Welcome
Logout
Chest and Vascular
1. A 79 year old male nursing home resident had become increasingly short of breath over the preceding few months. A GP chest x-ray shows bilateral symmetrical lower zone fibrosis and a small left pleural effusion. Which of the following is the single most likely cause of this appearance in this patient?
Rheumatoid disease
Sarcoid
Chronic Extrinsic Allergic Alveolitis (EAA)
Ankylosing spondylitis
Aspirin
Fibrosis in rheumatoid disease involves the subpleural regions in particular the lower lung zones. Pleural effusions are the most common radiographic manifestation of rheumatoid disease and are more common in men. Sarcoid, Chronic EAA and ankylosing spondylitis are all causes of bilateral upper lobe fibrosis. Aspirin can cause pulmonary oedema and pulmonary haemorrhage.
2. A 50 year old post renal transplant patient is admitted with chest pain. A chest x-ray shows the outer ends of the clavicles are eroded. The most likely cause in this patient would be:
Hyperparathyoidism
Gorlin syndrome
Rheumatoid arthritis
Cleidocranial dysplasia
Osteogenesis imperfecta
Hyperparathyroidism and rheumatoid arthritis can cause erosion of the lateral end of the clavicles. In Gorlin syndrome and cleidocranial dysplasia the lateral ends of the clavicles can be hypoplastic. Osteogenesis imperfecta usually causes diffuse demineralisation with multiple fractures. As this patient has a renal transplant, the most likely diagnosis in this case is hyperparathyroidism.
3. A 35 year old male undergoes a CT pulmonary angiogram at which a 4 cm non-calcified cyst is seen between the oesophagus and carina which displaces the carina anteriorly. What is the most likely diagnosis?
Hamartoma
Neuroenteric cyst
Aberrant left pulmonary artery
Bronchogenic cyst
Oesophageal duplication cyst
Bronchogenic cysts usually contact the carina or main bronchi and usually have a CT density similar to water (although haemorrhage or infection in the cyst can cause an increased CT density). Hamartomas are frequently located peripherally of the lung and often contain central fat density or calcification. Neuroenteric cysts are usually located between the oesophagus and spine. An aberrant left pulmonary artery can displace the carina anteriorly, although would not appear as a cystic structure. Oesophageal duplication cysts have similar appearances to bronchogenic cysts but usually present in childhood.
4. A 5 year old patient has a barium swallow for dysphagia. A small smooth indentation is noted posteriorly at the oesophagus at the level of T4. What is the most likely diagnosis?
Aberrant left pulmonary artery
Double aortic arch
Left aortic arch with an aberrant right subclavian artery
Anomalous left common carotid artery
Right aortic arch with right descending aorta and aberrant left subclavian artery and persistent left ductus
An aberrant left pulmonary artery (pulmonary sling) causes a posterior tracheal indentation and an anterior oesophageal impression on barium swallow. Answers B and E (vascular rings) both cause an anterior tracheal indentation with a large posterior oesophageal impression and are usually associated with significant symptoms such as chronic stridor or wheeze. An anomalous left carotid artery can cause anterior tracheal indentation.
5. A 30 year old man presents with night sweats, weight loss and anorexia. His ESR is elevated and a serum ACE is normal. A chest radiograph shows bilateral hilar lymphadenopathy. What is the most likely diagnosis?
Sarcoidosis
TB
Hodgkins lymphoma
MALT
Multiple myeloma
Sarcoid can be associated with a raised ACE. Primary tuberculosis often presents with hilar lymphadenopathy, although bilateral hilar lymphadenopathy is less common. MALT (mucosa-associated lymphoid tissue) is a primary lymphoma of the lung and is rare.
Your total score:
Modules
Chest and Vascular
Musculoskeletal and Trauma
Gastro-intestinal (including liver, biliary, pancreas and spleen)
Genito-urinary, Adrenal, Obstetrics & Gynaecology and Breast
Paediatric
Central Nervous and Head & Neck (including spine, eyes, ENT, salivary glands and dental)
