Chest Radiology

Chest Radiology Indian Medical PG Question 1: A patient of road traffic accident presents to the emergency with increasing restlessness and difficulty in breathing. The respiratory rate is 26 breaths/minute; there are distended neck veins; trachea is deviated to the right side with hyper-resonant note and absence of breath sounds on the left side. Which of the following statements are correct? 1. The most probable clinical diagnosis is left tension pneumothorax 2. Immediate chest decompression using wide bore cannula in left 2nd intercostal space is to be done 3. Immediate chest X-ray should be done to confirm the clinical diagnosis 4. Definitive chest tube insertion in left fifth intercostal space should be done

• A. 2, 3 and 4
• B. 1, 2 and 4 (Correct Answer)
• C. 1, 2 and 3
• D. 1, 3 and 4

Chest Radiology Explanation: ***1, 2 and 4*** - The clinical presentation with **increasing restlessness**, **difficulty in breathing**, **distended neck veins**, **tracheal deviation away from the affected side** (to the right for a left-sided collection), **hyper-resonant note**, and **absent breath sounds on the left** is pathognomonic for **left tension pneumothorax** (Statement 1 is correct). - **Immediate needle decompression** with a wide-bore cannula in the **2nd intercostal space** along the mid-clavicular line on the affected side is a **life-saving intervention** that must be performed immediately (Statement 2 is correct). - After needle decompression, **definitive chest tube insertion** in the **5th intercostal space** (mid-axillary line) should be performed (Statement 4 is correct). - Statement 3 is **incorrect** because tension pneumothorax is a **clinical diagnosis** requiring immediate treatment without delaying for imaging, which could be fatal. *2, 3 and 4* - This combination is incorrect because Statement 3 is wrong. - **Immediate chest X-ray should NOT be done** for suspected tension pneumothorax as it is a **clinical emergency** requiring immediate decompression without delay for imaging. - Statement 1 (the correct diagnosis) is also missing from this option. *1, 2 and 3* - This combination is incorrect because Statement 3 is wrong. - **Delaying treatment to obtain imaging** can be **fatal** due to cardiovascular collapse from mediastinal shift and impaired venous return. - Statement 4 (definitive chest tube insertion) is also missing from this option. *1, 3 and 4* - This combination is incorrect because Statement 3 is wrong. - The diagnosis is **clinical**, and treatment (needle decompression - Statement 2) should be initiated immediately to prevent hemodynamic compromise and death. - Statement 2 (immediate needle decompression) is also missing from this option.

Chest Radiology Indian Medical PG Question 2: Which of the following findings are seen in a high-resolution CT scan of fungal pneumonia? 1. Interlobular septations 2. Peripheral wedge-shaped consolidation 3. Pleural effusion 4. Cavitatory lesions with surrounding ground glass opacities

• A. 1,2,3
• B. 2,3,4
• C. 1,2,4 (Correct Answer)
• D. 1,3,4

Chest Radiology Explanation: ***1,2,4*** - **Interlobular septations** and **peripheral wedge-shaped consolidations** are common findings due to the **vascular invasion** and **infarction** characteristic of fungal pneumonia. - **Cavitary lesions with surrounding ground-glass opacity**, also known as the **halo sign**, are highly suggestive of invasive fungal infections like aspergillosis. *1,2,3* - While interlobular septations and peripheral wedge-shaped consolidations are seen in fungal pneumonia, **pleural effusion** is less common and not a primary diagnostic feature. - The absence of the characteristic cavitary lesions with ground-glass opacities makes this option incomplete. *2,3,4* - This option correctly includes peripheral wedge-shaped consolidation and cavitary lesions with ground-glass opacity, but the inclusion of **pleural effusion** and exclusion of **interlobular septations** make it less accurate. - Interlobular septations are a significant indicator of **lymphatic involvement** as seen in fungal diseases. *1,3,4* - Although interlobular septations and cavitary lesions with ground-glass opacities are relevant, the presence of **pleural effusion** as a primary finding is less typical for fungal pneumonia. - The absence of **peripheral wedge-shaped consolidation**, which arises from vascular occlusion, makes this option less comprehensive.

Chest Radiology Indian Medical PG Question 3: Chest CT shows bilateral ground-glass opacities with crazy paving pattern and preserved bronchial markings. Likely diagnosis?

• A. Pulmonary alveolar proteinosis (Correct Answer)
• B. Edema
• C. ARDS
• D. Pneumonia

Chest Radiology Explanation: ***Pulmonary alveolar proteinosis*** - **Bilateral ground-glass opacities** with a **"crazy paving" pattern** (interlobular septal thickening superimposed on ground-glass opacities) are highly characteristic imaging findings for pulmonary alveolar proteinosis. - The **preserved bronchial markings** further support this diagnosis, as it indicates that the airspaces are filled with proteinaceous material without significant destruction of the bronchial tree. *Edema* - While pulmonary edema can cause **ground-glass opacities**, it typically presents with additional features such as **peribronchial cuffing**, **interlobular septal thickening** uniformly without "crazy paving," and often **cardiomegaly** or **pleural effusions**. - The "crazy paving" pattern is uncommon in pure pulmonary edema. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** is characterized by widespread **ground-glass opacities** and **consolidation**, but it usually involves significant **loss of lung volume**, **air bronchograms**, and often **bronchial distortion**, rather than perfectly preserved bronchial markings. - The "crazy paving" pattern is not a primary or characteristic finding in ARDS. *Pneumonia* - **Pneumonia** often presents with **focal consolidation**, **ground-glass opacities**, or **lobar infiltrates**. - While some forms of atypical pneumonia might have ground-glass opacities, the distinct **"crazy paving" pattern** and **preserved bronchial markings** are not typical features.

Chest Radiology Indian Medical PG Question 4: Blunt trauma to right side of chest, hyperresonance on right side on percussion, dyspnea, tachypnea. Heart rate-100, BP-120/80, best initial diagnostic step is

• A. Needle decompression
• B. Chest X-ray (Correct Answer)
• C. O2 inhalation
• D. IV fluids

Chest Radiology Explanation: ***Chest Xray*** - The symptoms (blunt chest trauma, dyspnea, tachypnea, hyperresonance on percussion) are highly suggestive of a **pneumothorax**. - A **Chest X-ray** is the **best initial diagnostic step** to confirm the diagnosis, determine its size, and rule out other life-threatening conditions like hemothorax or tension pneumothorax. *Needle decompression* - This is a **therapeutic intervention** for a **tension pneumothorax**, not a diagnostic step. - While the symptoms are concerning, without confirmation of a tension pneumothorax (e.g., severe hypotension, tracheal deviation, absent breath sounds), empirical needle decompression is not the first step. *O2 inhalation* - **Oxygen administration** is a supportive measure for dyspnea and hypoxemia but does not diagnose the underlying cause of the respiratory distress. - While often given immediately, it's not the primary diagnostic step to understand the chest injury. *IV fluids* - **Intravenous fluids** are used to manage hypovolemia or shock, which is not indicated by the patient's current stable blood pressure (120/80 mmHg). - There is no clinical evidence of significant blood loss or dehydration from the provided information to warrant IV fluids as the best initial step.

Chest Radiology Indian Medical PG Question 5: Investigation of choice in bronchiectasis?

• A. Bronchoscopy
• B. Chest X-ray
• C. MRI
• D. HRCT (Correct Answer)

Chest Radiology Explanation: ***HRCT*** - **High-resolution computed tomography (HRCT)** is the gold standard for diagnosing bronchiectasis, as it provides detailed images of the bronchial tree. - It effectively visualizes the characteristic **bronchial dilation**, **lack of bronchial tapering**, and **"signet-ring" appearance** of the airways. *MRI* - **Magnetic resonance imaging (MRI)** is generally not the primary imaging modality for bronchiectasis due to its lower spatial resolution compared to CT for lung parenchyma. - While it can provide functional information, it is not as effective in visualizing the characteristic anatomical changes of bronchiectasis. *Bronchoscopy* - **Bronchoscopy** is an invasive procedure primarily used to identify the cause of bronchiectasis (e.g., foreign body, infection, endobronchial obstruction) or for therapeutic lavage. - It is not the initial diagnostic investigation of choice for confirming the presence and extent of bronchiectasis itself. *Chest X-ray* - A **chest X-ray** may show non-specific findings such as increased bronchial wall opacity or tram-track lucencies, which are suggestive of bronchiectasis but not definitive. - It lacks the sensitivity and specificity of HRCT to confirm the diagnosis and delineate the extent of the disease.

Chest Radiology Indian Medical PG Question 6: What does the 'Kerley B lines' appearance on a chest X-ray indicate?

• A. Pulmonary fibrosis
• B. Pulmonary edema (Correct Answer)
• C. Pneumonia
• D. Pleural effusion

Chest Radiology Explanation: ***Pulmonary edema*** - **Kerley B lines** are thin, horizontal lines located peripherally in the lung fields on a chest X-ray, typically indicating the presence of **interstitial pulmonary edema**. - They represent **edematous interlobular septa** thickened by fluid, often seen in conditions like **congestive heart failure**. *Pulmonary fibrosis* - Characterized by **reticular opacities**, **honeycombing**, and **traction bronchiectasis** on a chest X-ray, which are distinct from Kerley B lines. - While both involve the interstitium, pulmonary fibrosis represents **irreversible scarring**, not acute fluid accumulation. *Pneumonia* - Typically presents as **lobar or patchy consolidation** (airspace opacities) on a chest X-ray, sometimes with air bronchograms, rather than thin linear opacities. - This condition involves inflammation and infection within the **alveoli**, leading to exudate. *Pleural effusion* - Appears as a **blunting of the costophrenic angles** and a **meniscus sign** (curvilinear shadow) on a chest X-ray, indicating fluid in the pleural space. - This is distinct from Kerley B lines, which are found within the lung parenchyma rather than the pleural space.

Chest Radiology Indian Medical PG Question 7: A chest X-ray shows a 'silhouette sign' with opacity obscuring the right heart border. Which lobe of the lung is most likely affected?

• A. Right upper lobe
• B. Right middle lobe (Correct Answer)
• C. Right lower lobe
• D. Left lower lobe

Chest Radiology Explanation: ***Right middle lobe*** - The **silhouette sign** occurs when two objects of similar radiographic density are in direct contact, obscuring their common border. - The **right middle lobe** is adjacent to the right heart border, so an opacity in this lobe will typically obscure the border. *Right upper lobe* - The right upper lobe is positioned superiorly and medially, meaning opacification would more likely obscure the **right paratracheal stripe** or the superior mediastinal borders. - It does not directly border the right heart, thus it would not produce a silhouette sign with the cardiac outline. *Right lower lobe* - The right lower lobe is primarily associated with obscuring the **right hemidiaphragm** when it collapses or becomes consolidated. - Although it is somewhat posterior to the heart, it usually does not directly obscure the anterior right heart border. *Left lower lobe* - The left lower lobe is on the opposite side of the chest and opacification would not affect the **right heart border**. - Consolidation here would more likely obscure the **left hemidiaphragm** or the medial part of the left cardiac silhouette in certain views.

Chest Radiology Indian Medical PG Question 8: A study was conducted to evaluate the diagnostic accuracy of ECG for detecting myocardial infarction. The results are shown in the 2x2 table below: Myocardial Infarction Present Absent Total ECG Positive 45 8,000 8,045 ECG Negative 5 32,000 32,005 Total 50 40,000 40,050 Consider the following statements: I. Sensitivity is 90%. II. Specificity is 80%. Which of the statements given above is/are correct?

• A. Both I and II (Correct Answer)
• B. Neither I nor II
• C. II only
• D. I only

Chest Radiology Explanation: **Both I and II** - **Sensitivity** = True Positives / (True Positives + False Negatives) = 45 / (45 + 5) = 45/50 = **0.90 or 90%** ✓ - **Specificity** = True Negatives / (True Negatives + False Positives) = 32,000 / (32,000 + 8,000) = 32,000/40,000 = **0.80 or 80%** ✓ - Both calculations are correct based on the 2×2 contingency table - **Sensitivity** measures the ability of the test to correctly identify those with disease (true positive rate) - **Specificity** measures the ability of the test to correctly identify those without disease (true negative rate) *I only* - Incorrect because Statement II (Specificity = 80%) is also correct, not just Statement I *II only* - Incorrect because Statement I (Sensitivity = 90%) is also correct, not just Statement II *Neither I nor II* - Incorrect because both statements are mathematically correct based on the given data

Chest Radiology Indian Medical PG Question 9: Under RNTCP, the target for case detection through quality sputum microscopy is at least:

• A. 70% (Correct Answer)
• B. 95%
• C. 85%
• D. 60%

Chest Radiology Explanation: ***70%*** - The **Revised National Tuberculosis Control Programme (RNTCP)** aimed for a minimum of **70% case detection** by identifying infectious smear-positive TB cases. - This target ensures that a significant proportion of **tuberculosis cases** are diagnosed and brought under treatment, thereby reducing transmission. *95%* - While 95% is a very high target, it was not the initial or primary target set by RNTCP for sputum microscopy case detection. - Such a high rate is often an ideal goal for **treatment success** or **cure rates**, rather than initial case detection. *85%* - The **85% target** was set for the **treatment success rate** for smear-positive pulmonary TB cases under RNTCP, not for initial case detection. - Achieving this target ensures effective treatment outcomes and prevents the development of **drug resistance**. *60%* - A 60% detection rate would be considered **insufficient** for effective TB control, as it would leave a large number of infectious individuals undiagnosed. - This low target would not adequately address the public health burden of **tuberculosis**.

Chest Radiology Indian Medical PG Question 10: What does this CT chest image show?

• A. Consolidation
• B. Pneumothorax
• C. Pleural effusion
• D. Segmental collapse (Correct Answer)

Chest Radiology Explanation: ***Segmental collapse*** - The CT image shows loss of lung volume in a specific segment, indicated by the **crowding of bronchi and vessels in the affected area**, which is suggestive of atelectasis or collapse. - The black arrow points to the collapsed segment, which appears as a **densified, airless region within the lung parenchyma**, consistent with segmental collapse. *Consolidation* - **Consolidation** typically presents as an area of increased opacification due to alveolar filling with exudate or fluid, but without significant loss of lung volume. - Unlike collapse, consolidation generally **retains the lung architecture** and does not show crowding of vessels and bronchi. *Pneumothorax* - A **pneumothorax** is characterized by the presence of air in the pleural space, which would appear as a dark, air-filled space between the lung and the chest wall. - This typically leads to a **collapsed lung that is displaced medially** and no longer touches the chest wall, which is not seen here. *Pleural effusion* - **Pleural effusion** is the accumulation of fluid in the pleural space, presenting as a homogenous, gravity-dependent opacity that obscures lung parenchyma. - It would typically cause **blunting of the costophrenic angles** and a meniscus sign, which are not the primary findings indicated by the arrow.

Chest Radiology Flashcard 1 of 10

Question: _____ of the lung presents similarly to pneumonia on CXR (hazy infiltrates, consolidation)

Answer: Adenocarcinoma in situ

Chest Radiology Flashcard 2 of 10

Question: _____ is the best investigation for pulmonary embolism.

Answer: Pulmonary CT angiography /MDCT

Chest Radiology Flashcard 3 of 10

Question: Kerley _____ lines, are exactly the same as Kerley B lines, except that they are seen on lateral chest radiographs in the retrosternal air gap

Answer: D

Chest Radiology Flashcard 4 of 10

Question: _____ sign, describes dilation of right descending pulmonary artery due to occlusion by the embolus in pulmonary embolism

Answer: Knuckle or sausage

Chest Radiology Flashcard 5 of 10

Question: On chest x-ray of a person with acute decompensated heart failure, you will most likely see:- prominent cephalization of _____- perihilar alveolar edema- blunting of the costophrenic angles (blue arrows)

Answer: pulmonary vessels (red arrows)

Chest Radiology Flashcard 6 of 10

Question: Best X-ray view for right lung is?_____

Answer: Left anterior oblique

Chest Radiology Flashcard 7 of 10

Question: The following CXR is highly suggestive of what restrictive pulmonary pathology in a ~ 50 year old man? _____

Answer: Idiopathic Pulmonary Fibrosis

Chest Radiology Flashcard 8 of 10

Question: X-ray shows holly leaf appearence in _____.

Answer: asbestosis

Chest Radiology Flashcard 9 of 10

Question: The following CXR is highly suggestive of what pulmonary pathology? _____

Answer: Primary Pulmonary HTN

Chest Radiology Flashcard 10 of 10

Question: CO-RADS _____ (Equivocal - Features compatible with COVID-19, but also other diseases)

Answer: 3