. Bronchogenic Carcinoma
• Which of the following is false regarding subcarinal lymph nodes?
a. Can easily be differentiated from bronchogenic cyst on CT
b. Involvement does not preclude surgical resection of primary lung cancer
c. Easily accessible by mediastinoscopy
d. Can posteriorly displace the left mainstem bronchus
e. Is best biopsied transthoracically
C. Not easily accessible, remember lung ca staging
• Which of the following avidly enhances in mediastinum?
a. Paraganglioma
b. lymphoma
c. thymoma
• A. Paraganglioma
• Which of the following is most likely to cause round atelectasis?
a. resolving pleural effusion
b. resolving pneumonia
• A. Resolving pleural effusion
• A type of focal atelectasis is rounded atelectasis. This type of atelectasis (which is often an incidental finding on chest radiograph) is a peripheral rounded type of atelectasis that is always associated with pleural thickening or less commonly, pleural effusion. It appears as a sharply defined mass abutting the pleura and ranging in size from 2 to 7 cm in diameter usually located posteriorly in the lower lobes. Air bronchograms or focal collections olf air (“psuedocavitation”) may be present within the atelectasis. The most distinctive finding is that vessels and bronchi located more centrally than the peripheral area of atelectasis are crowded together in a “whorled” pattern coursing like a “comet tail” toward the hilum. On CT the finding is that of a rounded peripheral lung mass associated with pleural thickening. The comet-tail appearance is more easily visualized. Rounded atelectasis can be associated with any cause of pleural thickening but particularly with asbestos-related disease.
Thoracic Radiology Requisites p. 45; Freundlich 2nd p. 105
• Which of the following is characteristic of smoking related emphysema?
a. Basilar predominance
b. Centrilobular distribution
c. Panlobular distribution
• B. Centrilobular Distribution
• There are four major types of emphysema defined anatomically. These are: 1. Centrilobular or centriacinar; 2. panlobular or panacinar; 3. paraseptal (distal acinar) emphysema; and 4. paracicatricial (irregular).
• Centrilobular emphysema affects the predominately the respiratory bronchioles in the central portion of the secondary pulmonary lobule. It usually identified in the upper-lung zones, and it is associated with cigarette smoking (causes up to 50%).
• Panlobular involves all the components of the acinus an therefore involves the entire lobule. It is classically associated with alpha-1 protease inhibitor (alpha-1-antitrypsin) deficiency (cause in 10-15%), although it may be seen without protease deficiency in smokers and eldely.
• Paraseptal involves the distal part of the secondary lobule (alveolar dusts and sacs). It can be an isolated phenomenon in young adults, and is associated with spontaneous pneumothorax. (Thoracic Requisites 288, Dähnert 5th p. 485)
• Which of the following does not run with or contain lymphatics?
a. Bronchial artery
b. bronchial vein
c. alveolar wall
d. pulmonary artery
e. interlobular septa
• C. Alveolar wall
• Pulmonary lymphatics are seen in all of the following locations except alveolar walls. There are two lymphatic plexuses that drain the lung: superficial and deep. The superficial lymphatic plexus lies deep to the viceral pleura and lymph vessels from it drain into the bronchopulmonary lymph nodes in the hilum. The deep plexus is located in the submucosa of the bronchi and in the peribronchial connective tissue. There are no lymph vessels in the walls of the alveoli. Lymph vessels from the deep plexus drain into the pulmonary lymph nodes, located along the large branches of the bronchi. Lymph vessels from these nodes follow the bronchi and pulmonary vessels to the hilum, where they drain into the bronchopulmonary lymph nodes.
Clinically Oriented Anatomy by Moore, Keith
• On an axial CT image which takeoff to the RLL do you see at the same level as the bronchus to the RML?
a. Superior
b. Medial Basal
c. Lateral Basal
d. Anterior Basal
e. Posterior Basal
• A. Superior
• At the level of the right middle lobe bronchus many structures are seen. The superior segment of the right lower lobe, the right middle lobe lateral and medial branches, the right and left superior veins and the left lower lobe. See Figure in Dähnert 5th p. 444 or Freundlich 2nd Fig. 3-20.
• Which of the following has similar histology as UIP (usual interstitial pneumonia)?
a. LAM
b. Histiocytosis X
c. Sarcoid
d. lymphoma
e. Lupus
• E. Systemic Lupus Erythmatosus
• Lupus and collagen-vascular diseases may have “UIP-like” areas of histology. Colby Atlas Pulm. Surg. Path., 1991, p. 24.
• A child who has had a bone marrow transplant has a 3 cm upper lobe nodule. Most likely diagnosis:
a. CMV
b. Invasive Aspergillus
c. TB
d. lymphoma
e. mycoplasma
• B. Invasive Aspergillus
• Given the Hx of bone marrow transplant (BMT), the child is presumably immunocompromised. Invasive Aspergillosis is then a concern, and findings include single / multiple ill-defined peripheral opacities 1-3cm in size (possibly with a halo of ground glass on CT). Time course is 2-3 weeks (neutropenic phase)—high mortality (70-90%) Dähnert 5th p. 458, 462.
• CMV pneumonia would certainly be a possibility, given the Hx, however it is characterized by multiple small nodules. Time course is 1st 100 days post transplantation.
• Late phase pulmonary complications include BOOP, chronic GVHD, and infections (in patients > 100 days post BMT).
• Mycoplasma favors the lower lobes and is typically not nodular.
• Radiology Review Manual, 1999. p.385
• Which of the following is false regarding traumatic rupture of a bronchus?
a. distal more involved than proximal
b. pneumomediastinum R/L pneumothorax
c. prompt / easy re-expansion with chest tube
d. commonly see pneumomediastinum and pneumothorax
• A. distal more involved than proximal
• The above statement is False (a correct choice)--
”The fractures usually involve the proximal main bronchi (80%) or distal trachea (15%) within 2 cm of the tracheal carina; the peripheral bronchi are involved in 5% of cases.” B&H p. 444.
• C. prompt / easy re-expansion with a chest tube
• The above statement is also False (a correct choice). If anything, a bronchial fracture will show inadequate reexpansion of lung despite adequate placement of one or more chest tubes (due to the large size of the air leak). Basically, the chest tubes can’t keep up. Dähnert 5th p. 488.
• Pneumothorax is seen in 70%, Fx of 1st 3 ribs (53-91%). Pneumomediastinum may be the only finding, particularly with injury to the left main stem bronchus, which has a longer mediastinal course. The fallen lung sign occurs with complete disruption of the main stem bronchus. The lung falls inferiorly and laterally to the base of the hemithorax in contrast to a pneumothroax from a partial bronchial tear, where the lung collapses medially and centrally. Thoracic Requisites 179
• A trauma patient has fracture of the right main stem bronchus. Which of the following is FALSE:
• he may get ipsilateral pneumothorax and mediastinum
• if he has a pneumothorax it will respond rapidly to chest tube placement.
• he is likely to have rib fractures
• his ipsilateral lung may collapse to a dependent position
• he may have subcutaneous emphysema
• The correct answer is B. A patient with tracheal or bronchial fracture usually has inadequate reexpansion of the lung despite chest tube drainage, due to large air leak.
• Which of the following is most likely to cause an exudative pleural effusion?
a. cirrhosis
b. congestive heart failure
c. neoplasm
d. nephrotic syndrome
e. Uremia
• C. Neoplasm
• Exudative effusion = high-protein pleural fluid
- Malignancy (e.g., pleural mets.): 60%
- Uremic pleuritis: 20%
- Infection: Empyema, TB, pneumonia
- other: SLE, Wegeners (50%), trauma, Meigs, pancreatitis, etc.
• Transudative effusion = low-protein [1.5-2.5 g/dL] pleural fluid
- CHF (increased hydrostatic pressure)
- cirrhosis (low osmotic pressure)
- nephrotic syndrome (low osmotic pressure)
- hypothyroid, constrictive pericarditis, overhydration
Dähnert 5th p. 438.
• Diagram of axial CT slice through superior mediastinum above aortic arch. Tubular structure labeled on right/anterior aspect of vertebral body. What is it?
a. azygous vein
b. hemiazygous vein
c. aberrant subclavian
d. paraspinal vessel
e. superior right intercostal vein
• E. Superior right intercostal vein
• The right superior intercostal vein lies along the spine superior to and draining into the arch of the azygos vein. It is above the arch of the aorta.
Netter, old notes; http://www.uhrad.com/ctarc/ct116.htm
• The azygos vein arches under the right mainstem bronchus into the SVC. This is about the level of the inferior part of the aortic arch. * Be aware that there is a variant of this question that shows a CT cut at the level of the heart and great vessels; in this case (below intercostals), the correct answer would be azygous vein.
• Which of the following is the most correct site of origin of the left bronchial artery?
• ascending aorta
• descending aorta
• pulmonary artery
• internal mammary artery
• left ventricle
• Answer: (B) – common repeater. Left bronchial artery most commonly originates from the descending thoracic aorta. I did an angiogram on myself to make sure:
• Best way to measure COPD emphysema:
a. FVC
b. FEV1
c. FEV1/FVC
d. VC
e. RV
• B. FEV1
• A simple staging system based on FEV1 has been proposed for COPD (American Thoracic Society)
- Stage I is an FEV1 50% or more of the predicted value. The
patients generally have mild exercise limitation because of
COPD and are at low risk of serious exacerbations.
- Stage II is an FEV1less than 50% but greater than 35% of
the predicted value. Stage III is an FEV1=35% or less of the
predicted value. The exercise capacity of patients with
- Stage III COPD is severely limited. These patients tend to have frequent exacerbations and consume the greatest expenditure of health care dollars for care among persons with COPD. MKSAP (medicine disc)
• Chronic air-flow obstruction (decrease FEV, DL, increased TLC, RV). The air-flow obstruction can be measured with pulmonary function tests by a diminution of the forced expiratory volume in one second (FEV) or the ratio of the FEV to the forced vital capacity (FVC).
Thoracic Requisites (289-90), Primer 48; B&H p. 451
• Most common lung infection in HIV:
a. Aspergilllus
b. Cryptococcus
c. PCP
d. TB
e. bacterial pneumonia
• C. PCP
• Opportunistic infection accounts for the majority of pulmonary disease in HIV:

• The most common lung infection in patients with AIDS is due to the Pneumocystis Carinii organism. 80% of HIV-infected individuals will experience an episode of this infection at some time

• - PCP (60-80%): bilateral interstitial disease (ground-glass
opacities), 25% fatal; CD4 count usually < 200; frequently
associated with pneumatoceles
- Fungal Disease e.g., Cryptococcus or Aspergillus (2-15%)
- Mycobacterial 20%
- Bacterial (staph, strep, H. Flue, nocardia) 5-30%
Dähnert 5th p. 452
• IV drug abuser with fever, chest pain, and multiple focal areas in lungs bilaterally. Which is most likely?
a. TB
b. Staph.
c. Endocarditis
• C. Endocarditis
• IV drug abusers get endocarditis of the tricuspid valve (right-sided endocarditis), which causes multiple septic pulmonary emboli. Mortality rate is only 3%-9%, lower than left-sided [aortic valve] endocarditis. Dähnert 5th p. 616
• Septic emboli are trapped in the pulmonary circulation. Consequently, patients typically present with cough and pleuritic chest pain. Chest radiographs typically show multiple round pulmonary infiltrates that may cavitate. Systemic complications are uncommon unless the mitral valve or the aortic valve has become secondarily involved. MKSAP (medicine disk)
• In patient with COPD, what is the most common cause of heart failure?
a. Pulmonary hypertension (Cor pulmonale)
b. atherosclerotic heart disease
• B. Atherosclerotic heart disease
• Cardiac disease in patients with chronic pulmonary disease is usually caused by coronary artery disease, especially in older patients with a history of smoking. Coronary artery disease leads to CHF (LHF) superimposed on the chronic lung disease. Right heart failure is much less common than left heart failure (LHF) and is most commonly caused by LHF. Other causes include increased pulmonary arterial pressure – pulmonary stenosis, tricuspid regurgitation, right ventricular infarction, and volume overload from septal defect. Conclusion: The most common cause of heart failure in a patient with chronic lung disease is atherosclerotic disease (of coronary arteries).
Freundlich 2nd p. 354
• Pleural effusion is not commonly seen with
a. lymphangiectic carcinomatosis
b. lymphoma
c. lupus
d. usual interstitial penumonitis (UIP)
• D. usual interstitial pneumonitis (UIP)
• Aortic stenosis commonly assoc with
• Angina
• Dilated Left ventricle
• Sinus of Valsalva aneurysm
• Aortic knob enlargement
• (this has been debated endlessly on old tests… would look it up for yourselves)
• Angina is best answer, see question #45 above.
• Dilated LV, no – LV could be normal size, enlarged, or small with thick walls.
• Which has a lower lobe predominance? (version 1)
• Which of the following does NOT usually involve the upper lobes (version 2)
a. EG
b. Silicosis
c. Sarcoid
d. Asbestosis
e. Ankylosing spondylitis
• B. Asbestosis
• Most severe in lower posterior subpleural zones (concentration of asbestos fibers beneath visceral pleura) Dähnert 5th p. 456.
Upper lobes: pnemonic “CASSET P”
CF, AS, Silicosis, Sarcoid, EG, TB, PCP

- Lower lobes: pnemonic “BADAS”
Bronchiectasis, Aspiration, Drugs/DIP, Asbestosis, Scleroderma/CVD
• Source: Primer 2nd ed. p.94
• Idiopathic pulmonary fibrosis: most common presentation?
a. Dyspnea
b. Fever
c. Fatigue
d. Weight loss
• A. Dyspnea
• UIP = IPF = mural type fitrosing alveolitis = cryptogenic fibrosing alveolitis
• IPF is a disease of unknown cause that is defined primarily by clinical, physiologic and radiologic criteria. Fraser 2nd p. 852.
• Disease of “middle age”: 4-6 decade. Male preponderance (2:1).
• Almost all patients present with breathlessness that is first noted with exercise. A dry cough is common and 50% of the patients hae constitutional symptoms such as fatigue and weight loss.
• Pulmonary function tests demonstrate a restrictive pattern. Diffusing capacity is reduced as it the blood oxygen level at rest. The prognosis in IPF is poor, with most patients dying of respiratory failure. The mean survival is approximately 4 years.
• Source: Dähnert 5th ed. p. 495;
• What is seen in Cronkhite-Canada syndrome?
a. Nail changes
b. Oral papilloma
• A. Nail changes
• This syndrome has nonneoplasic nonhereditary polyps (as in juvenile polyposis) associated with ectodermal abnormalities; no familial predisposition. Nail atrophy as well as exudative protein-losing enteropathy, diarrhea, weight loss, abdominal pain, brownish macules of hand + feet and alopecia can been seen.
• Radiologic findings include multiple polyps (stomach, small bowel and colon) and thickened gastric rugae.
• Source: Dähnert 5th ed. p.810-811
• The most common cause of pneumomediastinum is:
a. Pneumothorax
b. Bleb rupture
c. Alveolar rupture
d. Extension from pneumoretroperitoneum
• C. Alveolar rupture
• What is the most common apperance of Legionella at the peak of the disease?
a. Bilateral airspace consolidation
b. Unilateral airspace disease
c. Cavitary lesion
• A. Bilateral airspace consolidation
• Common radiographic features include bilateral severe disease, rapidly progressive, pleural effusions and lower lobe predilection. Associated hyponatremia. Seroconversion for dx takes 2 weeks. Starts as peripheral patchy consolidation. Source: Primer 3rd ed. p.11
• The characteristic roentgenographic pattern [of legionella] is one of airspace consolidation…in most cases, the pneumonia is unilateral and unilobar when first seen; however, there is a tendency to bilateral involvement particularly at the peak of the disease. There is a distinct lower lobe predilection. Fraser 2nd p. 310.
• Which of the following communicates with the tracheal bronchial tree?
a. Extralobar sequestration
b. Congenital Cystic Adenomatoid Malformation (CCAM)
c. Neuroenteric cyst
d. Bronchogenic cyst
e. Intralobar sequestration
• B. Congenital Cystic Adenomatoid Malformation (CCAM)
• What portion of the tracheobronchial tree is affected first in chronic interstitial pneumonitis?
a. Terminal bronchi
b. Interstitium
c. Capillary
d. Alveoli
• D. Alveoli
• Stereotypical inflammatory response of alveolar wall to injury. In acute phase, fluid + inflammatory cells exude into alveolar space, mononuclear cells accumulate in edematous alveolar wall. Source: Dähnert 5th ed. p.412
• Which of the following features can be used to differentiate sarcoid from lymphangitic spread on high resolution CT?
a. Septal thickening
b. Subpleural nodules
c. Bronchovascular nodules
d. Ground glass opacification
e. Architectural distortion
• E. Architechural distortion
• What TNM stage is a 4cm mass in the lung parenchyma with ipsilateral mediastinal lymph nodes but no distant metastasis?
a. T1N0MX
b. T1N1M1
c. T2N1M0
d. T2N2M0
e. T2N2M1
• D. T2N2M0
• Which of the following is seen in RUL collapse?
a. Bronchus intermedius medially displaced
b. Posterior aspect of the middle lobe is hyperexpanded
c. Left upper lobe herniation
d. Elevation of the right hemidiaphragm
• B. Posterior aspect of the middle lobe is hyperexpanded
• What structure is immediately anterior to the left upper lobe pulmonary bronchus?
a. Left pulmonary artery
b. Ascending aorta
c. Left atrial appendage
d. Main pulmonary artery
e. Superior pulmonary vein
• E. Superior pulmonary vein
• Source: Atlas of Human Anatomy, Netter plates 187,194
• Heart borders on AP CXR include all of the following except?
a. Left ventricle outflow tract
b. Right ventricle outflow tract
c. Main PA
d. Right atrium
e. Left atrial appendage
• B. Right ventricle outflow tract
• Radiologist in reviewing a patient’s films finds an abnormality that was missed by his colleague. The radiologist named is your chairman. Which of the following is NOT appropriate?
a. Inform your colleague so he can learn from his mistakes
b. Tell the chairperson so he can learn from the mistake
c. You as a radiologist tell the patient
d. Call the referring physician and tell him about it since this is a major cause of law suits
e. Let the radiologist decide whether to tell or not to tell about the missed finding
• C or E
• Which of the following has a similar appearance of lymphangioleiomyomatosis on HRCT?
a. Rheumatoid lung
b. Scleroderma
c. Sarcoid
d. Histiocytosis X (eosinophilic granuloma)
e. Panacinar emphysema
f. Alpha-1 antitrypsin deficiency
g. Cystic fibrosis
• D. Histiocytosis X (Langerhan’s cell histiocytosis)
• 30 year old woman presents with massive acute hemoptysis: CXR shows cavitary lesion in upper lobe.
a. TB
b. PE with infarct
c. RA
d. AVM
e. Aspergillosis
f. Bronchogenic ca
g. Bronchioaortic fistula
• A. TB
• The most common cause of hemoptysis overall is bronchitis and carcinoma. In a patient this age and with a cavitary lesion TB is the best answer. Massive hemoptysis is caused by Rasmussen aneurysm.
• Source: Fraser 2nd ed. p.144
• What is the most common mycotic pneumonia in a patient with AIDS?
a. Cryptococcus
b. Aspergillosis
c. Blastomycosis
d. Histoplasmosis
e. Coccidiomycosis
f. Candida
• A. Cryptococcus
• While fungal infections in AIDS are uncommon (< 5% of patients) cryptococcus is the most common – of these, 90% have CNS involvement.
• Source: Primer 3rd ed. p.24
• Which of the following is the correct definition of tidal volume?
a. Amount of gas that can be expired after a maximal inspiration without force
b. Amount of gas that can be expired after a maximal expiration without force
c. Amount of gas moving in and out with each respiratory cycle
d. Amount of gas remaining in the lung after a maximal expiration
e. Volume of gas remaining in the lungs at the end of an expiration
• C. Amount of gas moving in and out with each respiratory cycle
• Tidal volume (TV)=amount of gas moving in and out with each respiratory cycle.
• Residual volume (RV)=amount of gas remaining in the lung after a maximal expiration
• Total lung capacity (TLC)=gas contained in lung at the end of a maximal inspiration.
• Vital capacity (VC)=amount of gas that can be expired after a maximal inspiration without force.
• Functional residual capacity (FRC)=volume of gas remaining in lungs at the end of a quiet expiration.
• Source: Primer 3rd ed. p.4
• 45 year old woman with dyspnea and exercise intolerance has low glucose and chest xray reveals a 10cm mass in her left chest. The most likely etiology is:
a. Benign fibrous tumor of the pleura
b. Large cell tumor of the pleura
c. Bungholoma
• A. Benign fibrous tumor of the pleura
• This is more commonly known as benign mesothelioma. It has NO recognized association with asbestos exposure as in malignant mesothelioma. It is prevalent in the 3rd to 8th decade with a mean age of 50-60 years. It is asymptomatic in 50% but can present with cough, fever, dyspnea and chest pain. It is associated with episodic hypoglycemia in 4%.
• Radiologically, it is seen as a sharply circumscribed spherical / ovoid lobular mass of 2-30 cm in diameter located near lung periphery / adjacent ot pleural surface / within fissure.
• Source: Dähnert 5th ed. p.504-505
• In patients with AIDS, what is the most common cause of cavitary lesion in the chest?
a. Coccidiomycosis
b. Histoplasma capsulatum
c. TB
• C. TB
• Opportunistic infections account for the majority of pulmonary disease in AIDS patients. In fact, pulmonary infection is often the first AIDS-defining illness. This includes PCP (60-80%), fungal disease (<5%), mycobacterial infection (10% per year), bacterial pneumonia (5-30%), CMV pneumonia and Toxoplasmosis. Of these, Coccidioycosis (fungal), TB, nocardia (bacterial) and Rhodococcus equii (bacterial) can present with cavitary lesions.
• Per Primer, TB (20%) > fungal (< 5%).
• AIDS patients are 500 times more likely to become infected with TB then the general population. Radiological studies show postprimary TB pattern with upper-lobe cavitating infiltrate. Source: Dähnert 5th ed. p.452; Primer 3rd ed. p.22
• Regarding asbestos-related pleural plaques: (T/F)
a. They are commonly seen in the region of the costophrenic angle
b. They span less than 4 ribs
c. They arise on the visceral pleura
d. They spare the apices
e. All can be seen on CXR
f. Most occur above the 4th rib
g. Most occur below the 6th rib
• Regarding asbestos-related pleural plaques: (T/F)
a. They are commonly seen in the region of the costophrenic angle
b. They span less than 4 ribs
c. They arise on the visceral pleura
d. They spare the apices
e. All can be seen on CXR
f. Most occur above the 4th rib
g. Most occur below the 6th rib

• False. Pleural plaques usually spare the costrophrenic angle and apices of the lung. The disease process is typically bilateral and involves the posterolateral aspect of the mid portions of the patient's thorax.
• True.
• False. The pleural plaques typically involve the parietal pleura.
• True.
• False. Pleural plaques may be seen on chest radiograph, although they are only seen in approximately 15% of cases.
• False. Pleural plaques are seen most commonly on the domes of the diaphragm, on the posterolateral chest wall between the seventh and tenth ribs and on the lateral chest wall between the sixth and ninth ribs.
• True.
• Source: Radiologic Diagnosis of DISEASES of the CHEST (Muller, Frasier, Colman, Pare) 1st ed. p.537,538 http://www.uhrad.com/ctarc/ct203.htm
• What is the appropriate positioning for an aortic balloon pump?
a. Descending aorta at the level of the diaphragm
b. Ascending aorta
c. Descending aorta just distal to the left subclavian artery takeoff
d. Aortic arch between the brachiocephalic artery and the left CCA
• C. Descending aorta just distal to the left subclavian artery takeoff
• Which of the following is NOT associated with pulmonary venous hypertension?
• Pruning of the pulmonary arteries
• Kerley B lines
• Pleural effusions
• Alveolar flooding
• Redistribution
• A. Pruning of the pulmonary arteries
• Three stages of cardiogenic pulmonary edema. 1)vascular redistribution 2)interstitial edema 3)alveolar edema
• Pruning is associated with Pulmonary Arterial Hypertension (PAH).
• Source: Primer 3rd ed. p.65; Dähnert 5th ed. p.573
• Which of the following cancers is LEAST likely to metastasize to the chest?
a. Osteosarcoma
b. Renal cell carcinoma
c. Prostate carcinoma
d. Melanoma
• C. Prostate carcinoma [least likely = lowest probability of metastasis]
• Probability of pulmonary metastases:
Kidney (75%), Osteosarcoma (75%), Choriocarcinoma (75%), Thyroid (65%), Melanoma (60%), Breast (55%), Prostate (40%), Head and Neck (30%), Esophagus (20%).
• Pulmonary metastases occur in 30% of all malignancies; mostly hematogenous.
• Incidence of pulmonary metastases: mnemonic “CHEST”
Choriocarcinoma 60%
Hypernephroma / Wilms tumor 30/20%
Ewing sarcoma 18%
Sarcoma (rhabdomyo-/osteosarcoma) 21/15%
Testicular tumor 12%
• Frequency found in chest (i.e., origin of pulmonary mets): Breast 22%, Kidney 11%, H+N 10%, Colorectal 9%, Uterus 6%, Pancreas 5%, Ovary 5%, Prostate 4%, Stomach 4%
• Source: Dähnert 5th ed. p. 506
• Regarding endotracheal intubation, which of the following is true?
a. The ETT moves caudally with flexion of the head
b. Inflation of the cuff prevents aspiration
c. Granuloma formation secondary to intubation most often involves the posterior wall of the trachea
d. An LPO CXR is the best way to evaluate for esophageal intubation
e. Left main stem bronchus intubation is more common than right main stem bronchus intubation
• A. The ETT moves caudally with flexion of the head
• Flexing of the neck can move the tip 2 cm inferiorly. Extending the neck can move the tip superiorly by 2 cm.
• Posterior granulomas usually affect the larynx, not trachea.
• While the balloon decreases the chance for aspiration, it cannot completely prevent it.
• The right main stem is more often intubated.
• Source: Primer 3rd ed. p.108
• Which of the following would be most helpful to determine the etiology of a mosaic pattern seen on high resolution CT?
a. Lateral decubitus film
b. MRI
c. Routine chest CT
d. High resolution CT in expiration
• D. High resolution CT in expiration
• A focal consolidation in the lung demonstrates Hounsfield units greater than 125 on chest CT. What is the most likely cause?
a. Amiodarone toxicity
b. Pseudolymphoma
c. Bronchogenic CA
d. BOOP
e. Sarcoid
f. CHF
• A. Amiodarone toxicity
• Amiodarone accumulates in the liver and in the lung where the drug and its major metabolites become trapped in the macrophage lysosomes and is thought to interfere with lipid degeneration and surfactant turnover. Results in high-attenuation parenchymal-pleural lesions on CT. May lead to a fibrotic reaction within lung.
• Source: Dähnert 5th ed. p.400;
• An area of the lung is normally perfused and hyperventilated. PO2 and pCO2 will most likely be:
a. pO2=40, pCO2=40
b. pO2=80, pCO2=40
d. pO2=50, pCO2=30
e. pO2=98, pCO2=30
f. pO2=98, pCO2=80
• E. pO2 = 98, pCO2 = 30Am I still in medical school? For general purposes, normal values are pO2 100 mm Hg and pCO2 40 mm Hg.
• Hyperventilation leads to decreased arterial pCO2 (CO2 blown off rapidly) and respiratory alkalosis. There is no respiratory compensation for respiratory alkalosis and the pO2 is unaffected.
• Source: Board Review Series: Physiology (Costanzo) 1st ed. p.166, 259 (question #48)
• Which of the following is least likely to occur in a long-term smoker?
a. Centrilobular emphysema
b. Chronic bronchitis
c. Eosinophilic granuloma
d. Hypersensitivity alveolitis
• D. Hypersensitivity alveolitis
• This is AKA extrinsic allergic alveolitis. It is due to exposure to organic dust <5um in size. It can present as recurrent episodes of fever, chills, dry cough and dyspnea following exposure after 6 hr interval (10-40% asymptomatic). Resolution may occur in days or weeks after exposures ceases. Chronic form may lead to honeycombing.
• Eosinophilic Granuloma – “It is interesting to note that 97% of those affected are either current smokers or have a previous history of smoking cigarettes.”Centrilobular emphysema and chronic bronchitis are associated with smoking.Source: Dähnert 5th ed. p.485,486; http://chorus.rad.mcw.edu/doc/00999.html ; http://www.vh.org/Providers/TeachingFiles/ITTR/HistiocytosisX/HistiocytosisX.html
• What part of the secondary pulmonary lobule is most commonly seen on HRCT?
a. Interlobular septa
b. Central pulmonary artery
c. Central bronchiole
d. Peripheral pulmonary vein
e. Peripheral lymphatics
• B. Central pulmonary artery
• Appearance of the Normal Secondary Lobule on HRCT
… The interlobular septa are seen only as rare fragments if the lung is normal. They are linear, nontapering structures that may be contiguous with the pleural surface. When the septa of numerous complete secondary lobules are visualized, this is an indication that the lung is abnormal. An average of three septa can be seen in a single lung slice when the collimation is 1.5 mm. An average of one septum can be seen in a single lung slice when the collimation is 3 mm.
• Since the interlobular septa are so rarely visualized, it is necessary to identify the peripheral pulmonary arteries in order to define the center of the pulmonary lobule. The smallest pulmonary arteriole that can be resolved by HRCT is approximately 0.2 mm and is a branching structure that does not reach the pleural surface. (There is usually a 5 mm clear space adjacent to the pleura.) The accompanying terminal bronchiole is too small to image as it enters the lobule. The last visible bronchus is located 2.5-3 cm from the pleural surface, unless the bronchial walls are thickened. Pulmonary veins are also branching structures that taper as they approach the pleural surface. It may be difficult to differentiate them from the pulmonary arteries, unless multiple contiguous slices are obtained. As noted previously, the pulmonary veins run separately, whereas the pulmonary arteries are accompanied by airways and lymphatics. The lymphatics are not normally visualized on HRCT sections.
• Source: http://www.vh.org/Providers/Textbooks/DiffuseLung/Text/NormAnat.html
• What travels with the vagus nerve through the diaphragm?
a. Esophagus
b. Thoracic duct
c. Aorta
• A. Esophagus
• A patient with a pulmonary AVM has an increased risk for all of the following except:
a. Pulmonary hypertension
b. Stroke
c. Brain abscess
d. Hemoptysis
• A. Pulmonary hypertension
• Pulmonary AVM is an abnormal vascular communication between a pulmonary artery and vein (95%) or systemic artery and pulmonary vein (5%).
• “The most common clinical manifestation is hemoptysis. Dyspnea is present in 60% of cases. Other findings include cyanosis and finger clubbing. Symptoms of central nervous system disease may be the result of metastatic abscess, hypoxemia, cerebral thromboemboli, cerebral vascular thrombosis from secondary polycythemia and cerbral hemorrhage from a concomitant intracerebral arteriovenous aneurysm.”
• Source: Dähnert 5th ed. p.513,514; Radiologic Diagnosis of DISEASES of the CHEST (Muller, Frasier, Colman, Pare) 1st ed. p.128,129
• Most common radiologic finding for a bronchoalveolar cell carcinoma is?
a. Solitary pulmonary nodule
b. Peripheral focal infiltrate
• A. Solitary pulmonary nodule
• A 3 year-old bone marrow transplant patient develops fever and chills, with a 2 cm round lung opacity on chest film. The etiology is most likely due to which of the following?
a. Invasive aspergillosis
b. Candida infection
c. Mycotic emboli
d. Lymphoproliferative disorder
e. Atypical mycobacteria
f. Histoplasmosis
g. Mycoplasma
h. Group B Strep
• A. Invasive aspergillosis
• Which structure passes under the aortic arch?
a. Left recurrent laryngeal nerve
b. Right recurrent laryngeal nerve
c. Left vagus nv.
d. Right vagus nv.
e. Left phrenic nv.
• A. Left recurrent laryngeal nerve
• Which disease is NOT predominantly located at the lung apices?
a. Silicosis
b. Alpha-1 antitrypsin deficiency
c. Lymphangioleiomyomatosis
d. Adult-onset cystic fibrosis
e. Centrilobular emphysema
f. Eosinophilic granuloma
g. Sarcoidosis
h. Ankylosing spondylitis
i. Asbestosis
j. TB
k Idiopathic pulmonary fibrosis
• B., C., I.,K.
• Apices – CASSETP:
- CF, AS, Silicosis, Sarcoid, EG, TB, PCP/Post xrt pneumonitis
• Bases – BADLASSRIF
Brochiectasis, Aspiration, DIP/Drugs, Lymphangioleiomyomatosis,Asbestosis, Scleroderma and other CVD, Sarcoid, Rheumatoid, IPF(UIP), Furadantin [Dähnert 5th ed p. 414]
• Centrilobular emphysema – areas of high V/Q - apices of upper and lower lobes.
• Alpha-1 antitrypsin def. – panacinar emphysema – uniform/diffuse. [Dähnert p. 485]
• Which disease does NOT cause decreased lung compliance? (AKA, which causes increased lung compliance?)
a. Idiopathic pulmonary fibrosis
b. Alpha-1 antitrypsin deficiency
c. Eosinophilic granulomatosis
d. Rheumatoid lung
e. CHF
f. Lymphangitic carcinomatosis\
g. Asbestosis
B. Alpha 1 antitrypsin
• The plain film finding most specific for left atrial enlargement is which the following?
a. Elevated left main bronchus
b. Double density of the left cardiac silhouette (AKA double contour sign)
c. Rounded contour of the left heart border
d. Bulging heart contour below hilum
e. Vascular redistribution
• B. Double density of the left cardiac silhoutte
• One of the earliest signs of slight left atrial enlargement is the appearance of the double density, which is the right side of the left atrium as it pushes into the adjacent lung. The following indirect signs are visible only if the left atrium is dilated at least moderately:
• - Displacement of the left main bronchus posteriorly on the lateral view and superiorly on the frontal view - "walking man sign"
• - Spreading of the carina
• - Posterior displacement of the barium-filled esophagus
• - Double density on the left side at the left atrium extends into the left lower lobe
• [Cardiac Radiology Requisites, p. 10-11]
• The best method to differentiate cardiomegaly from a large pericardial effusion uses which sign?
a. Abnormal cardiac pulsation
b. Abnormal contour of IVC
c. Flasked shaped heart
d. Dilated azygous vein
e. decreased visualization of PA on CXR
I think C
• The acinus begins where?
a. Alveoli
b. Terminal bronchi
c. Bronchus
d. Distal to the respiratory bronchiole
• B. Terminal bronchiole
• Which of the following is NOT associated with left atrial enlargement?
a. Mitral stenosis
b. Left atrial myxoma
c. Atrial fibrillation
d. Decreased compliance of the left ventricle
e. VSD
f. ASD
g. Aortic stenosis
• F. ASD
• Lymphatics are NOT associated with or adjacent to which of the following structures?
a. Alveoli
b. Interlobular septa
c. Pulmonary veins
d. Bronchi
e. Bronchial artery
f. Bronchial vein
g. Pulmonary artery
• A. Alveoli
• “The lymphatic vessels extend as far as the alveolar ducts but do not enter the alveolar walls.” see Felson Chest Roentgenology p. 241-250 for a discussion.
• The secondary pulmonary lobule contains the pulmonary arteriole, the bronchiole, the bronchial artery and vein, as well as lymphatic drainage. The pulmonary veins lie within the interlobular septa. The pulmonary veins and lymphatics are peripheral structures that lie within the interlobular septa. The alveoli lie too far peripheral for lymphatic drainage. [Thoracic Radiology Requisites, p. 16, 17. Netter, plates 193, 19].
• Note: Segmental bronchus - subsegmental bronchus - bronchiole - terminal bronchiole - respiratory bronchiole - alveolar sac and alveoli (resp to alveoli = acinus)
• Alveoli develop fully by which age?
a. Birth
b. 2 years
c. 4 years
d. 8 years
• D. 8 years
• At about 28 weeks gestation, differentiation into Type 1and Type II alveolar epithelial cells has clearly begun. At this time, a blood gas barrier exists that is capable of permitting gas exchange. A substantial number of alveoli are added after birth. The majority appear during early childhood, probably by two years of age. The age at which alveolar development is completed is also controversial, although it appears likely that some multiplication occurs until at least eight years of age. [Fraser and Pare, p. 139]
• Only 1/6 of the adult number of alveoli are present at birth. The remaining alveoli are formed during the first ten years of postnatal life. Langman's Medical Embryology.
• Notes from AFIP: Alveoli increase in size and # until 2 years; After 2 yo, alveoli only increase in size.
• Which native structure is preserved during an orthotopic heart transplant?
a. Pulmonic valve
b. Posterior wall of left atrium
c. Right atrial appendage
d. Coronary sinus
e. Non coronary sinus of Valsalva
• B. Left atrial wall
• Which agent is NOT used in pleurodesis?
a. Talc
b. Ethanol
c. Bleomycin
d. Tetracycline
e. Doxycycline
f. Minocycline
• . Ethanol
• Chemical Methods:
- Tetracycline (Not available anymore)
- Doxycycline
- Bleomycin. Expensive option.
- Nitrogen mustard, Atabrine,
• Surgical:
- Pleurectomy
- Thoracoscopic Talc pleurodesis (Current favoured method)
• Radiotherapy:
- Radioactive gold: (Used in the past. Requires special dispoition of body because of radioactive material)
- External Radiation (Loose lung function, not used any more)
• Which vessel does this represent? (see arrow)
a. Azygos vein
b. Hemiazygos vein
c. Aberrant right subclavian artery
d. Pulmonic vein
e. Right superior intercostals vein
f. Pulmonary artery
• A. Azygous vein
• A 35 year-old male develops sudden onset flu-like illness with extrinsic bulbous mediastinal lymphadenopathy (AIDS was not a choice). Which is the most likely diagnosis?
a. E. coli
b. Silicosis
c. Burkitt's lymphoma
d. Bacterial pneumonitis
e. Mycoplasma
f. Silicoproteinosis
g. Kleisbella
h. Inhalational anthrax
• H. Inhalation anthrax
• Which of the following is the most likely etiology for swelling of the head and upper extremities and signs of SVC obstruction in a 50 year-old male?
a. Bronchogenic carcinoma
b. Non-Hodgkin's lymphoma
c. Thymoma
d. Seminoma
e. Fibrosing mediastinitis
f. Sarcoid
• A. Bronchogenic carcinoma
• Phenytoin and cyclosporine can both result in which of the following?
a. Noncardiogenic edema
b. Cardiogenic edema
c. Hypersensitivity reaction
d. Pleural effusion
e. Mediastinal lymphadenopathy
• E. Mediastinal lymphadenopathy
• The use of phenytoin may result in an acute hypersensitivity reaction with blood eosinophilia and a diffuse reticular-nodular pattern on chest radiograph, both of which resolve within two weeks after drug withdrawal. Mediastinal lymph node enlargement simulating lymphoma has also been reported; the lymphadenopathy is usually a reflection of the hypersensitivity reaction. [Fraser and Pare, p. 2564]
• Cyclosporine causes drug-induced lymphoproliferative disorder involving the lungs, GI, and LN’s. .
• A high-resolution chest CT demonstrates 3 mm irregular Y and V-shaped thickening approximately 2 to 3 mm from the pleural surface. This imaging appearance is most consistent with which of the following:
a. Lymphangitic carcinomatosis
b. Bronchiolitis
c. Bronchogenic ca.
d. PIE
e. Alveolitis
f. Microinfarcts
g. Pulmonary edema
h. Consolidation
• B. Bronchiolitis
• The question is describing the “tree in bud” appearance. See Dähnert 5th ed p. 409-410.
• The most common mediastinal mass in a child between the ages of 6 and 12 years old is which disease?
a. Teratoma
b. Neuroblastoma
c. Ganglioneuroma
d. Lymphoma
e. Bronchogenic cyst
• D. Lymphoma
• In an older male patient with a left upper lobe opacity that parallels the hilar vessels, the next appropriate step in management of the patient would be which of the following?
a. Bronchoscopy
b. Thoracentesis
c. Percutaneous biopsy
d. Thoracotomy
e. Mediastinoscopy
f. Video assisted thoracoscopy
g. Tube thoracostomy
• A. Bronchoscopy
• Parallel vessels in the LUL can be a sign of atelectasis, i.e. “vascular crowding”- therefore bronchoscopy would be the procedure of choice to evaluate for intraluminal mass, mucus, etc. Any lesion/mass that parallels the hilar vessels is too central for percutaneous biopsy.
• “A major indication for bronchoscopy is suspected pulmonary carcinoma… Other situations include hemoptysis, selected interstitial lung disease cases, infection (esp. TB), and rejection of a lung transplang.” Fraser 2nd p. 149.
• This is likely just common sense stuff. There was a 1999 question regarding percutaneous lung biopsy which emphasized the following facts: biopsy may still be indicated even if bronchoscopy is negative; there is an increased risk of pneumothorax if the patient has emphysema; biopsy should not be performed if the platelet count is < 50; and bronchoscopy is (obviously) the best method for evaluation of an endobronchial lesion.
• The most resistance to pulmonary blood flow is located at which site?
a. Main pulmonary artery
b. Segmental arteries
c. Capillary bed
d. Mitral valve
e. Left or right pulmonary arteries
f. Muscular arteries and arterioles
g. Subsegmental arteries
• F. Muscular arteries and arterioles
• The most common cause of left heart failure in the setting of COPD is which of the following?
a. Eisenmenger’s syndrome
b. Chronic obstructive pulmonary arterial disease (PAH)
c. Atherosclerotic coronary artery disease (CAD)
• C. Atherosclerotic coronary artery disease (CAD).
How to distinguish between ground glass and dependent atelectasis on CT:
prone imaging
• deeper inspiration
• expiration
• Reformat images on the workstation
• A. Turn patient prone and rescan
• This is the best way to negate dependent atelectasis
• Which of the following entities does NOT cause pulmonary hypertension?
a. Asthma
b. COPD
c. Pulmonary AVM
d. Mitral stenosis
e. Chronic hypoxia
f. Eisenmenger's syndrome
g. Cystic fibrosis
h. Phen-fen
i. emphysema
j. Pulmonary embolism
• C. Pulmonary AVM
• A previously healthy child presents with new symptoms of SVC obstruction and diffuse mediastinal calcifications. Which of the following is the most likely etiology?
a. TB
b. Teratoma
c. Burkitt’s lymphoma
d. Histoplasmosis
e. Thymoma
• D. Histoplasmosis
• The most common benign causes (only 10% to 20% collectively) of SVC syndrome are granulomatous mediastinitis and post-iatrogenic manipulation (long-dwelling lines, etc.). Between TB and Histoplasmosis, Histoplasmosis more classically results in mediastinal fibrosis and also results in more fulminant lymphadenopathy than TB. Histo is also not an opportunistic infection, and would therefore reasonably be seen more frequently. (Dähnert, Radiology Review Manual,5th p. 648.)
• Lymphoma is probably more common overall, but the only lymphoma with calcifications would be treated – not good for a previously healthy child. The calcifications in TB, teratoma, and thymoma would be more focal than diffuse. Histo could cause SVC obstruction from fibrosing mediastinitis.
• SVC syndrome in adults: caused by malignant lesion in 80-90% - bronchogenic CA in > 50% and lymphoma; benign: granulomatous mediastinitis (usu histo, sarcoid, TB), substernal goiter, ascending aortic aneurysm, pacer wires, constrictive pericarditis
• The cause of fibrosing mediastinitis is an abnormal immune response to Histoplasmosis. Dähnert 475
• A 65 year-old male is two years status post single-vessel CABG. Pre operative catheterization at that time revealed a non right dominant system with severe RCA disease. He now presents with chest pain and EKG changes consistent with posterior wall reversible defect. What is the most likely etiology?
a. Graft occlusion
b. Native RCA occlusion proximal to the graft
c. Native RCA occlusion distal to the graft
d. New left coronary disease/LAD ischemia
e. Circumflex ischemia
• E. Circumflex ischemia
• Pure posterior wall infarcts are extremely rare. They are usually posteroinferior or posterolateral. In this patient whom we know has a small RCA (because of a non right dominant system) the presenting chest pain with posterior wall reversible defect is likely more posterolateral in distribution. This therefore likely represents new left circumflex disease.
• Coronary artery distributions:
LCx – posterolateral
RCA – posteroinferiorseptal
LAD – anterior
PDA - inferiorapical
• What is the most common cause of unilateral lymphangitic carcinomatosis of the lung?
a. Bronchogenic carcinoma
b. Breast cancer
c. Colon cancer
d. Pancreatic cancer
e. Testicular cancer
• A. Bronchogenic carcinoma
• Bronchogenic carcinoma goes from local dissemination via lymphatics to the unilateral lung. The other options are metastatic foci from extrathoracic sites. The tumor origin in lymphangitic carcinomatosis in order is bronchogenic cancer and breast cancer (56%), stomach (46%), then thyroid, pancreas, larynx, and cervix. The location is usually bilateral, or unilateral iv the lung is the primary
• Source--pnemonic: Certain Cancers Spread By Plugging The Lymphatics
- cervix, colon, stomach, breast, pancreas, thyroid, larynx [Dähnert, p. 418]
• The azygos vein enters the SVC at which location?
a. Anterior aspect inferior to the right main bronchus
b. Posterior aspect inferior to the right main bronchus
c. Anterior aspect superior to the right main bronchus
d. Posterior aspect superior to the right main bronchus
• D. Posterior aspect superior to the right main bronchus
• Which of the following is NOT typically noted in the appearance of rheumatoid lung?
a. Hilar adenopathy
b. Pleural effusion
c. Lower lobe interstitial disease
d. Cavitary nodules
e. Honeycombing
• A. Hilar adenopathy
• Which of the following cells regenerate following alveolar damage?
a. Type I pneumocyte
b. Type II pneumocyte
c. Type III pneumocyte
d Macrophage
• B. Type II pneumocytes
• Which of the following maneuvers best distends the azygos vein?
a. Upright position with Valsalva maneuver
b. Supine position with Valsalva maneuver
c. Supine position with Mueller maneuver
d. Upright position with Mueller maneuver
• C. Supine position with Mueller maneuver
• Mueller maneuver = rapid forced inspiration against a closed glottis with decrease in intrathoracic pressure and increased venous return
• Valsalva maneuver = increase in intrathoracic pressure and decrease in cardiac output mostly secondary to decrease in venous return to the heart
• The normal or abnormal azygos vein always shrinks dramatically when the patient assumes the upright position, takes a deep inspiration, or performs the Valsalva maneuver. [Felson’s Chest Roentgenology, p. 236]
• Patients with tracheal laryngeal papillomatosis are at increased risk for which of the following?
a. Squamous cell carcinoma
b. Adenocarcinoma
c. Carcinoid
d. Large cell undifferentiated carcinoma
e. Mucoepidermoid carcinoma
• A. Squamous cell carcinoma
• Tracheal laryngeal papillomatosis is caused by the human papilloma virus types 6 and 11. It rarely undergoes malignant transformation. Juvenile tracheal laryngeal papillomatosis starts in the trachea and spreads throughout the tracheobronchial tree. Repeated laser treatments and antiviral therapy make up the treatment. Rarely squamous cell carcinoma arises from a bed of recurrent respiratory papillomatosis. [Lung Pathology text. Dähnert, p. 326]
• Which of the following is NOT part of the post-cardiac injury syndrome?
a. Fever
b. Pleural fluid
c. Pericardial effusion
d. PE
e. Transient focal pulmonary opacity
• D. PE (not part of syndrome)
• Dressler Syndrome (< 4%)
- autoimmune reaction, 2-3 weeks post-MI
- fever
- pericarditis ± pericardial effusion
- pleuritis ± pleural effusion
- pneumonitis p. 638 Dähnert .
• PE is a well known complication of post MI state but not included in the syndromes which are thought to be autoimmune phenomena
• The patient is status post RUL lobectomy now has RML gangrene, what is the cause?
a. aspiration
b. RML torsion
c. thrombosis of right superior pulmonary vein
d. ligation of interlobar artery
e. Surgical interruption of PA
f. Surgical interruption of pulmonary vein
g. Ligation of bronchus intermedius
• B. RML Torsion
• If you ligate the INTERLOBAR artery one would necrose not only the RML but the RLL as well.
• Masses, pl eff, PTX, PNA, surg resection of inf pulm ligament predispose to torsion.
RML is most common, rotates on bronchovasc pedicle, causes obstruction of venous flow, ischemia, necrosis. This happens less commonly cuz they tack down the RML during surgery. Inf pulm lig are reflections of the parietal pleura that extend from just below the inf margins of the pulm hila inferiorly and to the diaphragm posteriorly.
Ref: Weissleder, p. 58
• Malignant mesothelioma most closely resembles grossly and histologically what?
a. Adenocarcinoma
b. Melanoma
c. TB
d. Uremia
e. Invasive thymoma
• A. Adenocarcinoma
• Both, invasive thymoma and adenocarcinoma can invade the pleura and grow as pleural masses circumferentially around the lung. Histological appearances of adenoCA and mesothelioma are equally confusing requiring use of special immunohistochemical stains and electron microscopy. (Fishman’s Pulmonary Diseases and Disorders)
• In a 34 yo asymptomatic construction worker a routine CXR reveals unilateral pleural effusion which resolves on its own in 6 weeks. Six months later the patient presents with a focal upper lobe opacity. What is the most likely cause?
a. lung cancer
b. PE
c. TB
d. Lymphoma
e. Viral infection
f. Asbestosis
g. Sarcoid
h. PCP
• C. TB
• TB pleural effusions in 23-38% adults and 10% children; usually with mediastinal LAD and one or more homogenous area of ill defined airspace consolidation of 1-7cm; atelectasis is seen in 8-18% especially in right anterior segment of the upper lung. Primer pgs. 12-15; Dähnert pgs. 444-445. Fraser 2nd p. 320.
• Which does not affect the cardiothoracic ratio?
a. Inspiration
b. Expiration
c. Lordotic view
d. Posterior view
e. Increasing the kVp
• E. Increasing the KVP
• see Bushberg.
• Regarding AIDS and TB, which one of the following is false?
a. Ring-enhancing low density lymph nodes on CT
• b. Miliary pattern is common
c. Resistant strains in institutionalized patients are common
d. There is a lack of inflammatory cells in pathologic specimens
e. Patients respond to antituberculous medications with the same level of efficacy as nonimmunocompromised patients
f. more common than MAI
• B. Miliary pattern is common

• As immunosuppression worsens, the incidence of diffuse pulmonary disease without cavitation, miliary TB and extra-pulmonary TB increase to up to 70% of AIDS patients.
• Patients with HIV infection have a similar response to anti-TB medications to that of HIV-negative patients.
• Regarding branchial cleft cysts:
a. usually type 1
b. at angle of mandible
c. present at 5-10 yrs
d. usually present as painful mass
e. multiloculated
• B. At angle of mandible
• Type I: near EAC or parotid, middle-aged women, presents as enlarging mass near lower pole of parotid gland
• Type II (most common, 95%): from 2nd branchial cleft, anterior triangle, angle of mandible; young to middle-aged adult, presents as mult parotid abscesses unresponsive to drainage or abx or otorrhea; cystic oval or round mass; may insinuate bet ICA and ECA (PATHOGNOMONIC) Dähnert 5th ed p. 369
• Which of the following is least likely to occur in the right upper lobe?
• Tracheal bronchus
• CCAM
• Aspiration in supine position
• Pulmonary sequestration
• Congenital lobar emphysema
• D. Pulmonary sequestration
• D. True: Bronchopulmonary sequestration is a congenital anomaly in which a portion of pulmonary tissue supplied by an arterial branch of the systemic circulation is sequestered from normal bronchial communication, either within a lobe (intralobar sequestration, or ILS) in 75% or outside of the normal lung (extralobar sequestration, or ELS). Bronchopulmonary sequestration is termed intralobar or extralobar depending on the relationship of the sequestered tissue to the lung. The sequestration usually is drained by the pulmonary venous system, but the drainage may be by the systemic circulation via the intercostal, azygos, or hemiazygos veins, or via the inferior or superior vena cava. In 98%, the ILS occurs in a lower lobe, generally on the left. ELS results when the sequestered tissue is contained in its own pleural covering. It may be located between the lower lobe and the diaphragm, within the diaphragm, in the mediastinum, in the pericardium, in a fissure, attached to the chest wall, or beneath the diaphragm. The arterial supply is similar to that of ILS. It is usually drained by the vena cava or the azygos or hemiazygos venous system, and occasionally by the portal system (in contrast to ILS, which usually drains into the pulmonary venous system). The sequestration is on the left side in 65% to 90% of cases, and it occurs four times more frequently in males. See Dänhert p 394-395, MGH p 747 for extensive discussion
• A. False: Tracheal bronchus/aberrant tracheal bronchus - the right upper lobe bronchus or a segment of the right upper lobe bronchus may originate of the trachea. This is of no clinical significance. Althought endotracheal intubation may obstruct this bronchus, leading to right upper lobe atelectasis.
• B. False: CCAM = intralobar mass of disorganized pulm tissue with NORMAL vascular supply and communication with bronchial tree (so A/F level does NOT always mean infxn). Occurs in all lobes with equal frequency. 25% assoc with CHD, renal anomalies, prune-belly, jejunal atresia, and chromosomal anomalies. Resp distress in 1st week (66%) to 1st year (90%) 90% Macrocystic - Stocker Type 1 cysts > 20 mm. Excellent prog. after resection - Stocker Type 2 cysts 5 – 12 mm. prog depends on assoc anomalies 10% Microcystic - Stocker Type 3 cysts < 5 mm. poor prog. due to pulm hypolplasia and hydrops
• C. False: Location: gravity-dependent portions of lung, posterior segments of upper lobes + lower lobes in bedridden patients, frequently bilateral, right middle + lower lobe with sparing of the left lung is common Dänhert 5th p459
• E. False: Congenital lobar emphysema may result in severe respiratory distress in early infancy and may be caused by localized obstruction. Familial occurrence has been reported. Symptoms usually become apparent in the neonatal period but may be delayed for as long as 5-6 mo in 5% of patients. Some patients remain undiagnosed until school age or beyond. A part, but more often all, of a lobe may be involved; the left upper lobe is most often affected. In many cases, obstruction is not demonstrable, but it is assumed to be produced by a check valve type of mechanism. Such obstructions have been attributed to defective or overly compliant cartilage in the bronchi, mucosal folds that create a valvelike obstruction, bronchial stenosis, and external compression by aberrant
• Regarding massive hemoptysis all of the following are true except:
• Can be due to a pulmonary artery lesion.
• Bleeding may occur from internal mammary and intrathoracic arteries
• Cystic fibrosis is a common cause
• Can be seen as sequalae of Pulmonary Embolus
• Bronchial arteries may be embolized
• spinal cord infract is a complication of bronchial arterial embolization
• Pulmonary AVM may be a cause
• B. Bleeding may occur form internal mammary and intrathoracic arteries
• B. False: not listed as source of hemoptysis Dänhert 5th p399
• A. True: Source of hemoptysis is bronchial artery-most common followed by pulmonary artery. (Dänhert 4th 337)
• C. True: CF causes bronchiectasis. The main problem is mucus plugging, recurrent infections. Complications include pneumothorax, hemoptysis, cor pulmonale and hypertrophic pulmonary osteoarthropathy-rare. (Dänhert 401-2)
• D. True: PE may present with hemoptysis, thrombophlebitis and friction rub in less than 33%. Only 10-33% are symptomatic. (Dänhert 431)
• E. True: Bronchial artery embolization is a treatment of hemoptysis. Primer 638
• F. True: Complications of bronchial artery embolication include spinal artery injury and paralysis. (Primer 638)
• G. True: abnormal vascular communication between pulmonary artery and vein and 10-15% can have hemoptysis Dänhert 5th p514
• Which is least likely to occur in the upper lobes?
• Silicosis
• Alpha-1-antitrypsin deficiency
• Centrilobular emphysema
• Cystic fibrosis
• Histiocytosis, adult-onset
• B. Alpha-1-antitrypsin deficiency-T
• b. Alpha-1-antitrypsin deficiency-T: With alpha-1-antitrypsin deficiency there is severe pan-acinar emphysema with a basilar predominance. Dänhert , 3ed, CDROM. This is a rare autosomal recessive disorder. Alpha 1 antitrypsin is a glycoprotein which is a proteolytic inhibitor of many proteins and proteases and neutralizes proteolytic enzymes. Without it, PMN’s and alveolar macrophages sequester into lung during infections and release elastase which digests basement membrane. Severe panacinar emphysema with basilar predominance, decreased size and number of lower lobe pulmonary vessels, redistribution of blood flow to upper lobes, bullae in lung bases, marked flattening of diaphragm. (Dänhert p. 339)
• a. Silicosis-F: Classical chronic simple silicosis causes small rounded opacities beginning in the upper and middle lung zones. Taveras and Ferrucci CDROM. Silicosis occurs after 10-20 yrs of dust exposure (silicon dioxide). Small <10 mm rounded opacities in upper and middle lung zones, 5-10% may calcify centrally, hilar LAD which may calcify in 5% (“eggshell”), +/- reticulonodular pattern. On HRCT, nodules , thickened intra- and interlobular lines, subpleural curvilinear lines (peribronchial fibrosis), ground-glass, traction bronchiectasis, honeycombing. (Dänhert p. 389)
• c. Centrilobular emphysema-F: Centrilobular emphysema has tendency for upper lobes.
• d. Cystic fibrosis-F: normally has apical distribution + posterior segments of upper lobes Dänhert 5th p481 CF is an autosomal recessive disorder. Mucus plugging of exocrine glands secondary to dysfunction of exocrine glands forming a thick tenacious material and decreased mucociliary transport. Increased susceptibility to infections with Staph aureus and Pseudomonas. Predilection for apical and posterior segments of upper lobes, “fingerlike” mucoid impaction, atelectasis, progressive cylindrical or cystic bronchiectasis, peribronchial cuffing, focal or generalized hyperinflation, pulmonary HTN, recurrent local pneumonias (Dänhert p. 358)
• e. Histiocytosis, adult-onset-F: Histiocytosis X is usually diffuse bilaterally symmetric, more prominent in the upper lobes, and spares the costophrenic angles. Dänhert 5th p109
• Interstitial lung disease distribution: (Dänhert 5th p413)
upper lobe predominance CASSET: cystic fibrosis, ankylosing spondilitis, silicosis, sarcoidosis, eosinophilic granuloma, TB (and centrilobular emphysema)
• lower lobe predominance: BAD LASS RIF: bronciectasis, aspiration, dermatomyositis, lymphangitic spread, asbestosis, sarcoid (again?), scleroderma, rheumatoid arthritis, IPF, furadantin
• Most commonly separates hyaline membrane disease from meconium aspiration on CXR:
• Pleural effusions
• atelectasis
• PTX
• hypoaearation
• Ground glass appearance
• D. hypoaeration
• Meconium aspiration syndrome is most common cause of neonatal respiratory distress in full term / postmature infants (RDS most common cause in premature infants); produces hyperinflation with areas of emphysema. Diffuse, bilateral opacities are seen. Rapid clearing is noted within 48 hours. Small pleural effusions are sometimes present (20%).
• Hyaline membrane disease, also known as respiratory distress syndrome of the newborn, is an acute disease with hypoinflation (stiff lungs), immature surfactant production, atelectasis, reticulogranular pattern, and prominent air bronchograms. Source: Dähnert 5th ed. p.504,520; Primer 2nd ed p.753
• In asymptomatic children with AIDS, a nodular infiltrate most likely represents
• Miliary TB
• PCP
• Lymphoma
• Lymphoproliferative interstitial pneumonitis
• D. Lymphocytic interstitial pneumonitis
• D Lymphocytic interstitial pneumonitis-T: In children with AIDS, the course of LIP is often indolent. (Brandt and Helms, Fundamentals of Diagnostic Radiology, 2nd ed, p.398, 427). Lymphocytic interstitial pneumonitis (LIP) is a lymphocytic infiltration of the interstitium consisting primarily of mature lymphocytes and other lymphoid cells, and thus it is generally regarded as benign. It is an AIDS defining illness is patients under 13 years old. (Taveras and Ferrucci CDROM). It is characterized by small nodular densities with hilar adenopathy. Patchy infiltrates are frequently superimposed.
• A Miliary TB-F: see generalized granulomatous intersititial small foci of pinpoint to 2.3 mm size. Occurs with severe immunodepresssion during postprimary state of infection so would first be symptomatic Dänhert 5th p534
• B PCP-F: PCP can be asymptomatic for several weeks, but the earliest radiographic presentation of this is a diffuse reticulonodular pattern. (Taveras and Ferrucci CDROM).
• C Lymphoma-F: Much less commonly, low grade lymphomas may have an indolent course. Pulmonary involvement is unusual at presentation, occurring in 4% of patients, and may occur without associated hilar adenopathy. Solitary or multiple pulmonary nodules occurring centrally or subpleurally follow the course of pulmonary lymphatic vessels and alveolar type involvement with localized or diffuse consolidation representing infiltration of the intraalveolar septa with extension into air spaces. (Taveras and Ferrucci CDROM). Burton and Brody, Essentials of Pediatric Radiology, 1st ed, p.296.
• Bronchoalveolar cell carcinoma is most likely to present as …
• Patchy airspace disease
• Solitary nodule
• Multifocal nodules
• Lobar pneumonia
• Lymphagitic carcinomatosis
• B. Solitary nodule
• Bronchoalveolar cell may present with severe bronchorrhea. Radiographic features: Solitary nodule (most common), hazy, ill-defined, “ground-glass” on CT, air bronchogram, consolidation, multiple nodules. Dänhert , 3ed, CDROM
• The bronchioloalveolar carcinoma (BAC), is a subtype of adenocarcinoma making up approximately 2% to 6% of lung cancers. Thirty percent to 50% of BAC cases occur in women. BAC begins as a single focus of tumor arising in the air spaces distal to any recognizable bronchus andhas a unique propensity for subsequent growth along the alveolar walls and septa (lepidic spread). In a review of 136 cases, Hill found a nodule smaller than 4 cm in 23%, a mass larger than 4 cm in 20%, diffuse nodules in 27%, consolidation in one lobe or less in 7%, and diffuse consolidation in 23%. I checked other sources and Dänhert which state that the most common presentation is a solitary lung nodule. However, with the pattern of lepidic/lipidic spread along the alveolar walls, this gives the appearance of ground glass attentuation, especially along the periphery of the nodules.
• Paul and Juhl's Essentials of Radiologic Imaging, 7th ed pp.1012-1013. Dänhert p. 390.
• Nonbacterial pneumonia in an adult is most likely caused by
• RSV
• Histoplasmosis
• Adenovirus
• Mycobacteria
• Coccidiomycosis
• C. Adenovirus (though mycoplasmal pneumonia is more common)
• In older children and adults, nonbacterial pneumonia is commonly caused by M. pneumoniae and less commonly by various viral agents, particularly adenoviruses and parainfluenza virus. Pneumonia in children most often is caused by respiratory syncytial virus and parainfluenza virus. Taveras and Ferrucci CDROM.
• The most likely etiology of a fungal pneumonia in AIDS is
• Aspergillus
• Candida
• Cryptococcus
• Coccidiomycosis
• Histoplasmosis
• C. Cryptococcus
• Cryptococcus is common. Aspergillosis is also seen. Taveras and Ferrucci CDROM.
• “Cryptococcus is the most common opportunistic mycotic infection in immunocompromised patients.” H. Page McAdams, AFIP lecture, 7-20-01.
• NOTE: PCP has recently been reclassified as a fungus and it is the most common so if it is a choice, pick it!
• The tip of an intra-aortic balloon pump should be:
• in descending aorta
• ascending aorta near valve
• just beyond aortic knob
• abdominal aorta
• C. just beyond the aortic knob
• Lines and tubes per Paul and Juhl (page 1102-1107):Intra aortic counterpulsation balloon pump (IABP) are used to increase coronary artery perfusion and to decrease the cardiac afterload. The result is a reduction in left ventricular work and oxygen requirement in patients with cardiogenic shock, severe ventricular dysfunction, and those who are undergoing high risk cardiac surgical procedures. The balloon is 26 to 28 cm in length and inflates during diastole and deflates during systole. During inflation, a long tubular lucency can be seen extending in a properly placed pump from the level just below the aortic knob to below the diaphragm at the level of the renal arteries. Only the tip is radiopaque. This placement allows maximal augmentation of diastolic pressure in the proximal aorta and decreases the risk of embolization to the cerebral arteries. Complications: If in the aortic arch or the left subclavian artery, risk of cerebral embolism increases. If tip placement is inferior to the aortic knob in the descending aorta, suboptimal counterpulsation occurs. If the balloon is too low, renal ischemia can occur. (Primer page 102)
• The embryologic origin of the trachea is …
• Foregut
• Thoracic somites
• 6th branchial arch
• 4-6th aortic arches
• 6th branchial pouch
• A. Foregut From Pediatric Radiology: The Requisites 1st Edition page 4-----During the fourth week of gestation the trachea arise as a ventral diverticulum from the foregut. At fifth week of gestation, the lobar bronchi appear. At 6th week, all subsegmental bronchi are present.
• What is the minimal stage for a primary lung tumour invading into the parietal pleua
• I
• II
• IIIa
• IIIb
• C. IIIA
• Staging of lung carcinoma:
• T1 = mass less than 3 cm in diameter, limited to the lung
• T2 = lesion greater than 3 cm, > 2 cm distal to the carina, invasion of the visceral pleura
• T3 = Tumor of any size with direct extension to chest wall, superior sulcus, diaphragm, parietal pleura, pericardium, within 2 cm of carina
• .T4 = invasion of mediatinal organs, carinal, vertebral body, or malignant pleural effusion(unresectable)
• N0 = absence of lymph node involvement
• N1 = metastases to the ipsilateral hilum
• N2 = ipsilateral mediastinal and paratracheal nodal involvement
• N3 = involvement of ipsilateral scalene or supraclavicular nodes, or contralateral nodal disease (unresectable)
• M0 = no metastases
• M1 = distant metastases (unresectable)
• Stages 0, I, II, and IIIA are resectable.
• Stage I = T1 or T2, N0, M0.
• Stage II = T1 or T2, N1, M0.
• Stage III A = T3, N2, M0.
• Stage IIIB (T4, any N, M0 or any T, N3, M0) or stage IV (any T, any N, M1) disease are usually unresectable.References: Armstrong's Imaging of Diseases of the Chest, second edition, page 285. Dänhert fourth edition page 392.
• An inverted hemidiaphragm with a large effusion is most appropriately evaluated by
• US
• MRI
• CT
• Fluoroscopy
• Right lateral decubitus x-ray
• Left lateral decubitus x-ray
• Repeat upright x-ray
• A. US – from old test Depends on the side of the effusion and diaphragmatic inversion. Diaphragmatic inversion is seen with moderate to large pleural effusions. It is more often seen on the left than right, likely secondary to liver support on the left. On the left it is most easily the diagnosed by plain film (PA/LAT CXR?), where the colonic and gastric gas pattern are displaced inferiorly. On the right it is most easily diagnosed by ultrasound. On CT diaphragmatic inversion resembles a cystic lesion of the liver. Differential diagnosis of diaphragmatic inversion:
• 1. Pleural effusion
• 2. pneumothorax
• 3. lobar emphysema
• 4. diaphragmatic neoplasm
• 5. myocardial aneurysm
• 6. pericardial cystUsually, it is asymptomatic. However, it can simulate an abdominal mass and can result in paradoxical diaphragm movement.Source: Armstrong, Imaging Diseases of the Chest, p. 661.
• Aspiration pneumonitis is mostly secondary to …
• pH < 2.5
• enzymes
• proteins
• bacteria
• lipid content
• A. pH < 2.5 The main factors determining the extent of illness caused by gastric acid aspiration are as follows: 1.The pH of the aspirate. The acidity of the material is the single most important contributor to lung injury. A pH of 2.5 or less has been proposed as a critical value for inducing severe pneumonitis from acid aspiration. 2.The presence of food particles. Aspiration of gastric food substances causes a severe pneumonitis and peribronchial inflammatory reaction in the absence of acid. 3.Volume of the aspirate. Aspirating as little as 30 mL of gastric acid is sufficient to cause pneumonitis in the adult. 4.Distribution of the aspirate. Many patients who aspirate immediately begin to cough, which may partially protect the lung from injury or may enhance dispersion of the acid over a greater area and create a diffuse injury. Acid in the trachea is rapidly distributed in the lungs and can reach the pleura in 12 to 18 seconds. It is rapidly neutralized by bronchial secretions; in less than 30 minutes, the pH at the bronchial surface returns to normal. Acid causes chemical burns of the bronchi, bronchioles, and alveolar walls, with subsequent exudation of fluid into the lungs. Plasma volume may decrease by as much as 35% in severe injury without fluid replacement, and cardiac output and systemic arterial blood pressure may fall. Pulmonary capillary wedge pressure is normal or low, indicating a nonhydrostatic cause of the pulmonary edema. The characteristics of phospholipids in the alveolar surface lining layer (surfactant) are altered, increasing surface forces and promoting early alveolar collapse. Lung compliance decreases secondary to the increase in interstitial fluids and altered surface forces. These disturbances of airways, alveoli, and vascular elements profoundly unbalance the normal ventilation-perfusion relationships. Increased intrapulmonary shunting is also common. As a result, hypoxemia is invariably present and is usually severe. Goldman: Cecil Textbook of Medicine, 21st ed p. 428-429
• Which is not true of pulmonary embolism?
• Rarely caused by emboli in upper extremities
• Central thrombus rarely causes infracts
• Frequently presents with a triad of cough, pleuritis, and hemoptysis
• C. Frequently presents as triad of cough, pleuritis, and hemoptysis
• The most common symptom of acute pulmonary embolism is dyspnea, which is often sudden in onset. Pleuritic chest pain and hemoptysis occur more commonly with pulmonary infarction due to smaller, peripheral emboli. According to Dahnert, less 1/3 of patients have the triad. More than 95% of pulmonary emboli arise from the proximal deep veins in the lower extremities. The dual pulmonary circulation, which includes both the pulmonary and bronchial arteries, prevents most emboli from causing pulmonary infarction. However, pulmonary infarction, characterized histologically by intra-alveolar hemorrhage and necrosis of alveolar walls, may be evident in areas of the peripheral lung supplied by smaller vessels and is more common in patients with pre-existing heart failure. Smaller emboli can travel out into the more peripheral vessels, where they may or may not cause infarction. In patients with adequate cardiovascular function, the bronchial artery supply can often sustain the lung parenchyma despite obstruction to the pulmonary arterial system. Under these circumstances, hemorrhages may occur, but there is no infarction of the underlying lung parenchyma. Only about 10% of emboli actually cause infarction. Cecil Textbook of Medicine, 21st ed p. 441-449; Dänhert p.431; Cotran: Robbins Pathologic Basis of Disease, 6th ed., p. 703-704; multiple other sources.
• Regarding PE , which of the following is false:
• peripheral emboli are more likely to cause infarct than proximal ones
• Saddle emboli ….
• The patient commonly presents with hemoptysis, cough and SOB
• Most commonly in the lower lobes
• C. Frequently presents as triad of cough, pleuritis, and hemoptysisThe most common symptom of acute pulmonary embolism is dyspnea, which is often sudden in onset. Pleuritic chest pain and hemoptysis occur more commonly with pulmonary infarction due to smaller, peripheral emboli. According to Dänhert , less 1/3 of patients have the triad. Distribution 25%-RLL and 26%-LLL, over 50% in the lower lobes.Infarction is discussed above.Cecil Textbook of Medicine, 21st ed p. 441-449; Dänhert p.431; Cotran: Robbins Pathologic Basis of Disease, 6th ed., p. 703-704
• Unilateral rib notching is seen in the following EXCEPT?
• AVF
• Brachial artery thrombosis
• Blaylock-taussig shung
• Coarctation between the common carotid arteries
• Coarctation with aberrant right subclavian artery
• B. Brachial artery thrombosis
• Blaylock-taussig shunt-anastamosis of subclavian artery to pulmonary artery for Tetralogy of Fallot, Aortic coartation - proximal to left subclavian artery ==> RIGHT, anomalous right subclavian artery ==> LEFT, and chest wall/intercostal AVM are mentioned as causes for unilateral rib notching. However, Brachial artery thrombosis is not mentioned as a cause in any of the sources that I checked. In addition, rib notching is usually a sign of long standing/chronic shunting. Brachial artery thrombus, esp. acute, would be seen clinically and should be corrected prior to these changes. In addition, subclavian stenosis is mentioned as a cause for notching. However, in the cause of a Brachial artery occusion/thrombus, collaterals would likely form from the subclavian artery proximally instead of the chest wall.Dänhert p.14; Primer of Dianostic Imaging p. 143; and the internet http://chorus.rad.mcw.edu/doc/00408.html
• Pulmonary contusion is most associated with
• usually has massive hemoptysis
• associated with osseous structures
• resolves in weeks to months
• universally present with blunt trauma
• B. associated with osseous structuresPer primer: occurs mainly in lung adjacent to solid structures appears 6 – 24 hours after injury, hemoptysis 50% mortality rate 15%-40%, resolve by 7 to 10 days.The definition of pulmonary contusion is lung parenchymal damage with edema and hemorrhage but without an accompanying pulmonary laceration.It is reported to be present in 30% to 75% of patients with significant blunt chest trauma, most often from automobile accidents with rapid deceleration. Great force is required to produce pulmonary contusion, such as a fall from height, auto accidents and other forms of significant trauma. The clinical manifestations include dyspnea, tachypnea, cyanosis, tachycardia, hypotension, and chest wall bruising. There are no specific signs for pulmonary contusion, but hemoptysis may be present in up to 50%, and moist rales or absent breath sounds may be heard on auscultation. Although isolated pulmonary contusions can exist, they are associated with extrathoracic injuries in 87% of patients. Overlying rib fracture is frequent. Surprisingly, many of the worst contusions occur in patients without rib fractures. Occurs mainly in lung adjacent to solid structures (ribs, vertebra, heart, liver). Resolves rapidly beginning after 24 hrs and completely by 2-10 days. Emergency Medicine: Concepts and Clinical Practice pp. 519-520. Dänhert p.430 and Primer p. 55
• Man with multiple cavitary pulmonary nodules, hemoptysis and positive C-ANCA:
• Aspergillosis
• Sarcoid
• Wegeners granulomatosis
• Churg Strauss
• C. Wegerner’s granulomatosisTypical presentation of Wegener's Granulomatosis is Cough and hemoptysis with multiple nodules/masses with cavitation in the periperal aspects of the lungs. Pt is also C-ANCA positive. In Churg Struass, the patient's are also C-ANCA positive and also may present with multiple nodules. However, the clinical history is of asthma and pronouced eosinophilia. The lung findings are varible but typically present with patchy areas of consolidation. Thoracic Requistes pp.262-265
• Bacteria that most commonly affect lungs of patients with CF:
• staph aureus and pseudomonas
• h flu and streptococcus
• salmonella and klebsiella
• A. staph aureus and pseudomonas Early in the disease, CF airways become colonized with bacteria, which are virtually impossible to eliminate. Staphylococcus aureus and Haemophilus influenzae are often found initially. However, with time Pseudomonas aeruginosa becomes very common, often as a mucoid species. Dänhert and the Thoracic Requisites also mention S. aureus and Pseudomonas as common infections in CF. Cecil Textbook of Medicine pp. 401-405; Dänhert pp.401-402; Thoracic Requistes p.391
• Most common offending organism in community acquired pneumonia:
• Strep pneumonia
• Staph pneumonia
• Mycoplasma pneumonia
• Hemophilus pneumonia
• Klebsielleae pneumonia
• TB
• Histoplasmosis
• CMV
• Coccidiomycosis
• A. Strep. Pneumonia
• Cecil Textbook of Medicine p. 436
• Most common nonbacterial pneumonia in adults:
• Adenovirus
• Respiratory syncytial virus
• Mycoplasma pneumonia
• Staphylococcus pneumonia
• C. Mycoplasma pneumoniae
• Mycoplasma pneumoniae is the commonest cause of nonbacterial pneumonia with a mild course, usually lasts 2-3weeks, only 10%of infected subjects develop pneumonia. Remember: cold agglutinins, pleural effusions in 20%, and rare hilar adenopathy (Dänhert 424).
• Staphylococcus is a bacteria. Out of the viral etiologies, Rhinovirus causes 43% of cases, RSV 12%, and adenovirus would be less common. (Dänhert 446) Of note, Dänhert lists Mycoplasma as a cause of viral pneumonia. According to Brant and Helms 404, Mycoplasma is an organism with bacterial and viral characteristics and is considered as a separate group. It is again noted to be the most common cause of “non bacterial” pneumonia. Answer 3 is correct.
• Rounded atelectasis is most commonly associated with:
• Pneumothorax
• Pleural effusion
• Pneumonia
• Pneumatocele
• arcoid
• B. Pleural effusionFraser & Pare: on conventional x rays rounded Atx is a fairly homogeneous, ill defined, pleural based opacity up to 7 cm in diameter, most commonly in the posterior lower lobes. The bronchovascular bundles are gathered together and appear curvilinear as they pass toward it (comet tail sign). Lung parenchyma below or lateral to it may be strikingly oligemic. On CT it's typically a rounded subpleural opacity that is densest at the periphery, the more central aspect showing an air bronchogram. Contiguous pleural thickening due to fibrosis is invariably present. The lesion has been considered to be due to folding of the lung secondary to pleural effusion. They consider it likely that the majority of cases are due to pleural fibrosis.
• Which of the following is most commonly associated with Kawasaki’s disease?
• Myocarditis.
• Gallbladder hydrops.
• Pericardial effusion.
• Pulmonary artery aneurysms.
• A. Myocarditis
• Although Dänhert associates both myocarditis and transient GB hydrops with Kawasaki’s, Kirk only mentions myocarditis of the options listed. According to Dänhert , myocarditis has a mortality of 0.4-3% that is related to myocardial infarction, myocarditis with congestive heart failure, or rupture of coronary artery aneurysm (pulmonary artery aneurysms are not associated with Kawasaki’s). A pericardial effusion may occur, but I could not find any reference that included it in the findings associated with Kawasaki’s disease. Kirks, 1998, p. 579 and Dänhert 4th ed. CD version.
• What is NOT a feature of Kawasaki’s disease:
• Hydrops of the gall bladder
• Renal failure
• Cervical lymph node enlargement
• Myocarditis
• Pericarditis
• Renal Failure

• Kawasaki’s (or mucocutaneous lymph node syndrome) is an acute febrile multisystem vasculities of unknown cause with a prediliction for the coronary arteries. It is seen in < 5 years age. M:F 1.5:1. It is associated with:
• -polyarthritis
• fever
• mucosal reddening (injected fissured lips, pharnx, strawberry tongue)
• cervical adenopathy
• maculopapular rash on extensor surfaces
• nonpurulent conjunctivitis
• erythema of palms and soles
• Coronary artery aneurysm, stenosis, occlusion
• Myocarditis, pericarditis, valvulitis]
• Intestinal pseudoobstruction
• Transient gallbladder hydrops
• A patient with a normal arterial PC02 and a low arterial PA02 that does not correct on 100% oxygen:
• Pulmonary embolism.
• Left to right shunt.
• Right to left shunt.
• V/Q mismatch.
• COPD
• C. Right to left shunt
• “[Regarding] hypoxia secondary to right-to-left extrapulmonary shunting…PaO2 cannot be restored to normal with inspiration of 100% O2.” Harrison’s Principles of Internal Medicine, 15th Ed., 2001, p. 214.- L to R shunts can also be associated with cyanosis if paired with R to L shunt (admixture lesions). Dänhert 4th ed. CD version Hypoxemia associated with PE and COPD is typically caused by V/Q mismatch and would therefore improve with supplemental 100% O2
• Least likely to be associated with pulmonary venous hypertension:
• Pruning of the pulmonary arteries.
• Kerley-B lines.
• Pleural effusions.
• Prominent interstitium
• Enlarged left atrium
• A. Pruning of the pulmonary arteriesDänhert 4th ed. CD version: "Pruning" of pulmonary arteries is associated with pulmonary arterial hypertension and represents a disproportionate increase in caliber of central fibrous arteries and decrease in caliber of smaller muscular arteries related to sustained increase in pressure.Kerley’s lines and pleural effusions are among many findings associated with pulmonary venous hypertension. (many references including Radiologic Diagnosis of Chest Disease, Sperber ed. Springer-Verlag, 1990, p. 360.)
• Patient with asymmetric pulmonary edema, the most likely etiology:
• Cardiogenic pulmonary edema.
• Noncardiogenic pulmonary edema.
• Other answers not recalled.
• B. Noncardiogenic pulmonary edema
• Dänhert ’s differential diagnosis for unilateral pulmonary edema does not include a true example of cardiogenic pulmonary edema—asymmetric pulmonary edema is likely related to noncardiogenic reasons. Dänhert 4th ed. CDThe Purple Primer DDx for asymmetric pulmonary edema: 1) Gravity (positional); 2) underlying COPD; 3) unilateral obstruction of pulmonary artery: PE; 4) unilateral obstruction of lobar pulmonary vein: tumor. Primer of Diagnostic Imaging, CD version.
• In chronic lung disease, what is the most likely cause of hypoxemia
• L-> R shunt
• VQ mismatch
• R/L shunt
• Tissue destruction
• B. VQ mismatch
• “It is believed that the principal mechanism underlying arterial blood gas derangements in COPD is the mismatching of ventilation and perfusion in regional lung units.” Textbook of Pulmonary Diseases, 6th Ed., Baum, et al. ed. 1998, p. 830.-Numerous other answers have been given on other tests including diffusion abnormalities and tissue destruction.
• What is the most likely cause of unilateral lymphangitic spread of cancer
• lung
• breast
• pancreas
• colon
• stomach
• thyroid
• A. Lung
• Lung is most common cause of lymphangitic carcinomatosis overall, breast is the most common met. Dähnert pg. 418. Brandt and Helms pg. 398.LYMPHANGITIC CARCINOMATOSIS = INTERSTITIAL CARCINOMA = tumor cell accumulation within connective tissue (bronchovascular bundles, interlobular septa, subpleural space, pulmonary lymphatics) from tumor embolization of blood vessels followed by lymphatic obstruction, interstitial edema, and collagen deposition (fibrosis from desmoplastic reaction when tumor cells extend into adjacent pulmonary parenchyma) Incidence: 7% of all pulmonary metastasesTumor origin: lung carcinoma, carcinoma of breast (56%), stomach (46%), thyroid, pancreas, larynx, cervix. (Dänhert )The incidence of lymphangitic carcinomatosis has been reported by two authors to be 6% and 8%, respectively. The majority of tumors are adenocarcinomas: 80% in 1 series (2) and 83% in another(3). Stomach, lung, and breast account for a majority of tumors causing lymphangitic metastases, but pancreas, prostate, colon, and a variety of others have also been noted. (1)1. Harold JT: Lymphangitis carcinomatosa of the lungs. Q J Med 21:353-364, 19522. Yang S, Lin C: Lymphangitic carcinomatosis of the lungs. Chest 62: 179-187, 19723. Janower ML, Blennerhassett JB: Lymphangitic spread of metastatic cancer to the lung. Radiology 101:267-273, 1971By the process of preliminary elimination, colon and thyroid are out. Although lymphangitic spread of stomach adenocarcinoma is classic, its incidence has significantly reduced since the paper (1) in the last century. The finalists are lung and breast adenocarcinoma, and the winner is…lung, as lung adenocarcinoma is the “most common tumor” to do this, it would be more difficult to say if the wording were “tumor most frequently spread lymphangitically”
• The following radiographic findings commonly precede auscultation findings in pulmonary edema except:
• Peribronchial cuffing
• Alveolar edema
• Upper zone redistribution
• Kerley B lines
• B. Alveolar edemaIf you assume you can’t “hear” pulm edema until fluid fills the airway then the order of things is as follows and B is the answerThe physiologic and anatomical response of the pulmonary vasculature and lung parenchyma to the effects of pulmonary venous hypertension are reflected in the chest film as four progressive stages:
• 1. Redistribution of pulmonary blood flow, which involves shunting of blood into the upper lobes and decrease in flow to the lower lobes (the earliest phenomenon)
• 2. Overt signs of interstitial edema that begins forming in the interstices of the lung, adjacent to the arterioles, arteries, bronchi, interlobular septa, central vessels, and so on
• 3. Edema in the alveolar air spaces themselves
• 4. Pulmonary changes in the alveoli and interstitium reflecting severe and chronic changes such as hemosiderin deposits and ossification.
• Accurate evaluation of the chest radiograph gives the opportunity to detect interstitial edema occurring before any auscultatory findings, and to determine its severity and etiology in most patients.
• Interstitial pulmonary edema = first phase of pressure edema with increase in quantity of extracellular fluid with early loss of definition of subsegmental + segmental vessels; mild enlargement of peribronchovascular spaces; appearance of kerley lines; subpleuroal effusions; blurring of vessels; Interstitial pulmonary edema is defined as “ there is often marked dissociation between clinical signs+symptoms + roentgeographic evidence”. Vascular upper zone redistribution comes even before interstitial edema. Peribronchial cuffing is associated with interstitial edema.Alveiolar Flooding edema = 2nd phase of pressure edema Dänhert 5th p402
• Concerning aortic transection:
• The majority rupture and exsanguinate if left untreated
• ascending aortic dissection is most common
• Mortality of the aortic root is most likely due to aortic insufficiency
• Laceration of the coronary vessels
• A. Rupture and exsanguination
• 70% fatal at the scene, those that reach the hospital alive 70% survive given appropriate treatment90% aortic isthmus just distal to subclavian, Overview of Traumatic Injury of the Thoracic Aorta: Radiographics: 1997 17 27-45By the DeBakey classfication, type III is most common. By the Stanford classification Type A is most common, however most of these are DeBakey type I which extend past the arch to involve the descending aorta. So whether or not B is true depends on which classification system you use and whether you interpret the question to mean involving the descending aorta ONLY. However, B is the best choice available and D.R. says he agrees with that statement. Brant&Helms states death is usually “due to retrograde dissection causing tamponade, massive Ao regurg, or rupture into pleural space”. Dänhert states 65% of dissections will have Ao insufficiency, however, CHF/death from AR is rare. Rupture into pericardial sac is less common but carries a 70% mortality rate. Although, I could not find a book that specifically states it, D.R. says tamponade is the most common cause of death. The 1 year mortality rate for untreated dissections is 80-95% however most of these deaths are due to the above complications (30% in 1st 24 hours, >50% in 1st week) not just exsanguination. Involvement of the coronary arteries occurs in 8% so I would not say this is characteristic.
• The azygos vein inserts with the superior vena cava:
• onto the anterior wall of the SVC above the RMS bronchus
• onto the posterior wall of the SVC above the RMS bronchus
• onto the anterior wall of the SVC below the RMS bronchus
• onto the posterior wall of the SVC below the RMS bronchus
• B. onto the posterior wall of the SVC above the RMS bronchus
• The azygos vein connects the superior and inferior venae cavae, either directly by joining the inferior vena cava or indirectly by the hemiazygos and accessory hemiazygos veins. It ascends in the posterior mediastinum, passing close to the right side s of the bodies of the inferior eight thoracic vertebrae. The azygos vein is covered anteriorly by the esophagus as it passes posterior to the root of the right lung. It then arches over the superior aspect of this root to join the superior vena cava. anatomy text and Netter’s Atlas, 1993 plates 218, 220
• No AP or superior-inferior pressure gradient in:
• pulmonary arterial pressure
• pulmonary venous pressure
• alveolar pressure
• pleural pressure
• pulmonary vascularity
• C. Alveoli
• Alveoli are small units without pressure gradients. Gas exchange is purely diffusion on the alveolus level.ORThe answer to this question depends on whether the patient is upright or not. If so, intraalveolar air pressure would be dependent on height with the alveoli in the apices at a lower pressure than the bases. The pleural pressure is not uniform throughout the pleural cavity, being more negative at the apex than the bases, with a vertical gradient of 0.2 cm water per centimeter of vertical height Source: Fraser and Parre, pp. 128, 174.
• Requirements for HRCT include:
• High spatial frequency algorithm
• Helical scanner
• Overlapping slices
• Windowing from –600 to –800
• IV contrast
• Small field of view
• A. High spatial frequency algorithm
• The following is the typical protocol:
• 1-1.5 mm collimation
• high resolution algorithm
• 120 – 140 kVp and 140 – 240 mA
• 512 x 512 matrix
• lung windows: L = -700HU and W = 1000HU
• Soft Tissue Window: L = 45 HU and W = 400HU
• No IV Contrast
• Note: a small FOV can be used but is not required - some centers focus on one lung at a time).
• True of type II pneumocytes, except:
• capable of DNA synthesis
• separated from other type II cells by intercellular bars (bonds)
• can regenerate
• synthesize surfactant
• they are comprise relatively small amount of the alveolar surface area
• B. Seperated from other type II cells by intercellular bars
• A. True: They can divide and regenerate both types of alveolar pneumocytes and contain mitochondria
• B. False: they are attached by tight junctions
• C. True: see A
• D. True Synthesize pulmonary surfactant which is stored in lamellar bodies
• BRS Cell biology and histology 3rd p226
• Which of the following is the most common cause of alveolar filling in a patient with systemic lupus erythematosis?
• Bacterial pneumonia
• Lupus pneumonitis
• Lymphoma
• Alveolar hemorrhage
• Lipoid pneumonia
• NOTE: question also asked as: What is most common bilateral airspace disease which might change the answer.
• A. Bacterial Pneumonia
• Pneumonia is probably the single most common pleuropulmonary abnormality in SLE occurring in about 50% of patients. The prevalence of lupus pneumonitis and acute pulmonary hemorrhage are 4% and 1.5% respectively. Imaging of Diseases of the Chest, 3rd Ed. Armstrong, ed, 2000, p. 567-571.Patients with SLE are at risk for developing primary lymphoma of the bowel. Dänhert 4th ed. CD versionPleuritis and pleural effusions are visible in over half of all patients with systemic lupus erythematosus (SLE) during the course of their disease. Pleural thickening is more common than effusion; both are common, along the pericardial effusion in drug-induced lupus (DIL). The pleural disease is often recurrent and usually abates with steroid therapy.Pulmonary infiltration in SLE occurs in acute or chronic forms that are not clearly related. Both occur in a minority of SLE patients, principally women with obvious systemic disease. No specific immune reaction has been defined for either form of pulmonary infiltration, although the presence of circulating immune complexes containing antibodies to host DNA suggests the involvement of a type III reaction. The acute form,”lupus pneumonitis”, is roentgenographically visible as diffuse or patchy densities involving the lower lung fields and often containing reticulations, small ill-defined nodules and associated volume loss, and pleural disease. Alveolar consolidative patterns may accompany acute symptoms. The appearance as well as the symptoms may suggest infection, and response to steroids has been suggested for differential diagnosis.The chronic form of pulmonary disease appears as lower lung field interstitial patterns, typical of type III immune reactions, often accompanied by volume loss and pleural disease; pulmonary function tests demonstrate restriction and decreased diffusing capacity.Many other roentgenographic manifestations of SLE are known. Lymph node enlargement unrelated to pulmonary disease may occur in hila and mediastinum. Other pulmonary infiltrates may also occur as the result of nephritis (including uremic pneumonitis). Horizontal linear densities, especially at the bases, may be the result of subsegmental atelectasis and may be related to vasculitis, causing infarction. Vasculitis may also lead to the presence of cavitary nodules. However, throughout the course of disease and treatment, infective pneumonias are the most common causes of pulmonary infiltrates in patients with lupus.David S. Feigin, Volume 1 Chapter 57 – Immunologic and Lymphoproliferative Disorders of the Lung in Radiology: Diagnosis, Imaging and Intervention, Taveras, J. Ed. 1998
• Which of the following is most commonly associated with systemic lupus erythematosis in lung findings?
• Pleural effusion
• Pulmonary hemorrhage
• A. Pleural Effusion
• Pleuritis, effusion, or both are the most common pleuropulmonary abnormalities in SLE. Thoracic Radiology-The Requisites pgs 257-259

• Pleuritis and pleural effusions are the most common pulmonary findings and affect almost 50% of patients with SLE.
• Evidence of alveolar injury with edema and hemorrhage is less frequent.
• Which of the following is the most common cause of a community acquired pneumonia in an elderly patient
• S. pneumonia
• S. aureus
• C. Klebsiella
• A. S. pneumoniaA. S. pneumonia – It is responsible for a third to a half of community acquired pneumonias in adults. These infections are more frequent in the winter and early sping. It is more common in alcoholic, debilitated, and other immunocompromised individuals. B. S. aureus – It rarely develops in healthy adults, but it is sometimes a complication of viral infections and is much more common in infants and children. In adults the disease is usually bilateral and preceded by an atypical pneumonia such as influenza.C. Klebsiella – Usually occurs in middle-aged or elderly patients, in those with underlying chronic lung diseas, and in alcoholic individuals.Cecil Textbook of Medicine p. 436
• Which of the following is most characteristic of a supine pneumothorax?
• Deep sulcus sign
• Eventration of the hemidiaphragm
• Hilum overlay sign
• Westermark’s sign
I think deep sulcus
• B. eventration of the hemidiaphragm
• Deep sulcus sign – on frontal view, larger lateral costo-diaphragmatic recess than on opposite side.
• Eventration of hemidiaphragm – upward displacement of abdominal contents secondary to congenitally thin hypoplastic HD
• Hilum overlay sign – abnormally dense hilum due to overlying intrapulmonary mass.
• Westermark’s sign – embolism without infarction: localized peripheral oligemia with or without distended proximal vessels.
• Hampton Hump – another sign of embolus. Pleural based shallow consolidation in form of a truncated cone with base against pleural surface + convex medial border. Lacks air bronchograms. Typically in the posterior or lateral CP sulcus.Brant and Helms.
• Which of the following statements regarding pulmonary emboli is not true
• Most often multiple
• Central cause infarcts more than peripheral
• Peripheral causes more infarcts than central
• It frequently presents with hemoptysis, cough, and chest pain
• B. Central causes infarcts more than peripheral
• Peripheral causes more than central due to decreased collateral flow from the bronchial systemic circulation. Most are multiple. The majority of patients with PE have a variety of symptoms, including dyspnea (84%), pleuritic chest pain (74%), anxiety (59%), and cough (53%). – Fewer have all three together Brant and Helms, 369
• Which of the following is characteristic of smoking related emphysema?
a. Basilar predominance
b. Centrilobular distribution
c. Panlobular distribution
d. paraseptal emphysema
• B. Centrilobular Distribution
• There are four major types of emphysema defined anatomically. These are: 1. Centrilobular or centriacinar; 2. panlobular or panacinar; 3. paraseptal (distal acinar) emphysema; and 4. paracicatricial (irregular).Centrilobular emphysema affects the predominately the respiratory bronchioles in the central portion of the secondary pulmonary lobule. It usually identified in the upper-lung zones, and it is associated with cigarette smoking (causes up to 50%). Panlobular involves all the components of the acinus an therefore involves the entire lobule. It is classically associated with alpha-1 protease inhibitor (alpha-1-antitrypsin) deficiency (cause in 10-15%), although it may be seen without protease deficiency in smokers and eldely. Paraseptal involves the distal part of the secondary lobule (alveolar dusts and sacs). It can be an isolated phenomenon in young adults, and is associated with spontaneous pneumothorax (Thoracic Requisites 288, Dähnert 5th p. 485)
• Patient with Left vocal cord paralysis. How low should you image.
• thyroid
• thoracic inlet
• AP window
• C. AP WINDOW
• The vagus innervates the larynx through the superior laryngeal nerve, which supplies the cricothyroid muscle and does not cause significant hoarseness or vocal cord paralysis, and the recurrent laryngeal nerve, which courses from the medulla through the jugular foramen in the carotid sheath and loops under the aortic arch on the left and under the subclavian artery on the right (Neuro Requisites p396).
• A pulmonary sling is associated with which of the following:
• Tracheal cleft
• Tracheal stenosis
• Tracheal esophageal fistula
• Tracheal web
• B. Tracheal Stenosis
• Aberrant Left Pulmonary Artery (Pulmonary Sling) = failure of development of Lt 6th aortic arch with development of collateral branch of Rt PA to supply Lt lung. The Lt PA courses ABOVE the Rt main bronchus and BETWEEN the trachea and esophagus causing POSTERIOR indentation of the trachea and ANTERIOR indentation of the esophagus. Age at presentation neonate-child due to stridor (most common), wheezing, cyanosis, recurrent infections, feeding problems. Associations:“Napkin-Ring Trachea” = Tracheobronchomalcia due to absent pars membranacea (50%)“Carrot shaped Trachea” = caudal narrowing of tracheal diameter causing functional stenosisDänhert p 485&505, MGH p128
• A true vascular ring may be caused by a double aortic arch and:
• Aberrant right subclavian artery with a right aortic arch
• Aberrant left subclavian with a right aortic arch
• Left aortic arch with an aberrant right subclavian
• B. Aberrant left subclavian with a right aortic arch
• Right AA with Aberrant Left Subclavian Artery 2nd most common vascular ring. (Double AA is most common - 55%)Most common right arch anomaly, 35-72%Aberrant LSCA passes BEHIND esophagus as opposed to pulm sling.Associated with CHD 5-12% Tet (70%) > ASD/VSD > CoarctationMay become symptomatic in childhood due to tracheal edema from bronchitis or in adulthood due to aortic tortuosityMay also have Diverticulum of Kommerell which is remnant of Lt arch at origin of Aberrant LSCARt arch with aberrant RSCA – Not a ring. Not in the books. I don’t know if this even really exists.Lt arch with aberrant RSCA NOT a complete true ring, usually asymptomaticDänhert p483-4, MGH127
• Regarding bronchial artery embolization all are true except:
• it is successful for treatment of bleeding in patient with cystic fibrosis
• one complication is spinal cord infarct
• gelfoam or small particles are the method of choice
• often cause pulmonary infarct
• D. often cause pulm infarct
• Bronchiectasis may result in life-threatening hemoptysis in CF. Bronchial arteries may be markedly enlarged. Bronchial artery embolization may successfully treat such episodes of hemoptysis but may be complicated by spinal cord infarct, as spinal arteries may arise from the intercostals. Particles or gelfoam should be employed, as larger and/or more permanent agents such as coils may preclude future access to bleeding vessels and hemoptysis tends to be a recurrent problem in CF. Alcohol is contraindicated because of resultant cell necrosis Bronchial artery embolization only rarely results in pulmonary infarct (e.g., concurrent pulmonary artery occlusion). References: Kadir, pp. 197-200; baby Fraser and Pare p. 278
• Which is seen with an exudative pleural effusion?
• Nephrosis
• Cirrhosis
• CHF
• Lung cancer
• D. Lung Cancer
• Exudate – increased permeability of abnormal pleural capillaries with release of high protein fluid into pleural space – seen with lung cancer 26-49%Transudate seen with CHF, Cirrhosis, and NephrosisDänhert 5th p438
• Decreased compliance of the lungs is seen with which of the following?
• CHF
• Alpha-1 antitrypsin deficiency
• Idiopathic interstitial fibrosis
• Scleroderma
• C. Idiopathic interstitial fibrosis
• Decreased compliance seen in edema, increased pulmonary venous pressures, fibrosis, granulomatous infiltration
• Dänhert 5th p450NOTE: don’t always see edema with CHF but could
• Regarding pulmonary Kaposi sarcoma:
• Usually asymptomatic
• Often precedes cutaneous Kaposi’s
• Cutaneous form is often a presenting problem with HIV pt’s
• C. Cutaneous form presenting problem in HIV
• A. False. "Kaposi's sarcoma in the lungs often leads to extensive interstitial disease with severe impairment of diffusing capacity and may result in massive pulmonary hemorrhage. Pulmonary Kaposi's sarcoma must be differentiated from P. carinii pneumonia, since both can present with fever and interstitial patterns on CXR. Pleural effusions and bilateral lower lobe infiltrates are much more common in Kaposi's sarcoma." Harrison's Principles of Internal Medicine, 12th Edition.B. False. "Kaposi's sarcoma, however, is the most common malignancy in AIDS patients, and cutaneous Kaposi's sarcoma is frequently the initial manifestation of the disease." Imaging of Diseases of the Chest, 2nd Edition, Armstrong.C. True See B
• All are true regarding pulmonary bleomycin toxicity EXCEPT:
• Is synergistic with 100% oxygen therapy
• Is synergistic with radiation therapy
• Occurs immediately
• Is dose dependent
• C. occurs immediately
• A. True. Bleomycin toxicity is augmented by oxygen toxicity
• B. True. Bleomycin toxicity is augmented by rad tx.
• C. False: Occurs 1-3 months following beginning of therapy
• D. True: occurs at doses >300mgDänhert 5th p400
• Most similar in appearance to lymphangiomatosis (LAM) on HRCT
• EG
• sarcoid
• emphysema centrilobular
• emphysema panacinar
• A. EG
• Eosinophilic Granuloma. HRCT findings: thin-walled cysts <5mm in size equally distributed in central and peripheral lung zones, centrilobular peribronchiolar nodules. HRCT findings in LAM include numerous randomly scattered thin-walled cysts of various sizes surrounded by normal lung parenchyma, bronchovascular bundles at periphery of cyst walls. Classic signs include: coarse reticular interstitial pattern, recurrent large chylothorax (50% to 75%), recurrent pneumothorax (40%), and increasing lung volume (only interstitial disease to develop increasing lung volumes). Sarcoidosis may cause progressive retraction and upper lobe fibrosis with bullae, but not cysts. Centrilobular emphysema is the most common type of emphysema and presents with bullae predominantly in the upper lobes, whereas the panacinar type is predominantly in the bases and is from alpha 1 antitrypsin deficiency. Dänhert 5th p 498 and 515
• True/False: What structures accompany the bronchus?
• 1. Bronchial artery
• 2. Bronchial vein
• 3. Pulmonary artery
• 4. Pulmonary vein
• 5. Lymphatics
• 1= T 2=T 3=T 4=F 5=T
• 1. T. The bronchial arteries normally arise directly from the aorta or the intercostobronchial trunk and usually number from 2‑4. The extrapulmonary branches course to the hila, where they form an intercommunicating circular arc around the main bronchi, from which the intrapulmonary arteries radiate. These vessels are situated within the peribronchial connective tissue and extend along the bronchial tree, branching with the airways. There is dual venous drainage via bronchial veins to the azygos and hemiazygous systems and via the pulmonary veins to the left atrium
• .2. T. They course along the bronchi.
• 3. T. The conducting and transitional airways are intimately related to the pulmonary vasculature, a branch of the pulmonary artery always accompanying the appropriate bronchus.
• 4. F. The pulmonary veins are located within their own interstitial sheath separate from the bronchoarterial bundles
• .5. T. Lymphatic channels and lymph nodes course along the bronchi and major branches. The interlobular septa contain veins and lymphatics. Pulmonary lymphatic channels form 2 major pathways, one in the bronchoarterial and the other in the interlobular septal connective tissue. The bronchoarterial lymphatics originate in the region of the distal respiratory bronchiols... and run proximally, eventually reaching the bronchial and hilar lymph nodes. The interlobular lymphatics drain partly into the bronchoarterial lymphatics and partly into the pleural system... . Anastomotic channels connect the interlobular lymphatics with those in the bronchoarterial sheath... midway between the hilum and the periphery of the lung. Distension of these communicating lymphatics and edema in the surrounding connective tissue results in Kerley A lines. Similar processes in the interlobular lymphatics and connective tissue results in Kerley B lines. Thoracic Requisites, 7-16 see also Netter plates 194-197
• Concerning the cardiac size on PA chest film (T/F):
• 1. The cardiac width is proportional to thoracic width
• 2. Is larger with slower heart rate
• 3. It is less prominent in size when compared with apical lordotic view
• 4. Is proportional to cardiac volume
• 1=T 2=T 3=T 4=F
• 1. T. Cardiac width is proportional to thoracic width. Hence the development of the Danzer carciothoracic ratio, with the normal in adults < 0.5. Because it measures the transverse heart diameter, the cardiothoracic ratio usually is normal when either the left atrium or the right ventrile is quite enlarged because neither of these two chambers is reflected in the transverse measurement. LV enlargement up to 66% above normal is often needed for the cardiothroracic ratio to reliably detect enlargement of the left ventricle.
• 2. T Marathon runners with heart rates in the range of 30 to 40 beats/minute occasionally have a cardiothoracic ratio between 0.5 and 0.55 (normal < 0.5). This reflects normal physiologic dilatation of the heart rather than any overall hypertrophy
• 3. T. Apical lordotic views are obtained AP.
• 4. F. As mentioned in 1 above, LVH can be significant before enlargement even detected using the Danzer ratio. Cardiac Requisites, 4-15
• Which can be seen with a small pneumothorax on supine CXR?
• 1. Deep lateral costophrenic sulcus
• 2. Lucency over the lung base.
• 3. Elevation of the hemidiaphragm
• 1=T 2=T 3=F
• Radiographic appearance (upright): air in pleural space radiolucent, white line of the visceral pleura distinctly visible, volume loss of underlying lung; (supine) deep sulcus sign, medial recess-juxtacaradiac outline, can accumulate in a subpulmonic location producing a sharply outlined hemidiaphragm. Elevation of the hemidiaphragm would come from atelectasis. Thoracic Requisites 498 and Primer, 3rd, 57-58
• Regarding use of high kVp technique for chest X-ray (T/F)?
• better bone detail
• lower patient dose
• better visualization of epicardial fat pad
• greater latitude
• lower contrast
• 1=T, 2=T, 3=F, 4=T, 5=T
• High kVp x-ray beams have high mean energies and are more penetrating. Increasing kVp generally reduces subject contract (a and c) and allows the X-ray output values (mAs) to be reduces and produce the same film density with reduced skin entry exposures. (b) Latitude and contrast are inversely proportional. Huda, Ch. 13
• A 31 y/o female has a 1cm cavitary left upper lobe mass. She presented with hemoptysis.
• TB
• Pulmonary AVM
• Lung cancer
• No collagen vascular disorder listed
• A. TB
• AVMs do not cavitate. Wegener’s tends to be lower lobe predominant and multiple, in older pts (5th decade), and M:F ratio is 2:1. Lung cancer age at diagnosis is usually 55-60 yrs ( range is 40-80yrs), M=F. Most common to cavitate is squamous cell CA which is central (2/3) rather than peripheral (1/3). Cavitation is the hallmark of reactivation TB. Usually the patient was infected as a child which was contained by hypersensitivity response and granuloma formation in 1-3 weeks. Other options after initial infection are progressive primary TB (inadequate immune mechanism with local progression ) or milliary TB (uncontrolled massive hematogenous dissemination overwhelming host defense system). In reactivation TB (which this case probably is) infection is under the influence of acquired hypersensitivity and immunity secondary to longevity of the bacillus and impairment of cellular immunity. Predominant occur in the upper lobes (85%). Apical and posterior segments most common. Primer, 3rd 12-14
• Man presents with swelling of the upper extremities and head and venous collaterals in neck and head. CXR shows widened upper mediastinum. Most likely cause:
• a. Bronchogenic carcinoma
• b. Lymphoma
• c. Germ cell tumor
• d. Fibrosing mediastinitis
• e. Thymoma
• A. Bronchogenic Carcinoma
• Causes for SVC syndrome as follows a) Malignant lesion (80‑90%) - Bronchogenic CA (>50%) - Lymphoma b) Benign lesion - Granulomatous mediastinitis (usually histo, sarcoid, or T.B.) - Substernal goiter - Ascending aortic aneurysm - Pacer wires/ central venous catheters (23%) - Constrictive pericarditis(Brant WE, Helms CA; Fundamentals of Diagnostic Radiology, 1994. pp623-624)
• What is CT densitometry most useful for in its evaluation?
• a. Bronchoalveolar cell ca
• b. Silicosis
• c. Lipoid pneumonia
• d. Hemosiderosis
• e. Alveolar proteinosis
• C. Lipoid pneumonia. Lipoid pneumonia usually occurs as the result of inadvertent aspiration of oily substances such as mineral oil. Usually results in multifocal consolidation typically at the lung bases. The diagnosis can be made with CT as the density numbers will be in the range of fatty tissue and therefore pathognomonic for lipoid pneumonia.Thoracic Requisites, 280
• Rounded atelectasis is most commonly associated with:
• a. Pneumothorax
• b. Pleural effusion
• c. Pneumonia
• d. Pneumatocele
• e. Sarcoid
• B. Pleural effusion. On conventional x‑rays rounded Atx is a fairly homogeneous, ill‑defined, pleural based opacity up to 7 cm in diameter, most commonly in the posterior lower lobes. The bronchovascular bundles are gathered together and appear curvilinear as they pass toward it (comet tail sign). Lung parenchyma below or lateral to it may be strikingly oligemic. On CT it’s typically a rounded subpleural opacity that is densest at the periphery, the more central aspect showing an air bronchogram. Contiguous pleural thickening due to fibrosis is invariably present. The lesion has been considered to be due to folding of the lung secondary to pleural effusion. They consider it likely that the majority of cases are due to pleural fibrosis. Primer, 3rd, 46 and Thoracic Requisites 241-243
• What is the most common cause for a pneumomediastinum?
• alveolar rupture
• pneumothorax
• pneumoperitoneum
• Trauma
• bulla rupture
• A. alveolar rupture. In most patients, the initial event is probably related to an incident that causes an abrupt rise in airway pressure, often accompanied by airway narrowing. The results in rupture of marginally situated alveoli whose bases are adjacent to airways or to pulmonary arteries or veins. Gas then passes into and along the perivascular or peribronchial interstitial tissue to the hilum and the mediastinum Thoracic Requisites 172 and Primer, 3rd, 82 and Fraser and Pare, p. 903
• What is the definition of vital capacity?
• normal inspiration to full inspiration
• normal expiration to full expiration
• normal inspiration to normal expiration
• full inspiration to full expiration
• D. Full inspiration to full expiration. There are four volume and three capacity measurements:Tidal volume – normal inspiration to normal expirationInspiratory reserve volume- normal inspiration to full inspirationExpiratory reserve volume – normal expiration to full expirationResidual volume – volume left in lungs after full expiration. Cannot be directly measured.Vital capacity – full inspiration to full expiration (IRV + TV + ERV)Functional residual capacity – volume left in lungs after normal expiration (ERV + RV)Cannot be directly measured.Total lung capacity- vital capacity + residual volume(Andreoli TE, Carpenter CC, Bennett JC, Plum F; Cecil Essentials of Medicine 4th ed, W.B. Saunders, 1997, p. 127)
• MRI is superior to CT for the evaluation of:
a. tumor invasion into mediastinal lymph nodes
b. rib invasion
c. superior sulcus tumor with invasion into brachial plexus
d. small cell lung carcinoma
• C. superior sulcus tumor with invasion into brachial plexus. It is a critical observation to evaluate chest wall invasion in superior sulcus tumor. The chest wall invasion alone dos not preclude surgical resection, but it does adversely affect prognosis. CT cannot reliably show chest wall involvement unless there is bone destruction or a large soft tissue mass adjacent to the chest wall. MR has the similar problem to CT in diagnosis chest wall invasion. In some series MR was better than the CT in demonstrating chest wall invasion. They're three basic reasons why MR might provide more information than CT:
1). Multiple plane scanning.
2). MRI provides excellent tissue contrast
3). The thin layer of extrapleural fat may be better shown on MRI than on CT.MRI does not offer any advantages over the CT for routine assessment of mediastinal invasion. MRI can, however, provide unique information in involvement of major mediastinal blood vessels, pericardium and the tracheal carina (T4 lesion). (Imaging of Diseases of the Chest, 2nd edition, pp 298-293, 1995).
• CD4 count at which the incidence of PCP dramatically increases:
• a. 1000
• b. 500
• c. 200
• d. 100
• e. 50
• C. 200.PCP tends to occur when the CD4 count is <200/mm3 and MAI occurs when CD4 count <50 Primer, 3rd, 22
• Which of the following is not typically seen in pulmonary involvement in rheumatoid?
• a. pleural effusion
• b. basilar fibrosis
• c. hilar adenopathy
• d. cavitating nodule
• e. Caplan's syndrome
• C. hilar adenopathy. The nodule of the pulmonary involvement in rheumatoid is intrapulmonary parenchymal nodule and pathologically identical to subcutaneous nodules and similar to the Caplan's nodules. Lymphoid hyperplasia is an uncommon histologic manifestation (5 of 40 open lung Bx). It is most marked along the airway, the term " follicular bronch(iol)it is used. Like PCP, typically there is not hilar adenopathy in pulmonary involvement in rheumatoid. (Imaging of Diseases of the Chest, 2nd edition, pp 502-508, 1995).
• Match the following obstructive bronchial pathologies:
• 1. obstructive pneumonitis
• 2. lipoid pneumonia
• 3. drowned lung
• 4. mucous plugging

a. atelectasis
• b. lobar expansion
• c. bronchiectasis
• d. fluid in the alveoli and interstitium
• e. inflammatory cells in the alveoli and interstitium
• 1 = E 2 = E 3 = B 4 = C
• All these questions are about pathological changes in obstructive bronchogenic carcinoma.
• Thoracic Requisites 44, 280 (Imaging of Diseases of the Chest, 2nd edition, p 279, 1995. Fundamentals of Diagnostic Radiology p 403, 1994).
• Matching:
• 1. Sickle cell
• 2. Sarcoid
• 3. Cystic fibrosis
• 4. Silicosis

a. Pseudomonas
• b. Tuberculosis
• c. Pneumococcus
• d. Saprophytic aspergillus
• 1 = C 2 = D 3 = A 4 = B
• Pts with sickle cell are at increased risk of pneumonia and infarction, hence the term acut chest syndrome both can be/are blanketed into. Pneumonias were originally thought to be due to pneumocci but now are thought to be due to viruses and mycoplasma.
• Sarcoid is most commonly associated with aspergillosis. Mycetoma formation is a well recognized complication of stage III cystic sarcoidosis. It is the second most common predisposing condition for mycetoma formation after tuberculosis. Hemoptysis is the most common symptom and may be life-threatening. Mycetomas are usually confined to the upper lobes and commonly bilateral. There has been an association between sarcoid with tuberculosis , but recent literature suggests a weak link
• Silicosis is most commonly asociated with tuberculosis. Two distinct histopathologic reactions to inhaled silica: silicotic nodules and silicoproteinosis. Patients with both fibrotic silicosis and acute silicoproteinosis are predisposed to tuberculosis. It is a common complication seen with the development of PMF.
• CF is a hereditary disease of autosomal recessive transmission characterized by mucus plugging of exocrine glands including sweat and salivary glands and those of the pancreas, large bowel, and tracheobronchial tree. The major clinical manifestations are COPD and pancreatic insufficiency. It occurs almost exclusivley in Caucasians with an incidence of 1:2000. Patients with cystic fibrosis have an increased susceptibility to pulmonary infection, particularly with Pseudomonas aeruginosa, P. cepacia, and S. aureus. Primer, 3rd, 16, 35-36, 43-44 55-56
• When are the alveoli fully developed?
• a. 16 weeks in utero
• b. 28 weeks in utero
• c. term infant
• d. 1 year old
• e. 8 years old
• E. 8 years old.
• Approximately 60 million primitive alveoli exist at birth. When fully developed, the number of alveoli is about 375 million at age 8‑12 years. (Pediatrics NMS p 313, 1992)
• An enlarged pulmonary artery in an adult is usually due to:
• ASD
• Emphysema
• VSD
• B. emphysema.
• Enlarged pulmonary arteries are seen in PAH. Causes include Pulmonary causes: COPD, interstital lung disease(CF, idiopathic fibrosis, sarcoid), Pulmonary embolic disease, idiopathic pulmonary hypertension. Cardiac causes includes left-sided failure with mitral stenosis, CHD ( ASD, ASD, PDA). Dahnert pg. 361. According to Anderson 382 VSD will have upper limits of normal or mild central pulmonary artery enlargement. ASD will have very large central vessels (Must be seen in Eisenmenger ASD or VSD). Mitral stenosis will also result in PAH, but will have manifestations of PVH. Primer, 3rd, 51-52
• Most common vascular ring (single best answer):
• a) Aberrant left pulmonary artery from right pulmonary artery
• b) Right arch with aberrant left subclavian artery
• c) Left arch with aberrant right subclavian artery
• d) Aberrant innominate artery
Most common is double aortic arch
• B. right arch with aberrant left subclavian
• Swischuck “the term vascular rings is, at times, loosely used to include all anomalies of the aortic arch and great vessels, but strictly speaking it should be restricted to those entities in which actual encirclement of the trachea and esophagus occurs” . The most common type of right aortic arch has an aberrant retroesophageal left subclavian artery. If a left ductus connects this left subclavian artery to the left pulmonary artery, a vascular ring is formed. 5% have symptoms (airway or esophageal compression).A double aortic arch is both the most common and most symptomatic of all vascular rings.
- Right arch with mirror image branching: the ductus arteriosus goes from the left subclavian artery to the left pulmonary artery in front of the trachea and does not cause a vascular ring (usually asymptomatic).
- Left aortic arch / aberrant right subclavian: most common congenital arch anomaly (1% of persons). Usually asymptomatic because no ring is formed (it’s a sling). Sources: Card. Req. p. 419-421; Primer 3rd. p. 134; Dähnert 5th p. 580.Peds req 15-16, Primer 3rd ed 133-136; Swischuck-imaging of newborn, infant, and young child 309-318
• CXR signs of pneumothorax (T/F)
• tongue-like contour of the the CP angle
• elevated right hemidiaphragm
• hilum overlay sign
• lucency at lung base
• rounded pericardial fat pad countour
• 1=T, 2=F, 3=F, 4=T, 5=T
• When patients must be examined supine, gas rises to the highest point in the hemithorax, in the vicinity of the diaphragm. Depending on the size, the result can be an exceptionally deep radiolucent costophrenic sulcus (“deep sulcus sign”), a lucency over R or L upper quadrant, or a much sharper than normal appearance of the hemidiaphragm, with or without visible visceral pleural line above the hemidiaphragm. (2nd edition Frasier and Pare).tongue-like contour is analogous to deep sulcus sign. elevated hemidiaphragm is seen in subpulmonic pleural effusion, altered pulmonary volume (ATX, hypolasia, etc), phrenic nerve paralysis, abdominal disease, diaphragmatic hernia, eventration of diaphragm, traumatic rupture of diaphragm, or diaphragmatic tumor (Dahnert p.l 281). hilum overlay refers to a hilar mass being anterior or posterior to the hilum on plain film, thus preserving the interface of the hilum. On supine view a juxtacardiac air collection can be seen. Thoracic Requisites 496-501
• A young patient with a calcified anterior mediastinal mass:
• Untreated lymphoma
• Teratoma
• bronchogenic cyst
• 1=F, 2=T, 3=FHodgkins lymphoma has two peaks, one at 30 and one at 70. Range for bronchogenic CA is 40-80 yesars. Non-Hodgkins occurs in all age groups with a mean of 50 years. Thymoma is most common between the 4th and 6th decades, and is rare in childhood.Lymphoma may calcify AFTER treatment, but doesn’t calcify before treatment Bronchogenic cysts occasionally have peripheral linear calcification Germ cell tumors, of which teratoma comprises 21%, calcify 25%-40% of the time. Thoracic Requisites 330-334, 436, 441-443
• Unilateral rib notcing is seen with all of the following except:
• Blalock-Taussig shunt
• Brachial artery occlusion
• Avm of forearm
• Coarctation with aberrent right subclavian artery
• Coarctation of the aorta between the right and left carotid artery
• B. Brachial artery occlusion.“Rib notching is seen in a wide variety of pathological conditions. Inferior rib notching is much more common than superior rib notching, and is due to enlargement of one or more of the structures that lie in the subcostal grooves (intercostal nerve, artery, or vein). The notching predominantly affects the posterior aspects of the ribs bilaterally and may be narrow, wide, deep, or shallow. The most common cause of bilateral inferior rib notching is coarctation of the aorta distal to the left subclavian artery…” other causes include Takayasu’s aortitis and aortic thrombosis. “Congenital heart disease associated with decreased pulmonary artery flow may lead to rib notching as the intercostal arteries enlarge in an attempt to suply collateral flow to the oligemic lungs. SVC obstruction can lead to notching throug increased flow through the intercostal veins.Unilateral rib notching may occur on the left when aortic coarctation occurs proximal to an aberrant right subclavian artery, and unilateral right-sided notching can occur when the coarctation is proximal to the left subclavian artery.Other causes of unilateral inferior rib notching include subclavian artery obstruction, and surgical anastamosis of the proximal subclavian artery to the ipsilateral pulmonary artery (Blalock-Taussig procedure).…intercostal neurofibromas in NF type I is the major nonvascular cause of inferior rib notching.”The brachial artery is distal to the junction with the internal thoracic artery, so if it occludes, there is no “steal” pathway available to the arm via the intercostals, so B must be the correct answer.As above plus Primer 3rd, 150-151 Per Fundamentals of Diagnostic Rad iology, Brant, William; Helms, Clyde; Williams & Wilkins, 1994. (1st edition), p. 513-514
• Which is the most accurate regarding endotracheal intubation?
• Mainstem bronchus intubation occurs most often on the left
• Cuff inflation prevents aspiration
• Neck flexion causes the tube tip to move caudally
• Other incorrect choices
• C. neck flexion causes the tube tip to move caudally.“Chin up, tube up; chin down, tube down” Dr. W.Mainstem bronchus intubation usually on right. Inflated cuff should not bulge tracheal wall. Tip should be below the thoracic inlet above the carina: Neutral neck: 4-6 cm above the carina Flexed neck: moves the tip inferiorly by 2 cm Extended neck: moves tip superiorly by 2 cmPrimer, 3rd, 108 and Thoracic Requisites 151-152
• Which does not occur in the upper lobes?
• Silicosis
• Asbestosis
• Sarcoid
• Ankylosing spondylitis
• B. Asbestosis
• Asbestosis presents usually with lower lobe disease progressing superiorly. GG density, interstitial thickening by both CT, HRCT, and plain film begin in peripheral, particularly lower lobe, in the lung. Reference: Dähnert 456..
• LAM has an appearance most closely related to:
• EG (histiocytosis X)
• IPF
• Sarcoid
• silicosis
• A. EG
• LAM is characterized by progressive proliferation of spindle cells resembling immature smooth muscle in the lung parenchyma and along lymphatic channels in the chest and abdomen. Proliferation along the bronchioles leads to air trapping and the development of emphysema and thin-walled lung cysts. Cyst rupture can lead to pneumothorax. The spindle cell proliferation can also involve the lymph nodes of the hila, mediastinum, extrathorax, and may produce dilatation of the intrapulmonary lymphatics and thoracic ducts. Involvement of the lymphatics can lead to chylous pleural effusion. Proliferation of cells in the walls of pulmonary veins may cause venous obstruction and pulmonary hemorrhage. Most patients present with dyspnea. 60% present develop chylous pleural effusions, 40% develop pneumothorax, 30-40% develop blood-streaked sputum or frank hemoptysis.Plain film findings include reticular, reticulonodular, miliary, and honeycomb pattern. Lung volumes are INCREASED. HRCT findings include numerous thin-walled cysts surrounded by relatively normal lung parenchyma. Cyst size increases with progression of disease. Irregularly shaped lung cysts, as are seen in patients with histiocytosis X, are common. Cysts are distributed diffusely throughout the lungs. Rarely see small nodules, adenopathy, GGO, interlobular septal thickening or increased linear septal thickening.Cystic air spaces are common in a variety of fibrotic interstitial lung diseases, especially end-stage IPF and HX. However, the difference in distribution of abnormalities and absence of extensive fibrosis in LAM allow differentiation.
1. A nodular component is present in pts with HX (uncommon in LAM).
2. The irregularly shaped cysts that are common to HX are uncommon in LAM.
3. HX involves the upper 2/3rds of the lungs, spares the CPA's. LAM involves the entire lungs. In some patients, the HRCT findings may be identical. Dähnert 502-503
• Regarding type II pneumocytes, the following are characteristics EXCEPT:
• responsible for the production of pulmonary surfactant
• are capable of DNA synthesis
• are joined to other type II pneumocytes by intercellular bars
• increase in number following injury to the lung
• C. are joined to other type II pneumocytes by intercellular bars. (False)The type I cell covers 95% of the alveolar surface area. It is the squamous pulmonary epithelial cell. The type II cell is a cuboidal cell, located usually at the septal junctions where its cytoplasm is seen to bulge into the air space. These produce pulmonary surfactant by exocytosis. Surfactant decreases surface tension, preventing atelectasis (collapse of the alveoli). Type II cells are the main cell type involved in the repair of alveolar epithelium after destruction of type I cells after injury. All cells forming the alveolar epithelium are joined by zonula occludens (i.e. tight junctions) that enable the cells to form a barrier between the air space and the other components of the septal wall. Terminal bar = junctional complex = zonula occludens (tight junctions) + zonula adherens + macula adherens (the three structures forming a band around the periphery of each cell. The zonula occludens is located at the most apical part of the lateral surface of the cell and represents a ring or circumferential band of plasma membrane union between neighboring cells. In highly impermeable epithelia, there are many points of membrane contact within the zonula occludens rendering the junction impervious to leakage and the cells extremely adherent to each other. The points of contact are anastomosing linear bands between the cells. They are comprised of linear arrays of protein particles that bind neighboring cells together and obliterate the intercellular space. The zonula adherens is a continuous band-like adhesion device that completely surrounds the cell joining it to its neighbors. The macula adherens (desmosome) is a strong, spot contact adhesion device that also participates in joining the cell to its neighbors. (Ross, Histology - A Text and Atlas, 1989) These tight junctions or terminal bars exist between adjacent type I pneumocytes, but type II pneumocytes are usually very far apart from each other, so the bars may be between type I and type II pneumocytes, but not usually between type II pneumocytes simply because of the large distance between them.Type II pneumocytes may differentiate into type I pneumocytes in response to damage to the alveolar lining.Unlike type I cells, type II cells are capable of cell division (DNA synthesis) and can produce type I pneumocytes if the latter are destroyed. Brent & Helms 297
• Which of the following is associated with increased pulmonary compliance?
• alpha 1-antitrypsin deficiency
• idiopathic pulmonary fibrosis
• congestive heart failure
• other choices
• A. Alpha 1 antitrypsin deficiency
• Compliance, or distensibility, is the volume change per unit airway pressure. Compliance is decreased if the pulmonary venous pressure is increased and the lung becomes congested/engorged with fluid (blood, edema). Alveolar edema reduces compliance by preventing the inflation of some alveoli. Diseases causing interstitial fibrosis of the lung decrease compliance. The compliance is increased by age and also by emphysema. In both cases, an alteration in the elastic tissue of the lung is probably responsible. (West, Respiratory Physiology - the Essentials, 1990).Alpha 1-antitrypsin is made in the liver, inhibits many proteases released during inflammatory reactions, and prevents the damaging effects of elastases released by macrophages and particularly neutrophils. Elastase has been shown to produce emphysema. Patients with reduced levels of A1-AT are at increased risk of developing emphysema, especially if they smoke, of the panacinar type. Emphysematous change has lower zone predominance. Bullae and bronchial wall thickening/bronchiectasis are not major features, but may be present. Dähnert 454
• An acute alveolar opacity is seen on chest x-ray in a patient with SLE is most likely due to (single best answer):
• Pneumonitis
• Pneumonia
• alveolar hemorrhage
• drug toxicity
• B. Pneumonia
• There are primary and secondary thoracic manifestations of SLE. However,
-Pneumonia is probably the single most common pleuropulmonary abnormality in SLE occuring in about 50% of patients.
-Acute lupus pneumonitis is an unusual life threatening condition characterized by fever, cough, tachypnea and radiologic consolidation. Clinically it resembles pneumonia, pulmonary infarction, and hemorrhage and is a diagnosis of exclusion. Cavitation is rare and suggests pneumonia or infarction.
-Acute pulmonary hemorrhage in SLE has 70% mortality. Radiographically it resemble Good Pastures Syndrome with airspace opacities that are usually bilateral and diffuse. These occur in a variety of patterns.
-Pleuritis is found in 40-60%. With 50% the pleuritis is dry without effusion. Effusion is exudative. Dähnert 526-527
• The most common community-acquired pneumonia of the elderly:
• Klebsiella pneumonia
• H. influenza
• S. aureus
• S. pneumonia
• S. pyogenes
• D. S. pneumonia
• Diagnosing the cause of pneumonia: 1. The age of the patient and any history of exposure to a specific organism. In infants, viral infections are the dominant cause of pneumonia (RSV), and Mycoplasma infection becomes an important cause in young children. Bacterial pneumonia is relatively rare at these ages. In adults, the predominant cause is bacterial. 2. The source of the infection, particularly whether it was hospital vs. community-acquired. Pneumococcal, mycoplasmal, and viral pneumonias are the common community-acquired pneumonias in adults, with Staph aureus, Strep pyogenes, Klebsiella, Chlamydia, Rickettsia, and Legionella as alternative agents. GNRs, S.aureus, anaerobic organisms, and pneumococci are the prevalent causes of hospital-acquired infections. 3. The character of the illness. Bacterial pneumonia typically presents as an acute illness with chest pain, chills, high fever, and cough productive of sputum. Neutrophilia is common. Mycoplasma and viral pneumonias usually have prodromal symptoms, mild pyrexia, and less sputum. Neutrophilia is absent, and the WBC count is usually only slightly elevated. 4. Predisposing conditions: Aspiration pneumonia is most often due to anaerobic, GNRs, or S.aureus and is common in alcoholics, recent general anesthesia/unconsciousness, or swallowing disturbance. Pneumococcal pneumonia is particularly common in sickle cell disease and following splenectomy. Pseudomonas or S.aureus is common in patients with cystic fibrosis. Klebsiella pneumoniae = Friedlander's pneumonia - like other gram (-) pneumonias, usually affects people with chronic, debilitating illnesses or alcoholism. Symptoms include high fever and toxemia and clinically resemble those of severe pneumococcal pneumonia. Consolidations are similar to pneumococcus, often confined to one lobe, with homogeneous nonsegmental consolidation that spreads rapidly to become a lobar pneumonia. Multilobar and bilateral consolidations may occur. The advancing edge of the pneumonia is sharp and distinct. There may be a predilection for the upper lobes, and bulging fissures is characteristic. Cavitation may occur early and progress quickly, is seen in 30-50% and distinguishes pneumococcus from Klebsiella. Cavities are frequently multiple and may be large. Solitary large chronic abscesses occasionally are seen. Massive necrosis (pulmonary gangrene) is a rare phenomenon. Pleural effusion and empyema are relatively uncommon. H. influenza is considered a gram (-) bacteria. GNRs together with Staph are by far the most frequent causes of hospital-acquired pneumonia. Affected patients usually have a known predisposing factor such as COPD, a major medical condition, or recent surgery. Aspiration is believed to be the common method by which the organisms enter the lungs. The xray pattern for GNRs varies from small, ill-defined nodules to patchy consolidation which may sometimes be confluent and resemble lobar pneumonia or pulmonary edema. Typically the consolidations are multifocal, with the lower lobes nearly always affected, usually bilaterally. 50% the upper and middle lobes are also involved. Cavitation is common. Parapneumonic pleural effusions are common in most GN pneumonias, with empyema a fairly frequent complication. Staph aureus pneumonia usually follows aspiration, especially in debilitated hospitalized patients. It can also be community-acquired in infants and the elderly, often complicating influenza. See patchy segmental consolidation with loss of volume, which may spread rapidly and resemble lobar pneumonia. Abscess cavities may form, common at any age. Pneumatoceles are much more common in childhood and may lead to pneumothorax. Pleural effusions and empyema are common. Streptococcus pneumoniae occurs at any age, is the most common community-acquired bacterial pneumonia across the board, and is a leading cause of hospital-acquired pneumonia. Dementia, seizures, institutionalization, smoking, splenectomy, and various chronic illnesses are predisposing factors. Radiographic picture ranges from round pneumonia (children most commonly) to classic lobar pneumonia, vs. a non-segmental pattern (crosses through pores of Kohn). 57% have parapneumonic pleural effusions, and occasionally the effusion may turn into an empyema. Cavitation is unusual. Pulmonary gangrene is a rare complication. Strep pyogenes is now much less common than pneumococcal pneumonia. It may complicate viral infections or may follow a streptococcal URTI. It appears as a lower lobe-predominant, confluent or patchy consolidation. Large pleural effusions and empyema are common. (Armstrong, Imaging Diseases of the Chest, 1995). Thoracic Req 92
• A 50-year-old woman with hypoglycemia and a 10cm mass in the right lung base on chest X-ray is most likely to have (single best answer):
• small cell lung cancer
• large cell lung cancer
• Mesothelioma
• benign fibrous tumor of the pleura
• D. Benign fibrous tumor of the pleura
• Small cell lung Ca is a neuroendocrine tumor which often causes paraneoplastic syndrome through ectopic hormone production but it is typically centrally located (90 %)and hypoglycemia would be a rare paraneoplastic syndrome. Usually ectopic ACTH, ADH, or parathyroid hormone is produced. Dähnert No association of hypoglycemia with large cell cancer or mesothelioma.
• Benign fibrous tumor of the pleura (formerly benign mesothelioma). Associated with episodic hypoglycemia in 4%.. Sharply circumscribed round/ovoid lobular mass 2-30cm in diameter located near lung periphery. No asbestos association. Dähnert 504 Brant & Helms 465
• A six-month-old with failure to thrive, diarrhea, weight loss and dehydration has interstitial opacities on chest x-ray. Least likely to be seen in this disease is (single best answer):
• meconium ileus equivalent
• Sterility
• Polyposis
• sinusitis
• C. Polyposis
• Assuming cystic fibrosis. Option b (sterility) would be quite common in males and a somewhat smaller number of females are sterile. Sinusitis is a very common findings with hypoplastic frontals.Meconium ileus equivalent (aka distal intestinal obstruction syndrome): intestinal obstruction due to inspissation of viscid intestinal contents in the distal small bowel. Plain films may demonstrate large amounts of feces in distal small bowel, cecum, and right colon, and evidence of obstruction. Treatment is conservative with NG suction, oral N-acetylcystein, Golytely, gastrograffin enemas.?? Polyposis. No association found, except nasal polyps Dähnert 481
• Asymptomatic child with AIDS and multiple pulmonary nodules seen on chest x-ray (single best answer):
• miliary TB
• Lymphocytic Interstitial Pneumonia (LIP)
• Kaposi
• Varicella pneumonia
• B. Lymphocytic interstitial pneumonia (LIP)

• Miliary TB: TB generally presents in kids as primary dz with hilar LAN and lung consolidation. Miliary dz (nodular) can occur but is rarer
• LIP: lymphocytic and plasma cell infiltration of alveolar and interlobular septa: usually have cough and mild hypoxia; older kids act like reactive airways dz; frequent clubbing; seen in 40% of perinatal acquired AIDS CXR: heterogeneous nodules with hilar and mediastinal LAN; the pattern can be fine reticulonodular, coarse RN, or RN with superimposed airspace dz; nodules may resolve with steroids; chronic: bronchiectasis and air cyst (probably postobstructive emphysema)KS: < 5% of kids with AIDS involves the lymph nodes, spleen, GI tract, liver, lung, but not skin (as opposed to adults)Varicella: not that common. When it does occur in kids, it can give irregular nodular masses (unlike the fine miliary pattern with late calcifications seen in adults).Dähnert 452, 502, 532
• In a patient with HIV, bilateral infiltrates and a negative gallium scan, the most likely disease is (single best answer):
• a. PCP
• b. MAI
• c. Kaposi’s
• d. Lymphoma
• C. Kaposi’s sarcoma
• Kaposi’s sarcoma is not Gallium avid (it is, however Thallium avid.) PCP demonstrates diffuse uniform or non-uniform bilateral uptake with intensity greater than liver, usually no uptake in lymph nodes. MAI classically demonstrates patchy lung uptake with hilar and nonhilar (i.e. axillary and inguinal) nodal uptake. Lymphoma rarely has pulmonary uptake, but will demonstrate uptake in involved lymph nodes. Nuc Req 207 Primer 926-927.
• Pulmonary lymphatics are not present:
• within alveolar walls
• within viscera pleura
• within walls of respiratory bronchioles
• within or adjacent to pulmonary veins
• A. alveolar wall
• Pulmonary lymphatics are not present in alveolar walls. (Fraser p.63) They are found in the vascular layer of visceral pleura, interloblar septa adjacent to pulmonary veins, within walls of respiratory bronchioles. The visceral pleura contains a superficial plexus of lymph vessels which drain via the connective tissue septa into a deep venous plexus surrounding the pulmonary blood vessels and airways. Lymph from the deep plexuses drains into the thoracic duct via several prominent lymph nodes within the hilar region. Lymph capillaries are not found in alveolar walls. The visceral pleura also contains numerous small blood vessels and capillaries. (Wheater, Functional Histology, 1987). Thoracic Nuc 482
• Terminal bronchiole defines:
• Segment
• primary pulmonary lobule
• secondary pulmonary lobule
• Acinus
• alveolus
• D. pulmonary acinus.
• Primary pulmonary lobule: consists of all alveolar ducts, alveolar sacs, and alveoli, together with blood vessels, nerves, and connective tissues distal to the last respiratory bronchiole. Approximately 23 million—not seen on X-ray or CT.
• Secondary pulmonary lobule: the smallest discrete portion of the lung that is surrounded by Connective tissue septa. It is composed of 3-5 terminal bronchioles And their transitional airways and parenchyma and has approximately Between 30 and 50 primary lobules.
• Pulmonary acinus: defined as the portion of lung distal to a terminal bronchiole comprising the respiratory bronchioles, alveolar ducts, alveolar sacs and alveoli. This is seen radiographically and proposed by some as the roentgenologic unit instead of the secondary pulmonary lobule.
• Pulmonary alveolus: small cup shaped out-pouching of respiratory bronchioles, alveolar ducts, And alveolar sacs. Region of air exchange. Contain pneumocytes; Dähnert 445-446
• The most common mycotic lung infection in AIDS is:
• Histoplasmosis
• Cryptococcosis
• Aspergillus
• Coccidioidomycosis
• Candida
• B. Cryptococcus
• The most common mycotic pulmonary infection in AIDS is Cryptococcus, usually occuring in association with brain/meningeal involvement. It demonstrates a wide variety of radiographic abnormalities, including single or multiple nodules that may progress to confluence or cavitation, mediastinal adenopathy, segmental consolidation, or bilateral foci of bronchopneumonia. With dissemination, diffuse interstitial or miliary disease may be observed. Rarely, may cause isolated pleural effusion. In endemic regions, histoplasmosis or coccidiomycosis may be more common. Radiology of AIDS. Federle, Megibow, Naidich, p.57-59. Dähnert 452 Thoracic Nuc 142Be aware that the #1 opportunistic infection in AIDS is Pneumocystis Carinii Pneumonia (PCP) seen in 60-80%. It is now classified as a fungus (see http://www.doctorfungus.org ) and would technically be the best answer if it were to be given as a choice.
• The pattern of pulmonary edema seen with upper airway obstruction is:
• Perihilar
• Generalized
• Basilar
• upper lobe
• peripheral
• D. Upper Lobe. Pulmonary edema that follows upper airway obstruction may occur in a variety of clinical situations. The predominant mechanism is forced inspiration against a closed or occluded glottis, inducing large intrapleural and transpulmonary pressure gradients favoring the transudation of fluid from the pulmonary capillaries into the interstitium. Postanesthetic laryngospasm has been implicated as the most frequent cause of this syndrome in adults. Risk factors for development of postlaryngospasm pulmonary edema include difficult intubation; nasal, oral, or pharyngeal surgical site; and obesity with obstructive apnea. The syndrome is recognized by development of hypoxia shortly (1-90 min) after a laryngospasm. A chest radiograph will reveal a symmetric bilateral infiltrate in and UPPER lobe distribution with normal heart size. Cardiogenic pulmonary edema and aspiration must be ruled out. Treatment is directed at correction of hypoxia with supplemental oxygen and use of diuretics (furosemide). Occasionally patients may require intubation. (Anesthesia Progress. 44(3):110-6, 1997 Summer).
• Which of the following is the most common type of TE fistula
• esophageal atresia with proximal TEF
• esophageal atresia with distal TEF
• H-type TEF
• esophageal atresia without fistula
• esophageal atresia with proximal and distal TEF
• B. Esophageal atresia with distal TEF
• Most common is EA and distal fistula (82%), then EA without fistula (9%), no EA with H-type fistula (6%), EA and two fistulas (2%), proximal fistula and distal EA (1%).Reference: Blickman, Pediatric Radiology, The Requisites, page 71.Dähnert 807
• Which of these help distinguish between meconium aspiration and surfactant deficiency
• Hypoaeration
• pulmonary interstitial emphysema
• Pneumothorax
• pneumomedistinum
• A. Hypoaeration
• Meconium aspiration: common cause of RDS in full term/ posterm infants. Hyperinflation with air trapping. Surfactant deficiency (HMD) common in premature infants. HypoaeratedComplication of both include pneumothorax, pneumomediastinum.PIE is usually seen after elevated airway pressures. Dähnert 504 Brant & Helms 1125-1128
• Which of the following causes an exudative pleural effusion?
a. Neoplasm
b. Cirrhosis
c. cardiogenic pulmonary edema
d. non-cardiogenic pulmonary edema
e. nephrotic syndrome/CRF
• A. Neoplasm
• Transudates (protein 1.5-2.5 g/dl) = CHF, constrictive pericarditis, cirrhosis with ascites, nephrotic syndrome, overhydration, glomerulonephritis, peritoneal dialysis, hypothyroidism, chylous
• Exudates (protein > 3 g/dl) = infection, cancer, PE, abdominal disease (pancreatitis, Boerhaave syndrome, subphrenic abscess, abdominal tumor with ascites, Meig’s syndrome, endometriosis, bile fistula, collagen vascular disease--SLE or drugs that cause a lupus like syndrome, trauma, sarcoid, XRT, pneumonitis. Dähnert 438-439
• The most likely cause for bilateral diffuse, granular infiltrate in an 8-year-old with AIDS without symptoms is:
• PCP
• Lymphoma
• Lymphocytic interstitial pneumonia (LIP)
• MAI
• Answers:
• A. False. "Patients with P. carinii or CMV pneumonia are usually chronically ill. The early radiographic findings are central interstitial infiltrates; this pattern may rapidly evolve into confluent airspace disease." Reference: Practical Pediatric Imaging, 3rd Edition, Kirks.
• B. False. "... primarily extranodal, ... solitary/multiple well defined pulmonary nodules often coexistent with pleural effusion +/- axillary / supraclavicular / cervical / hilar adenopathy, ... alveolar infiltrates, paraspinal masses...." Reference: Radiology Review Manual, 3rd Edition, Dähnert .
• C. True. "LIP usually has an insidious clinical onset with only mild cough and dyspnea; radiographically there are diffuse reticulonodular densities." Reference: Practical Pediatric Imaging, 3rd Edition, Kirks.
• D. False. "... adenopathy, pulmonary infiltrates, nodules, miliary disease..." Reference: Radiology Review Manual, 3rd Edition, Dähnert .