RD respiratory formatted Flashcards
- Dyspnea on exertion, weight loss, clubbing. CT chest shows nodular septal thickening, asymmetric. What is the most likely diagnosis? (also recalled as beading along bronchovascular bundles, lymphadenopathy & pleural effusions)
a. Sarcoid
b. Lymphangitic carcinomatosis
c. Extrinsic allergic alveolitis
d. Idiopathic pulmonary fibrosis
b. Lymphangitic carcinomatosis = classic findings
- Dyspnea on exertion, inspiratory crackles. CT chest shows bilateral ground glass and centrilobular nodules. What is the most likely diagnosis
a. Pulmonary oedema
b. Hypersensitivity pneumonitis
c. Pneumocystis pneumonia
b. Hypersensitivity pneumonitis T upper>lower zone, centrilobular nodules, patchy GGO, headcheese sign
- Dyspnea on exertion, inspiratory crackles. CT chest shows bilateral ground glass and centrilobular nodules. What is the most likely diagnosis
a. Pulmonary oedema T possible, esp. if perihilar & LZ predominance. Usually no abnormal physical findings when purely interstitial oedema.
b. Hypersensitivity pneumonitis T upper>lower zone, centrilobular nodules, patchy GGO, headcheese sign
c. Pneumocystis pneumonia F centrilobular nodules less common
- Which of the following is not a recognised feature of primary pulmonary amyloidosis:
a. Nodules in tracheobronchial tree
b. Bronchopleural fistula
c. Peripheral parenchymal nodules
d. Adenopathy
b. Bronchopleural fistula
Pulmonary amyloidosis
• Nodules in tracheobronchial tree
• Parenchymal nodules – peripheral/subpleural
• Adenopathy[Dahnert]
[SK – added a, c & d – only one option recalled]
- Lung disease, which does not cavitate.
a. Small cell cancer
b. Sarcoidosis
c. Wegeners granulomatosis
d. Squamous cell carcinoma
e. Tuberculosis
f. Coccidoidomycosis
a. Small cell cancer F does not normally cavitate (“distinctly rare” – StatDx) – usually central, rapid growth, early mets
4. Lung disease, which does not cavitate.
a. Small cell cancer F does not normally cavitate (“distinctly rare” – StatDx) – usually central, rapid growth, early mets
b. Sarcoidosis T cavitation of occasional nodule (atypical though)
c. Wegeners granulomatosis T cavitation occurs commonly
d. Squamous cell carcinoma T most common lung Ca to cavitate; cavitation occurs commonly in the peripheral form (although SCC more frequently)
e. Tuberculosis T cavitation is a hallmark of secondary TB
f. Coccidoidomycosis T, esp. with more chronic forms
- Most likely location of a pulmonary sequestration
a. Right upper lobe
b. Right middle lobe
c. Left upper lobe
d. Right lower lobe
e. Left lower lobe
e. Left lower lobe
- Typical appearances of PCP (which is true?)
a. Apical location (superior lobe involvement)
b. 25% associated with pleural effusion
c. Usually have associated hilar adenopathy
d. Associated with CMV pneumonia
e. A gallium scan will only become positive once the radiographic findings are clearly evident
d. Associated with CMV pneumonia T CMV has similar predisposition (cell-mediated immunodeficiency); Most common associated infection with PCP; also DDx for PCP; Bilateral diffuse ground-glass opacities most frequent finding
6. Typical appearances of PCP
a. Apical location (superior lobe involvement) ?T typically perihilar progressing to diffuse, often with peripheral sparing. However upper lobe distribution may occur, esp. with aerosolized pentamidine prophylaxis. Cysts, when they occur, are usually upper lobe distribution.
b. 25% associated with pleural effusion F pleural effusion very unusual (< 5%), suggests alternate Dx
c. Usually have associated hilar adenopathy F hilar adenopathy uncommon (10%), more common with other fungal or bacterial infections
d. Associated with CMV pneumonia T CMV has similar predisposition (cell-mediated immunodeficiency); Most common associated infection with PCP; also DDx for PCP; Bilateral diffuse ground-glass opacities most frequent finding
e. A gallium scan will only become positive once the radiographic findings are clearly evident F bilateral & diffuse Ga-67 uptake without mediastinal involvement prior to radiographic changes (Dahnert)
- PCP Radiographic findings: McLoud p125/130-1, B&H p476o Initially bilateral, perihilar or diffuse, symmetric interstitial pattern – may have a finely granular, reticular/reticulonodular or ground-glass appearanceo Untreated progresses over 3-5 days to a homogeneous, diffuse alveolar consolidationo Hilar adenopathy & pleural effusion very unusual (< 5%), suggests alternate Dxo Typically diffuse perihilar with peripheral sparing – less commonly upper lobe distribution, may be assoc/ w/ aerosolised pentamidine prophylaxis
- HRCT findings: may be positive when CXR is normalo Symmetric/bilateral with a central, perihilar or upper lobe predominance*
o Patchy or diffuse GGO*
• May result in a mosaic pattern (normal lung b/w focal GGOs)
• May progress to consolidation
o Cystic changes
• Thin or thick walls, may coalesce to form multiseptated cysts (upper lobe predominance)
• Present in 20-35% of AIDS patients, uncommon in non-AIDS patients
• May cause PTX
o Reticulation & interlobular septal thickening (resolving disease) – may produce a crazy-paving pattern (superimposed on GGO)
o Less common findings incl. focal consolidation (10% of AIDS patients), bronchiectasis or bronchiolectasis, centrilobular or diffuse nodules, pleural effusion & lymphadenopathy
- Which is most correct regarding the typical features of ARDS (LAS recall – ‘false regarding ARDS’)
a. 10% have residual lung changes
b. Changes are typically anterior and non-dependent (LAS – ‘residual CXR’ are in anterior non-dependent portions of lungs)
c. CXR changes often precede clinical respiratory failure
d. Diffuse thromboembolism is a recognized complication
most true A
most false C
- Which is most correct regarding the typical features of ARDS (LAS recall – ‘false regarding ARDS’) (StatDx)
a. 10% have residual lung changes T – mild chronic fibrosis & low lung volumes in 10% (80% return to normal)
b. Changes are typically anterior and non-dependent (LAS – ‘residual CXR’ are in anterior non-dependent portions of lungs) F for acute setting, T for chronic setting. Acute = Dependent intense pulmonary opacification and more nondependent ground-glass opacities (GGO) (like oil and water in a glass). Chronic = Mild reticular pattern in anterior lung (85%), residual GGO (60%), lobular hyperinflation (50%) &/or emphysema (33%).
c. CXR changes often precede clinical respiratory failure F radiographs typically are normal for the first 12-24 hours after the acute injury, despite the presence of dyspnoea. This latent period is suggestive of ARDS
.d. Diffuse thromboembolism is a recognized complication T? = presumably have ↑ risk of thromboembolism (? Can’t find a reference)
- Patient with ascites and splenomegaly (LAS – chronic liver disease). Enhancing (vivid) round structure above the right hilum.
a. Enlarged pulmonary vein
b. Enlarged pulmonary artery
c. Azygos vein
d. Bronchogenic carcinoma
c. Azygos vein
Could represent an enlarged azygos vein in RHF, in the setting of CLD/portal HTN.“Azygos vein enlargement can be detected in congestive heart failure, portal hypertension, inferior vena cava thrombosis, right atrial mural thrombosis, a pulmonary embolism, congenital azygos continuation to the inferior vena cava, and the arteriovenous fistula.” Clinical Imaging July 1999.
If enlarged “hilum”, rather than “above hilum” would think of hepatopulmonary syndrome, a triad of:
• Chronic liver disease (usually cirrhosis)
• Increased alveolar-arterial oxygen gradient on room air (> 15 mmHg)
• Intrapulmonary vascular dilatation Also think of TB (increased risk in chronic liver disease)
40 yo man. ill defined centrilobular nodules. Non-productive cough. Thickened septal.
a. HP
b. lymphangitis
c. RA
d. asbestosis
A = T = hypersensitivity = centrilobular fuzzy nodules; interstitial pattern late (fibrosis)
40 yo man. ill defined centrilobular nodules. Non-productive cough. Thickened septal.
a. HP
b. lymphangitis
c. RA
d. asbestosis
A = T = hypersensitivity = centrilobular fuzzy nodules; interstitial pattern late (fibrosis)
B = F = lymphangitis = perilymphatic distribution (which incl. centrilobular, but typically perihilar; also not usually ill-defined); fissural thickening is present
C = RA = would be atypical
D = Asbestosis = no centrilobular nodules
smoker. 7mm nodule on CT. fisher follow up. what is it?
depends on what type of nodule and risk factor (low, high - only for solid lesions)
solid single
- low : f/u 6- 12mth. Then consider 18-24 mth.
- high : f/u 6- 12 mth. Then 18- 24 mth
Partial solid- 3-6 mth.
Then every 2 years.
if solid > 6 mm is suspicious.
Ground glass - f/u 6 - 12 mth. then every 1 year. If bigger consider resection
which is classically associated with expansion of a lobe?
BAC is a cause of lobar consolidation with bulging fissures.
Also think of Klebsiella pneumonia.
Patient had pneumonia. Treated with antibiotics and then develops thin walled cysts with fluid level. most likely
a. pneumatoceles
b. caveatting pneumonia
c. abscess
A = pneumatocele = produced by virulent organisms (esp. S. aureus) – thin walled cysts filled with air or partially with fluid; thin & smooth-walled
A = pneumatocele = produced by virulent organisms (esp. S. aureus) – thin walled cysts filled with air or partially with fluid; thin & smooth-walled
B = cavitating pneumonia = thick & irregular walls, often with air-fluid level
C = abscess = thick-walled with shaggy inner lining
Drug related lung change. which is false
a. amiodarone and interstitial infiltrates
b. cyclosporine and mass
c. methotrexate and pneumatoceles
d. pneytoin and pleural effusions.
e. an antibiotic and hypersensitivity pneumonia or something like that
C = methotrexate ?F = NSIP is the most common pattern of methotrexate-induced lung disease; also common is hypersensitivity reaction; usually cause diffuse reticulonodular opacities with lower zone predominance; usually subacute allergic response
A = amiodarone T = 18% get lung toxicity, esp. chronic interstitial pneumonitis; upper zones. *LW - pneumonitis and fibrosis.
B = cyclosporine T = drug-induced lymphoproliferative disorder which may appear as solitary mass, multiple lung nodules & hilar nodes
C = methotrexate and pneumatoceles ?F = NSIP is the most common pattern of methotrexate-induced lung disease; also common is hypersensitivity reaction; usually cause diffuse reticulonodular opacities with lower zone predominance; usually subacute allergic response. *LW - hypersensitivity pneumonitis
D = phenytoin = vasculitis, drug-induced SLE; Pleural effusion is a rare complication of phenytoin use that usually occurs early in the course [Chest 2009].
E = hypersensitivity reaction T: cromolyn sodium, erythromycin, nitrofurantoin, isoniazid, penicillin, sulfonamides, bleomycin, methotrexate, procarbazine, penicillamine; features incl. Interstitial and/or alveolar opacities, patchy peripheral airspace opacities, basilar reticulonodular interstitial opacities (opacities may be fleeting)
Patient who you’ve done a CT guided chest biopsy on. small apical pneumothorax post procedure and 4 hrs post has not increased. Next appropriate management:
a. repeat x-ray in 24 hours
b. immediate chest tube
c. repeat car in 4 hrs
d. oxygen
ANS = A ? repeat CXR in 24 hours
Kandarpa V&IR p482
• Small, asymptomatic PTX, stable
o No Tx needed
• Treat PTX if: SOB, acute CP, size > 30% or continues to increase in size
o Aspiration by 18G angiocath; Place biopsy side down position; Serial CXR
o Small (11 Fr) thoracic catheter into pleural space. Can remove several hours later if air leak has ceasedJMIRO 2006In much of the published work with regard to needle lung biopsy carried out as an outpatient procedure, it is commonly cited that patients are discharged when there is no pneumothorax detected after biopsy on a chest radiograph obtained 1–3 h after biopsy. Some researchers recommend a shorter observation period of 30 min from lung biopsy to discharge of patients without pneumothorax. However, in cases complicated by pneumothorax, management thereafter has not been fixed and varies widely. Also, criteria for hospitalization after pneumothorax vary.When pneumothorax detected on CT immediately after lung biopsy is too small to provide a space for insertion of a needle for aspiration or if a detected pneumothorax completely or almost completely disappears after manual aspiration, the required observation period would be short, that is, approximately within 2 days. In such cases, the likelihood of need for a chest tube is slight and early discharge would be a strong possibility. However, in cases when the size of the pneumothorax does not change or increases despite manual aspiration, the requirement of both chest tube placement and hospitalization would be highly possible, as is suggested by the fact that all eight patients belonging to category C of the present study required chest tube placement. In addition, when the pneumothorax tends to decrease after manual aspiration but remains, chest tube placement may be required. Thus, these patients must be carefully observed until confirmation of disappearance of pneumothorax, as suggested by the three patients belonging to category B who required chest tube placement. Also supporting this suggestion is that although 23 category B cases did not require a chest tube, the period until disappearance of pneumothorax was significantly longer than category A patients or those not necessitating aspiration.
- Regarding bronchogenic cysts, which is the LEAST correct?
a. Communicate with the bronchial tree
b. Occur in the mediastinum more than the lung
c. Are part of a spectrum of foregut cysts
d. When have a thick contrast enhancing wall indicate infection
e. High T2 signal
a. Communicate with the bronchial tree F Do not communicate with bronchial tree & thus do not contain air – however, may become infected, when they may gain communication with the tracheobronchial tree. Note – CCAMs do communicate with bronchial tree, while BPS does not communicate.
b. Occur in the mediastinum more than the lung T 65-90% in1.
Regarding bronchogenic cysts, which is the LEAST correct?
a. Communicate with the bronchial tree F Do not communicate with bronchial tree & thus do not contain air – however, may become infected, when they may gain communication with the tracheobronchial tree. Note – CCAMs do communicate with bronchial tree, while BPS does not communicate.
b. Occur in the mediastinum more than the lung T 65-90% in middle mediastinum; less commonly in lung parenchyma esp. lower lobes
c. Are part of a spectrum of foregut cysts T (= foregut duplication cyst)
d. When have a thick contrast enhancing wall indicate infection T wall may enhance with surrounding consolidation if infected
e. High T2 signal T
- Thoracic outlet syndrome, least likely finding on arteriography and venography.
a. Subclavian artery dissection
b. Subclavian artery aneurysm
c. Subclavian artery stenosis
d. Subclavian artery thrombosis
e. Subclavian vein thrombosis
a. Subclavian artery dissectionoracic outlet syndrome, least likely finding on arteriography and venography.a. Subclavian artery dissection
b. Subclavian artery aneurysm T – SCA aneurysm
c. Subclavian artery stenosis T – narrowing of SCA which is positional (abduction)
d. Subclavian artery thrombosis T – mural thrombi
e. Subclavian vein thrombosis T – may be occlusive or non-occlusive
- 25 year old is treated with antibiotics for RLL pneumonia. 1/52 later a RLL cavity with an air fluid level is demonstrated. (LAS Victoria – thick-walled)
a. Infection of bronchogenic cyst
b. Bronchiectasis
c. Cavitary pneumonia
d. Pulmonary abscess
e. Pneumatocoele
**LJS - I would go cavitary pneumonia. Lots of overlap and inconsistency btw terms cavitary pneumonia, necrotising pneumonia, and lung abscess. Lung abscess often due to aspiration in immunocompromised/alcoholic etc. Seems less likely in 25yo
d. Pulmonary abscess – T rounded, focal; thick-walled with shaggy inner lining; typically caused by Staph., Klebsiella, Pseudomonas & Proteus.
25 year old is treated with antibiotics for RLL pneumonia. 1/52 later a RLL cavity with an air fluid level is demonstrated. (LAS Victoria – thick-walled) (SK, JA agree)
a. Infection of bronchogenic cyst – T 10-35% are parenchymal, usually in lower lobes medially. Presence of air indicates infection. Wall thickening may also be seen with infection (StatDx).
b. Bronchiectasis – T cystic bronchiectasis can have air-fluid levels. Least likely answer in this case though.
c. Cavitary pneumonia – T may occur due to S. aureus, gram negatives, anaerobes & TB; thick irregular walls; air-fluid level often present
d. Pulmonary abscess – T rounded, focal; thick-walled with shaggy inner lining; typically caused by Staph., Klebsiella, Pseudomonas & Proteus
e. Pneumatocoele – ?F thin-walled cyst which has thin & smooth walls & may be partially fluid-filled; more common in kids with virulent bugs (S. aureus)If thick-walled, best answer is D.
- 81 year old man presents with a pneumothorax. Which finding is MOST relevant in deciding to insert a chest drain?
a. Complete collapse of the lung
.b. Ipsilateral mediastinal shift.
c. Air fluid level.
d. Visceral pleura has a sharp outline.
e. Lung markings are seen peripherally
**LJS opinion:
Hx does not state there is a haemothorax or hx of trauma/surgery to make you suspect one (and even if there were, you wouldn’t stick in a drain without knowing why they were bleeding). Common for ptx to have reactive effusion - not an indication for chest drain.
e. lung markings seen peripherally - i.e. it’s not a ptx?? If this is what is meant then this would be most relevant in deciding whether to insert a drain!
Otherwise I would say a. (unlikely to re-inflate without drain if complete collapse)
*LW:
Tricky wording, agree with LJS re peripheral lung markings imply no PTx and hence no chest drain should be inserted, while conversely the question states he presents with a PTx….
Also not enough info to decide if primary spontaneous or secondary spontaneous and clinical condition as below guidelines favour put heavy weighting on clinical stability…..
UpToDate guidelines for primary spontaneous:
–> https://www.uptodate.com/contents/image?imageKey=PULM%2F121366&topicKey=PULM%2F117232&source=see_link
- Clinically stable patients with PSP who fail observation or aspiration, patients who are unstable due to pneumothorax, and patients with recurrent PSP should have a tube or catheter thoracostomy placed.
- Thoracostomy is also appropriate in centers without expertise for aspiration as well as in patients with bilateral or very large pneumothoraces (eg, complete collapse), severe symptoms, concurrent hemothorax or pleural effusion necessitating drainage, complex loculated pneumothorax (unusual in PSP).
UpToDate guiedlines for secondary spontaneous:
- Unstable patients should undergo chest tube thoracostomy.
- Stable patients, most should be treated with chest tube as underlying lung disease more likely to increase likelihoof of aspiration failure and development of tension.
BTS 2010 guidelines:
- decision tree is based on wheter Ptx is >2cm or breathless, neither of which are supplied in above question.
- In a Patient > 50yrs with a spontaneous Ptx, > 3cm or breathless, chest drain recommended with admission. If less 1cm and not breathless - admit for observation.
- Selected patients with large PTx who are asymptomatic may be managed with observation alone.
- To add further confusion, recent NEJM paper states conservative management no inferior in outcomes….. (https://www.nejm.org/doi/full/10.1056/NEJMoa1910775)
Previous answer
c. Air fluid level. T all patients with PTX and concurrent haemothorax should undergo chest tube insertion, then thoracoscopy (UTD)
Original answer:
4. 81 year old man presents with a pneumothorax. Which finding is MOST relevant in deciding to insert a chest drain? (SK – from UTD & BTS guidelines 2003)
a. Complete collapse of the lung. ?F Degree of lung collapse not a reliable predictor – total collapse may be prevented by underlying lung disease
b. Ipsilateral mediastinal shift. ¬F contralateral mediastinal shift may indicate tension PTX, however it does not invariably indicate tension & often does not occur if on PPV
c. Air fluid level. T all patients with PTX and concurrent haemothorax should undergo chest tube insertion, then thoracoscopy (UTD)
d. Visceral pleura has a sharp outline. F a sign of PTX
e. Lung markings are seen peripherally. F
Bilateral perilymphatic/bronchovasuclar nodules. lymphadenopathy. no effusion. centrilobular nodules. most likely.
a. sarcoid.
b. lymphangitis carcinomatosis.
A = T = ticks all the boxes, classic; pleural effusion uncommon but can occur (StatDx)
B = certainly possible; 50% have an effusion
young woman. miliary nodular pattern with relative dense nodules. black pleura.
a. alveolar microlithiasis.
b. secondary haemosiderosis
c. sarcoid
A = alveolar microlithiasis = dense lungs; dense miliary calcifications with “sandstorm” appearance; “black pleura” due to small subpleural cysts; average age 35, Turkish people
B = secondary haemosiderosis = nodular interstitial thickening, often with nodular calcification (esp. longstanding mitral stenosis)
C = sarcoid = can have diffuse micronodular pattern; no black pleura though
man with cough not responding to antis. Subpleural shifting consolidation. most likely a. COP
Considerations in migratory consolidation
• Eosinophilic pneumonia
• COP
• Aspiration
• WegenerCOP
• Resembles bronchopneumonia – patchy air space consolidation
• Fails to clear with Abs! Corticosteroids may cause clearing
• Normal lung volumes
pneumothorax post trauma with fractured ribs. biggest reason to worry.
a. dropped lung
b. air /fluid leve
lc. other options that are definition of pneumothorax
***LJS opinion:
dropped lung probably means fallen lung sign - as indication of tracheobronchial injury - rare high mortality injury with high likelihood of other significant injury. I think this is a bigger reason to worry than a haemothorax (could just be bleeding intercostal vessel), might not be terrible given that we know nothing about their haemodynamic state
*LW: agree with above, if referring to fallen lung, this indicates signifcant lung injury with associated mortality, vs relatively common haemopneumothorax…fallen lung - lacerated tracheobronchial tree requires immediate surgical intevention, vs drain for large haemopneumothoraces…
previous answer
B = indicates haemopneumothorax, so needs chest tube & thoracoscopy
25) 25yo female. Ran marathon the previous day and presents with left sided pleuritic chest pain. Low probability VQ scan result. ED reg concerned about ?PE. Asks which imaging test is most appropriate. Which of the following is most appropriate in this clinical setting?:
i) CTPA CTCA triple rule ou
ii) CTPA
iii) Lower limb Doppler
iv) Venous Angiogram
v) Home
*AJL - CTPA - There is a 20% chance of having a PE with a low probability V/Q therefore CTPA is required to rule out PE.
(Previous answers)
CTPA T according to WA imaging pathways
iii) Lower limb Doppler T/F Possibly, according to UTD/PIOPED pathway, although as per UTD “Many patients with PE are likely to be missed. In one report, only 29 percent of patients with PE (determined by V/Q scan or pulmonary angiogram) had venous thrombosis detected by compression ultrasound”1)
25yo female. Ran marathon the previous day and presents with left sided pleuritic chest pain. Low probability V/Q scan result. ED reg concerned about ?PE. Asks which imaging test is most appropriate. Which of the following is most appropriate in this clinical setting?:
i) CTPA CTCA triple rule out F.
ii) CTPA T according to WA imaging pathways
iii) Lower limb Doppler T/F Possibly, according to UTD/PIOPED pathway, although as per UTD “Many patients with PE are likely to be missed. In one report, only 29 percent of patients with PE (determined by V/Q scan or pulmonary angiogram) had venous thrombosis detected by compression ultrasound”
iv) Venous Angiogram F
v) Home
2) 25yo female. Known asthmatic. Chest pain and SOB. Wells score 1. D-dimer –ve. ED reg concerned about ?PE. Asks which imaging test is most appropriate. Which of the following is most appropriate in this clinical setting?:
i) VQ Scan
ii) CTPA
iii) Lower limb Doppler
iv) Venous Angiogram
v) Home
v) Home
Lol this would never happed in chch, CTPA…
Negative D-dimer and low-risk (PE unlikely) clinically = PE excluded. According to WA pathways still need a CXR though
27) 45yo male factory worker presents to respiratory physician with 1-2 weeks of shortness of breath. Afebrile, non smoker, previously healthy. CXR shows interstitial pattern. HRCT shows poorly defined centrilobular nodules and ground glass opacity. Most likely diagnosis?
i) Hypersensitivity pneumonitis
ii) Sarcoid
iii) Silicosis
iv) Asbestosis
v) Pulmonary haemorrhage
i) Hypersensitivity pneumonitis T
3) 45yo male factory worker presents to respiratory physician with 1-2 weeks of shortness of breath. Afebrile, non smoker, previously healthy. CXR shows interstitial pattern. HRCT shows poorly defined centrilobular nodules and ground glass opacity. Most likely diagnosis?
i) Hypersensitivity pneumonitis T
ii) Sarcoid F perilymphatic nodules & septal thickening
iii) Silicosis F perilymphatic
iv) Asbestosis F UIP-type pattern + plaques in 80%
v) Pulmonary haemorrhage F consolidation/GGO
30) Post lung biopsy Xray shows PTX >50% lung volume. No shift or respiratory distress. Best management:
i) Immediate chest drain
ii) Chest drain in 4 hours
iii) Repeat CXR 4 hours
iv) Repeat CXR next day
i) Immediate chest drain The 2006 JMIRO article suggests needle aspiration first, then chest drain if fails. BTS (not specifically post-biopsy) says if > 2cm aspirate, then chest drain if no success. Large (>2cm width or > 50% volume)
31) 28 y.o female sees GP for work physical. CXR shows bilateral hilar and right mediastinal lymphadenopathy. Most likely?
i) TB
ii) Lymphoma
iii) Sarcoidosis
iv) Glandular fever
v) Bacterial Pneumonia
iii) Sarcoidosis T 50% asymptomatic; 1-2-3 sign (Garland’s triad)
Young man. rib lesion with destruction and pleural effusion. most likely.
a. askin tumour
b. fibrous dysplasia
c. neuroblastoma met
A = Askin tumour = PNET = young patients (M=F, 20-30 yrs); rib destruction + malignant effusion (DDx = Ewing, lymphoma, chest wall hamartoma)
A = Askin tumour = PNET = young patients (M=F, 20-30 yrs); rib destruction + malignant effusion (DDx = Ewing, lymphoma, chest wall hamartoma)
B = Fibrous dysplasia = expansile in rib; well defined borders
C = Metastases very possible, but not neuroblastoma in a young man
PE question. true?
a. 75% lower lobe
b. haemorrhage implies infarction
c. viable pneumocystis excludes PE?
A = T = 75% of infarcts occur in lower lobes(Question may belong in Path MCQs)
A = T = 75% of infarcts occur in lower lobes
B = F = haemorrhage commonly occurs WITHOUT infarction
C = F = infarcts only in 10-15%
TB. true?
a. primary TB more effusion than reactivation
b. primary TB is mostly in the upper lobe
A = T = pleural effusions more common in primary than secondary TB
Primary: - initial infection -> can be anywhere. -> predilection for upper or lower zone
- imaging may be-> normal 15%
-> consolidation (70% children, 90% adult),
-> LN low density (90% children, 30% adult)
-> pleural effusion (30-40% in adult, 10-20% in children)
-> miliary 7%
-> form tuberculoma (non-caveating granuloma) - mass like opacity
-> Gohn’s complex (calcified tuberculoma)
-> Ranke complex (gohns + calcified LN)- disease resolve if there is enough host response- completely normal 2/3- gohn 15%- tuberculoma 9%- healing : fibrosis + calcification
Post-primary TB:
- location
-> upper lobe posterior segment
-> superior segment lower lobe
- imaging
-> patchy consolidation
-> more likely to cavitate 50%
-> LN uncommon (1/3)
-> bronchial stenosis
-> cause tree in bud and centrilobular nodules (10-40%)- less common appearance
-> lobar consolidation- miliary TB- tuberculoma (well circumscribed mass in upper lobe) 5%
lateral CXR (which is false)
a. left pulmonary artery posterosuperior
b. bronchus intermedium wall < 3mm
c. right pulmonary artery and vein posterior to bronchus intermedium
c. right pulmonary artery and vein posterior to bronchus intermedium - false
36) 25yo male presents to GP for insurance medical. CXR shows linear structure paralleling right heart border thought to be scimitar vein. CXR from 2 yrs previously shows no change. Which additional finding is most likely?
i) Pulmonary sequestration
ii) Absent ipsilateral pulmonary artery
iii) Mediastinal shift away from the abnormality
iv) Hypoplastic right hemithorax with ipsilateral mediastinal shift
v) Pleural cyst
d. Hypoplastic right hemithorax with ipsilateral mediastinal shift T Scimitar syndrome – right lung hypoplasia, right-sided PAPVR to IVC50.
25yo (? 30 yo) male presents to GP for insurance medical (? With cough). CXR shows linear (? Curvilinear) structure paralelling right heart border thought to be scimitar vein. CXR from 2 yrs previously shows no change. Which additional finding is most likely?
a. Pulmonary sequestration F – although often assoc/ w/ anomalous systemic arterial supply to right lung base
b. Absent ipsilateral pulmonary artery F
c. Mediastinal shift away from the abnormality F shift towards
d. Hypoplastic right hemithorax with ipsilateral mediastinal shift T Scimitar syndrome – right lung hypoplasia, right-sided PAPVR to IVC
e. Pleural cyst Ff. Diaphragmatic eventration ?T – is assoc/ w/ “diaphragmatic abnormalities”
COP. most correct?
a. consolidation on CT
b. does not respond to steroid
c. traction bronchiectasis.
d. honeycombing
A = T = subpleural & peribronchovascular patchy bilateral consolidation; can be focal (persistent nodule/mass)
A = T = subpleural & peribronchovascular patchy bilateral consolidation; can be focal (persistent nodule/mass) B = F = Corticosteroids result in rapid clearing of opacities C = F = not listed D = F
CF in a child. Typical CXR. which is false A. upper lobe bronchiectasis. b. bands of atelectasis c. hypoinflation. d. confluent consolidation
C = F = early hyperinflation, earliest finding (StatDx) – may be reversible early & then permanent
A = T , but later finding
B = T = atelectasis & air-trapping due to mucoid plugs
C = F = early hyperinflation, earliest finding (StatDx) – may be reversible early & then permanent
D = T = esp. in setting of pneumonia (recurrent Pseudomonas, Staph & H. influenza)
CCAM. false.
a. most common in lingual and middle lobes.
b. pulmonary hypoplasia
c. 4 times more common in males
d. multiple cysts < 12mm
e. single cyst > 2cm
A = F = no lobar predilection (unlike CLE & BPS) – StatDx, DahnertNote:- no lobar predilection- if large -> can cause pulmonary hpoplasia- more common in male (radiopedia)
Association:
- pulmonary hypoplasia
- mixed lesion (pulmonary sequestration)- congenital heart disease
- renal agenesis
- cancer
- > pleuroparenchymal blastema
- > lung cancer
- > rhabdomyosarcoma
Complication
- pneumothorax
- haematothorax
- pyeothorax
- cancer
- hydrops, pulmonary hypoplasia, fetal death
type I
most common: 70% of cases 3 large cysts one or more dominant cysts: 2-10 cm in size may be surrounded by smaller cysts
type II
15-20% of cases 3 cysts are <2 cm in diameter associated with other abnormalities renal agenesis or dysgenesis pulmonary sequestration congenital cardiac anomalies
type III
~10% of cases microcysts: <5 mm in diameter typically involves an entire lobe has a poorer prognosis
type IV
unlined cyst typically affects a single lobe indistinguishable from type I on imaging
41) Post pneumonectomy, most concerning sign of complication
a. Rising air-fluid level
b. Mediastinal shift toward surgery side
c. Mediastinal shift away from surgery side
d. No change in position of mediastinum
e. Filling cavity
f. Decreased volume of pneumonectomy hemithorax
c. Mediastinal shift away pneumonectomy side ¬T concerning for bronchopleural fistula
Normal post-pneumonectomy findings
o Immediate: expanded contralateral lung, midline trachea, air-filled post-pneumonectomy space
o < 7 days: mediastinum remains midline or shifts toward surgery side
o 7 days: air-fluid level at lower 1/2 to 2/3 of hemithorax
o 2-4 months: complete filling post-pneumonectomy space with fluid
o > 4 months: opaque post-pneumonectomy space, permanent mediastinum shift to surgery side
Bronchopleural fistulao 2-13% of patientso Right > left (shorter length & less effective concealment of bronchial stump, also supplied via single bronchial artery)
o Causes:
• Early BP fistula – due to inadequate surgical technique (bronchial ischaemia) or infection of the bronchial stump
• Late BP fistula (months) – recurrent malignancyo Risk factors:
• Uncontrolled pre-op pleuropulmonary infection
• Pre-op XRT
• Steroids, malnutrition
• Trauma
• Post-op PPV
• Faulty closure of bronchial stump
o CXR
• Failure of pneumonectomy space to fill with pleural fluid
• Abrupt decrease in air-fluid level in pneumonectomy space (a drop of > 2 cm in previous location of air-fluid level
)• Contralateral shift of mediastinum following pneumonectomy
• Persistent PTX despite functioning chest tubes
• New collection of air in a previously completely opacified pneumonectomy space
- 60yo male with 20 pack year Hx of smoking. Pre-employment CXR which shows 1.5cm nodule in LLL. CT chest confirms LLL nodule and minor emphysema. No other significant findings. Full body FDG-PET is performed to assess for malignancy. PET shows no uptake in the LLL. Which of the following is the next apprioprate investigation strategy
a. Stop, malignancy exluded
b. Repeat CT in 3/12
c. Dynamic contrast-enhanced CT
d. Repeat PET 3/12
e. Broncoscopy
b. Repeat CT in 3/12 T – according to WA imaging pathways, perform serial CT or biopsy For SPN larger than 1.0 cm, PET has sensitivity and specificity of 95-98% and 73-85% respectively. Tumor with low metabolic rate (low grade adenocarcinoma, BAC, carcinoid) may show minimal uptake.
- Which of the following statements regarding asbestos related chest disease is TRUE?
a. A hemorrhagic effusion excludes the diagnosis of a benign pleural effusion
b. Pleural effusion is usually the earliest manifestation
c. Contrast enhancement of round atelectasis is a usual feature on CT
d. Asbestosis commonly occurs in the absence of pleural plaques
e. The apical and costo-phrenic angles are sites of predilication for benign pleural plaques
b. Pleural effusion is usually the earliest manifestation T – “Earliest asbestos-related pleural abnormality” (Dahnert); often occurs within 8-10 years of asbestos exposure. May eventually evolve into diffuse pleural thickening. StatDx: “Most common early (within 10 years of exposure) manifestation of asbestos-related pleural disease but latent period may be significantly longer”
- *LJS - agree with b.
https: //pubs.rsna.org/doi/full/10.1148/radiographics.22.suppl_1.g02oc10s167
c. Contrast enhancement of round atelectasis is a usual feature on CT T homogenous enhancement of atelectatic lung – can also be seen with bronchogenic carcinoma! (StatDx)
2. Which of the following statements regarding asbestos related chest disease is TRUE?
a. A hemorrhagic effusion excludes the diagnosis of a benign pleural effusion F benign effusion may be serous or blood
b. Pleural effusion is usually the earliest manifestation T – “Earliest asbestos-related pleural abnormality” (Dahnert); often occurs within 8-10 years of asbestos exposure. May eventually evolve into diffuse pleural thickening. StatDx: “Most common early (within 10 years of exposure) manifestation of asbestos-related pleural disease but latent period may be significantly longer”
c. Contrast enhancement of round atelectasis is a usual feature on CT T homogenous enhancement of atelectatic lung – can also be seen with bronchogenic carcinoma! (StatDx)
d. Asbestosis commonly occurs in the absence of pleural plaques F pleural plaques present at CT in 80% with asbestosis (StatDx)
e. The apical and costo-phrenic angles are sites of predilication for benign pleural plaques F most frequently occur on the anterior & posterolateral aspects of the costal pleura & on the diaphragmatic pleura
- With regards to cryptogenic organizing pneumonia (COP), which of the following statements is TRUE?
a. Lung volumes are reduced in most cases
b. There is a strong association with smoking
c. Areas of consolidation are evident on HRCT
d. The apices are predominantly involved
e. Areas of fibrosis alternating with normal lung are evident on HRCT.
c. Areas of consolidation are evident on HRCT T
- 30yo male CXR for Ix of cough. Normal physical examination. CXR is normal except for a retrocardiac density which splays carina. No calcification or spinal lesions. MOST LIKELY explanation for the retrocardiac density is?
a. Bronchogenic cyst
b. Neurogenic cyst
c. Hiatus hernia
d. Left atrial enlargement
e. Oesophageal tumor
a. Bronchogenic cyst T often subcarinal & may have mass effect
4. 30yo male CXR for Ix of cough. Normal physical examination. CXR is normal except for a retrocardiac density which splays carina. No calcification or spinal lesions. MOST LIKELY explanation for the retrocardiac density is?
a. Bronchogenic cyst T often subcarinal & may have mass effect
b. Neurogenic cyst F expect spinal changes
c. Hiatus hernia F posterior mediastinum
d. Left atrial enlargement F can cause splaying of carina, but would expect cardiomegaly (LA & LV enlargement usually, e.g. in MR)
e. Oesophageal tumor F
- CCAM, which is the most correct?
a. 5% of all congenital lung disease
b. The lung mass has a well-defined internal bronchial tree
c. The mass often has a number of large air-filled cysts
d. It most commonly appears as a homogeneous lung mass
e. CCAM receives its blood supply from the systemic circulation
c. The mass often has a number of large air-filled cysts T type I lesions have cysts > 2cm
5. CCAM, which is the most correct?
a. 5% of all congenital lung disease F 25% of all congenital lung disorders, or 95% of cystic lung disease
b. The lung mass has a well defined internal bronchial tree F classically communicate with bronchial tree, however lung tissue is dysplastic
c. The mass often has a number of large air-filled cysts T type I lesions have cysts > 2cm
d. It most commonly appears as a homogeneous lung mass F variable
e. CCAM receives its blood supply from the systemic circulation F normal pulmonary vascular supply & drainage type I 50% single/multiple large cyst(s) >20mmtype II 40% multiple uniform cysts 5-12mmtype III 10% microcystic (3-5mm cysts, appears solid).
- Which of the following is NOT a significant predisposing factor for acquiring a bronchopleural fistula post pneumonectomy?
a. Left pneumonectomy
b. Uncontrolled pulmonary infection
c. Pre-operative XRT
d. Post-operative positive pressure ventilation
e. Faulty closure of the bronchial stump
a. Left pneumonectomy F More common with a right sided pneumonectomy due to shorter bronchi and single bronchial artery.
6. Which of the following is NOT a significant predisposing factor for acquiring a bronchopleural fistula post pneumonectomy? (Straight from RG 06 article)
a. Left pneumonectomy F More common with a right sided pneumonectomy due to shorter bronchi and single bronchial artery
.b. Uncontrolled pulmonary infection T pre-op
c. Pre-operative XRT T
d. Post-operative positive pressure ventilation T
e. Faulty closure of the bronchial stump T
- Which of the following statements is the MOST correct description for intralobar sequestration?
a. It does not have a complete pleural investment
b. May occur above, within or below the diaphragm
c. Typically has venous drainage to the pulmonary veins
d. Usually occurs on the right side
e. Often presents as a cavitating mass
c. Typically has venous drainage to the pulmonary veins T usually to inferior pulmonary vein (95% of ILS drain to pulmonary veins)
7. Which of the following statements is the MOST correct description for intralobar sequestration?
a. It does not have a complete pleural investment T no pleural covering (contained within the substance of the lung); StatDx – contiguous with normal lung & a thick fibrinous visceral pleural lining; shares visceral pleura of normal lung
b. May occur above, within or below the diaphragm F contained within the substance of the lung
c. Typically has venous drainage to the pulmonary veins T usually to inferior pulmonary vein (95% of ILS drain to pulmonary veins)
d. Usually occurs on the right side F LLL>RLL
e. Often presents as a cavitating mass T? can appear as an air-containing single or multicystic lesion (not sure if “often” though)ILS usually presents later than ELS. Patients with ILS usually present in late childhood or adolescence with recurrent pulmonary infections. ELS more apt to present in early life from resp distress / cyanosis / or assoc abnormalities. Both can be an incidental antenatal Dx too. 65% of ELS assoc with other anomalies. ILS not associated with other anomalies. ILS occurs more commonly (70%) vs ELS (30%). ELS is almost always LLL. In ILS LLL (60%) > RLL (40%). Congenital anomalies ELS>ILS.
- 10yo male, previously well. 7d Hx of fever and dry cough. CXR patchy airspace opacity at both lung bases with assoc linear atelectasis. No other abnormality. Which of the following is MOST LIKELY Dx?
a. Pneumococcal pneumonia
b. Pneumocystis pneumonia
c. Mycoplasma pneumonia
d. Staphylococcal pneumonia
c. Mycoplasma pneumonia – causes 30% of LRTIs in school-aged children; CAP in previously well; typically reticulonodular opacification often confined to one lobe; may evolve into patchy segmental airspace consolidation (esp. lower lobes), which may coalesce to produce lobar consolidation.
10yo male, previously well. 7d Hx of fever and dry cough. CXR patchy airspace opacity at both lung bass with assoc linear atelectasis. No other abnormality. Which of the following is MOST LIKELY Dx?
a. Pneumococcal pneumonia – most common cause of lobar pneumonia in childhood; typically homogenous consolidation with air bronchograms; lobar or sublobar
b. Pneumocystis pneumonia – unlikely without immunosuppression, perihilar
c. Mycoplasma pneumonia – causes 30% of LRTIs in school-aged children; CAP in previously well; typically reticulonodular opacification often confined to one lobe; may evolve into patchy segmental airspace consolidation (esp. lower lobes), which may coalesce to produce lobar consolidation
d. Staphylococcal pneumonia – a cause of multiple bilateral alveolar infiltrates; causes patchy bilateral opacities
- 25yo female. Ran marathon the previous day and presents with left sided pleuritic chest pain. ED reg concerned about ?PE. Asks which imaging test is most appropriate. Which of the following is most appropriate in this clinical setting?
a. CTPA CTCA triple rule out scan
b. Lower limb duplex US
c. Proceed to CTPA
d. Proceed to V/Q
e. Proceed to CTPA and CT pelvic and lower limb venography
c. Proceed to CTPA
Controversial
Deep Vein Thrombosis and Pulmonary Embolism in Endurance Athletes…endurance athletes are exposed to many of the physical factors contributing to DVT, experiencing repetitive microtrauma, endothelial damage, and dehydration/hemoconcentration during competition, followed by periods of inactivity, immobility, and stasis while traveling to and from and/or recovering from the athletic event. There are several published case studies regarding athletes who have experienced DVT and PE following competition or physical activity. Of interest (i.e. a possible MCQ):Chris Staniforth, a video game designer at the UK’s Leicester University, died earlier this year as a result of what was later found to be a pulmonary embolism——after he reportedly spent hours engaged in a marathon gaming session on his Xbox. Classification for PiopedHigh probabilitytwo or more large mismatched segmental defects or equivalent moderate/large defects with a normal x-rayany perfusion defect substantially larger than the radiographic abnormalityIntermediate probabilitymultiple perfusion defects with associated radiographic opacities>25% of a segment and less than two mismatched segmental perfusion defects withnormal radiographone moderate segmentalone large or two moderate segmentalone large and one moderate segmentalthree moderate segmentaltriple match: solitary moderate-large matching segmental defect with matching radiographdifficult to characterize as high probability or low probabilitysingle matched ventilation-perfusion defect with clear chest radiographthis is considered borderline low/intermediate probability, but should be classified as intermediate in most circumstances by most readers, as described in Table 5 of Gottschalk article 1Low probabilitynonsegmental defects: small effusion, blunting costophrenic angle, cardiomegaly, elevated diaphragm, ectatic aortaany perfusion defect with a substantially larger radiographic abnormalitymatched ventilation and perfusion defects with a normal chest radiographsmall subsegmental perfusion defectsNormal scanno perfusion defects
- Regarding pulmonary scintigraphy, which is TRUE?
a. Technegas is given as a dose 5x that of macro-aggregated albumin
b. Modified PIOPED reporting criteria includes a “normal” scan
c. Pleural perfusion seen overlying a deeper perfusion defect is high probability
d. Technigas examination is performed after perfusion study
e. Pregnancy is an absolute contra-indication to V/Q scanning.
b. Modified PIOPED reporting criteria includes a “normal” scan T (high, intermediate, low & normal)
10. Regarding pulmonary scintigraphy, which is TRUE?
a. Technegas is given as a dose 5x that of macro-aggregated albumin ? T Technegas 900-1300 MBq, MAA 110-185 MBq
b. Modified PIOPED reporting criteria includes a “normal” scan T (high, intermediate, low & normal)
c. Pleural perfusion seen overlying a deeper perfusion defect is high probability F I think they’re talking about the “stripe sign” which has a “very low probability” of being a PE
d. Technegas examination is performed after perfusion study F the ventilation study is usually performed first, i.e. technegas before perfusion MAA
e. Pregnancy is an absolute contra-indication to V/Q scanning. F some advocate it over CTPA in pregnancy (mainly for the breast dose, fetus dose actually higher than in CTPA)
- Regarding imaging in the Immunocompromised patient, which is TRUE?
a. Low density lymphadenopathy on CT is characteristic of Kaposi’s sarcoma
B. MRI is sensitive to early changes in HIV encephalitis
c. Pneumocystic carinii pneumonia typically involves the lung bases following Rx with inhaled pentamidine
d. MAC infection, peripheral lymphadenopathy is usually more marked than abdominal lymphadenopathy
e. Toxoplasmosis lesions occur most commonly in the basal ganglia
e. Toxoplasmosis lesions occur most commonly in the basal ganglia T Basal ganglia, corticomedullary junction, thalamus, cerebellum most common sites (StatDx)
11. Regarding imaging in the Immunocompromised patient, which is TRUE?
a. Low density lymphadenopathy on CT is characteristic of Kaposi’s sarcoma F markedly enhancing lymphadenopathy
b. MRI is sensitive to early changes in HIV encephalopathy ?F can’t find in Dahnert, StatDx or Google.
c. Pneumocystis carinii pneumonia typically involves the lung bases following Rx with inhaled pentamidine F some have upper lobe predominance if on pentamidine (StatDx)
d. MAC infection, peripheral lymphadenopathy is usually more marked than abdominal lymphadenopathy F – thickened SB folds; mesenteric & periportal adenopathy with low-attenuation nodes
e. Toxoplasmosis lesions occur most commonly in the basal ganglia T Basal ganglia, corticomedullary junction, thalamus, cerebellum most common sites (StatDx)
- Which following drug associations is NOT an association?
a. Cyclosporine and solitary pulmonary mass
b. Methotrexate and pneumatoceles
c. Amiodarone and interstitial infiltrates
d. Phenytoin and pleural effusion
e. Sulfasalazine and peripheral eosinophilic pneumonia
b. Methotrexate and pneumatoceles ?T = NSIP is the most common pattern of methotrexate-induced lung disease; also common is hypersensitivity reaction; usually cause diffuse reticulonodular opacities with lower zone predominance; usually subacute allergic response; ALTHOUGH 10% of subacute HS pneumonitis get “lung cysts” (statdx). StatDx says 10% of HSP get cysts, RG09 says ‘occasionally’ find lung cysts’ in HSP.
12. Which following drug associations is NOT an association?
a. Cyclosporine and solitary pulmonary mass T = drug-induced lymphoproliferative disorder which may appear as solitary mass, multiple lung nodules & hilar nodes
b. Methotrexate and pneumatoceles ?T = NSIP is the most common pattern of methotrexate-induced lung disease; also common is hypersensitivity reaction; usually cause diffuse reticulonodular opacities with lower zone predominance; usually subacute allergic response; ALTHOUGH 10% of subacute HS pneumonitis get “lung cysts” (statdx). StatDx says 10% of HSP get cysts, RG09 says ‘occasionally’ find lung cysts’ in HSP.
c. Amiodarone and interstitial infiltrates T = 18% get lung toxicity, esp. chronic interstitial pneumonitis; upper zones. *LW - pneumonitis and fibrosis.
d. Phenytoin and pleural effusion = ?T = vasculitis, drug-induced SLE; Pleural effusion is a rare complication of phenytoin use that usually occurs early in the course [Chest 2009].
e. Sulfasalazine and peripheral eosinophilic pneumonia T common
- Most common cause of unilateral or asymmetric pulmonary oedema
a. COPD with fluid overload
b. Neurogenic pulmonary oedema
c. ARDS
d. Excessively rapid draining of a large pleural effusion
e. Prolonged decubitus position in congestive heart failure.
e. Prolonged decubitus position in congestive heart failure.Unilateral oedema with ipsilateral pathology- severe mitral valve regurgitation- positioning- re-expansion pulmonary oedema- pulmonary vein occlusion- congenital or surgical right-to-left shunt (e.g. Blalock-Taussig shunt)
- 40yo working male with 2 week Hx progressive dyspnoea. Smokes pack of cigarettes a day. Afebrile. No significant medical history. CXR shows diffuse interstitial infiltrate and HRCT shows centrilobular nodular ground glass infiltrates. MOST LIKELY Dx?
a. Hypersensitivity pneumonitis
b. Asbestosis
c. RB-ILD
d. Pulmonary hemorrhage
c. RB-ILD T “Centrilobular ground-glass opacities in the upper lobes”
14. 40yo working male with 2 week Hx progressive dyspnoea. Smokes pack of cigarettes a day. Afebrile. No significant medical history. CXR shows diffuse interstitial infiltrate and HRCT shows centrilobular nodular ground glass infiltrates. MOST LIKELY Dx?
a. Hypersensitivity pneumonitis F smoking protects from hypersensitivity pneumonitis (StatDx)
b. Asbestosis F 20-40 year latency period (i.e. too young); UIP pattern
c. RB-ILD T “Centrilobular ground-glass opacities in the upper lobes”
d. Pulmonary hemorrhage – F diffuse haemorrhage usually acute onset with diffuse bilateral GGO & consolidation
- Enlargement of lobe of lung?
a. Alveolar cell carcinoma
b. Pulmonary sequestration
c. Bronchiectasis
d. Meliodiosis
e. Radiation pneumonitis
a. Alveolar cell carcinoma T Lobar consolidation may cause lobar expansion with bulging fissures (StatDx) – now called adenocarcinoma in-situ (previously BAC)
15. Enlargement of lobe of lung?
a. Alveolar cell carcinoma T Lobar consolidation may cause lobar expansion with bulging fissures (StatDx) – now called adenocarcinoma in-situ (previously BAC)
b. Pulmonary sequestration F
c. Bronchiectasis F
d. Meliodiosis F Burkholderia pseudomallei is a fungus which can present as pneumonia; can cause lobar consolidation, can’t find lobar expansion (ERJ September 1, 2003 vol. 22 no. 3 542-550)
e. Radiation pneumonitis F Pulmonary consolidation with sharply defined linear or curvilinear interface
- Not characteristic of UIP
a. Basal predominance
b. Nodules
c. Honeycombing
d. Reticular pattern
e. Traction bronchiectasis
b. Nodules T not a feature of IPF & most other causes of UIP pattern, but can occur in UIP secondary to HSP
- Lateral CXR, most correct?
a. Left pulmonary artery forms the superior and anterior aspects of hilar shadow
b. Anterior part of hilar complex is isodense with heart
c. RUL bronchus lies above LUL / Left main bronchus
d. Composite shadow of right pulmonary artery and right and left pulmonary veins lies behind bronchus intermedius
e. Posterior wall of bronchus intermedius should be 5mm thick
c. RUL bronchus lies above LUL / Left main bronchus T see below
17. Lateral CXR, most correct?
a. Left pulmonary artery forms the superior and anterior aspects of hilar shadow F superior & posterior
b. Anterior part of hilar complex is isodense with heart ?F
c. RUL bronchus lies above LUL / Left main bronchus T see below
d. Composite shadow of right pulmonary artery and right and left pulmonary veins lies behind bronchus intermedius F lies anterior to BI
e. Posterior wall of bronchus intermedius should be 5mm thick F normally < 3mm
- Which of the following is not a typical radiographic feature of CF in children?
a. CXR abnormality at birth
b. Hyperinflation of lungs
c. Upper lobe predominant bronchiectasis
d. Hilar lymphadenopathy
e. Apical cystic airspaces
a. CXR abnormality at birth F lungs normal at birth
18. Which of the following is not a typical radiographic feature of CF in children
a. CXR abnormality at birth F lungs normal at birth
b. Hyperinflation of lungs T
c. Upper lobe predominant bronchiectasis T
d. Hilar lymphadenopathy T – recurrent infection, superimposed on PAH
e. Apical cystic airspaces T upper lobe predominance
60.A 24 year old athlete presents with left pleuritic chest pain after running a marathon yesterday. VQ scan was reported as low probability of PE. CXR showed no abnormality. The ED medical staff phone you for advice regarding the next most appropriate step and you advise:
- No further imaging required
- CTPA
- Repeat the VQ scan in 1 week
- Ultrasound both legs
- CTPA and lower limb venography
- CTPA - T Possibly, according to WA imaging pathways
- A 24 year old athlete presents with left pleuritic chest pain after running a marathon yesterday. VQ scan was reported as low probability of PE. CXR showed no abnormality. The ED medical staff phone you for advice regarding the next most appropriate step and you advise: (SK)
- No further imaging required - F
- CTPA - T Possibly, according to WA imaging pathways
- Repeat the VQ scan in 1 week - F – you want another low probability result?
- Ultrasound both legs - T/F Possibly, according to UTD/PIOPED pathway, although as per UTD “Many patients with PE are likely to be missed. In one report, only 29 percent of patients with PE (determined by V/Q scan or pulmonary angiogram) had venous thrombosis detected by compression ultrasound”
- CTPA and lower limb venography - F -
- Regarding the thymus, which is most correct?
- An increase in size post chemotherapy is indicative of disease recurrence
- Hyperplasia of the thymus is the most common cause of a mediastinal mass in adolescence
- Thymolipoma compresses vessels
- Thymoma spreads by direct extension along pleural reflections
- Thymoma spreads by direct extension along pleural reflections – T/F – True if question specified ‘invasive’ thymoma which is locally invasive, spread by contiguity along pleural reflections, extension along aorta reaching posterior mediastinum/crus/retroperitoneum. [Dahnert pg537]
- Regarding the thymus, which is most correct? (GC/SK) RG 2010 article
- An increase in size post chemotherapy is indicative of disease recurrence - F - rebound hyperplasia may occur post chemotherapy (atrophies during chemo, then grows back to its original/larger size after cessation). However, a mediastinal mass arising in adolescents and adults after treatment for cancer is suspicious of relapse [Eur J Pediatr 1992]. Distinguishing a prominent but normal thymus in young pts, and thymic hyperplasia from lymphomatous involvement is problematic; the use of chemical shift MRI and PET have been described [Thymus RG 2006]. The thymus may show striking FDG avidity in rebound hyperplasia (RG 2010].
- Hyperplasia of the thymus is the most common cause of a mediastinal mass in adolescence – T/F - Normal thymus reaches its maximum (absolute) weight in puberty and subsequently undergoes involution. Thymic hyperplasia is the most common cause of an anterior mediastinal mass in adolescent (D p536). HOWEVER “Lymphoma is the most common cause of an anterior mediastinal mass in children and the second most common cause of an anterior mediastinal mass in adults [RG 2010]. AND “Lymphoma is the most common anterior mediastinal mass in children” [Radiology assistant]
- Thymolipoma compresses vessels – T/F - may drape around heart (enlarged CTR, or apparent elevated hemidiaphragm); no compression/invasion of adjacent structures; fatty mass with fibrous septa. HOWEVER RG 2010 states they are pliable, but about 50% cause mass effect without invading neighbouring structures – also although mostly asymptomatic, can present with compression-related symptoms
- Thymoma spreads by direct extension along pleural reflections – T/F – True if question specified ‘invasive’ thymoma which is locally invasive, spread by contiguity along pleural reflections, extension along aorta reaching posterior mediastinum/crus/retroperitoneum. [Dahnert pg537] BEST ANSWER – LIKELY NO. 4
- 65 year old male construction worker. Dyspnoea and hilar mass with calcifications. The most likely explanation is
- Asbestosis
- Silicosis
- Sarcoidosis
- Tuberculosis
2.Silicosis - T - given Hx of construction worker. Complicated silicosis (= PMF) - large opacities in hilar region resulting from nodule coalescence. The large opacities gradually migrate toward hilum. CT features of PMF are focal soft-tissue masses, often with irregular or ill-defined margins and calcifications, surrounded by emphysematous change. Simple silicosis = multiple nodular opacities that are well defined and uniform in shape and attenuation and that range from 1-10mm in diameter. Upper lobe and posterior portion of lung predominance. Calcification of nodules seen on CXR in 10-20%. 3.
65 year old male construction worker. Dyspnoea and hilar mass with calcifications. The most likely explanation is (TW)
- Asbestosis - F - potential exposure, but would have calcified plaques, and round atelectasis peripheral and not calcified.
- Silicosis - T - given Hx of construction worker. Complicated silicosis (= PMF) - large opacities in hilar region resulting from nodule coalescence. The large opacities gradually migrate toward hilum. CT features of PMF are focal soft-tissue masses, often with irregular or ill-defined margins and calcifications, surrounded by emphysematous change. Simple silicosis = multiple nodular opacities that are well defined and uniform in shape and attenuation and that range from 1-10mm in diameter. Upper lobe and posterior portion of lung predominance. Calcification of nodules seen on CXR in 10-20%.
- Sarcoidosis
- Tuberculosis
63.Which of the following is the most correct regarding primary tuberculosis (more than secondary form)?
- Upper lobe cavity
- Effusion more in primary
- Absence of lymphadenopathy
- Consolidation in posterior segment of upper lobe
- Effusion more in primary - T - pleural effusions occur most often in primary TB which occurs in about 25% patients (effusion is often sole manifestation of TB and usually manifests 3-7 months after initial exposure). Effusion is usually unilateral. In postprimary TB approx 18% of patients have effusion (usually small and associated with parenchymal disease; effusion typically septated and can remain stable in size for many years).
- Which of the following is the most correct regarding primary tuberculosis (more than secondary form)? (TW)
- Upper lobe cavity - F - predominance in lower and middle lobes, especially in adults, typically adjacent to interlobar fissure.
- Effusion more in primary - T - pleural effusions occur most often in primary TB which occurs in about 25% patients (effusion is often sole manifestation of TB and usually manifests 3-7 months after initial exposure). Effusion is usually unilateral. In postprimary TB approx 18% of patients have effusion (usually small and associated with parenchymal disease; effusion typically septated and can remain stable in size for many years).
- Absence of lymphadenopathy - F - distinguishing feature of postprimary TB vs primary.
- Consolidation in posterior segment of upper lobe - F - earliest finding in parenchymal TB in postprimary disease is patchy, poorly defined consolidation, particularly in the apical and posterior segments of the upper lobes. Majority of cases more than one pulmonary segment is involved, with bilateral disease in 1/3 to 2/3rds.
