Abdominal Ultrasound — MCQs
In a patient with acute cholecystitis, referred pain to the shoulder is known as
Which of the following is the most appropriate initial test for the diagnosis of ascites?
The imaging modality primarily used in FAST (Focused Assessment with Sonography for Trauma) exam is:
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 25-year-old patient presents in emergency with abdominal trauma. Why is FAST done?
All the following are true about acute cholecystitis, except
Best advantage of doing transcranial Doppler ultrasound?
A female patient presents to you with six weeks of amenorrhea, associated with abdominal pain and vaginal bleeding with normal blood pressure. Investigations revealed beta-hCG to be 1400 mIU/mL. An ultrasound scan was done which showed a trilaminar endometrium with normal adnexa. What is the next best step in the management of this patient?
A pregnant female presents with pain in abdomen. On examination, tenderness is found in right lumbar region. TLC is 12000/cmm and urine examination is normal. The most appropriate diagnostic test is:
To differentiate pancreatic ascites from ascites secondary to cirrhosis of the liver, the most important test is :
Abdominal Ultrasound Indian Medical PG Practice Questions and MCQs
Question 1: In a patient with acute cholecystitis, referred pain to the shoulder is known as
- A. Murphy's sign
- B. Gray Turner sign
- C. Boas' sign (Correct Answer)
- D. Cullen's sign
Explanation: ***Boas' sign*** - **Boas' sign** refers to the presence of hyperesthesia below the right scapula, which can also manifest as referred pain to the **right shoulder** or back [1]. - This symptom in acute cholecystitis is due to the **irritation** of the **phrenic nerve**, which shares sensory pathways with the shoulder region. *Murphy's sign* - **Murphy's sign** is elicited by asking the patient to exhale, then placing the examiner's hand below the costal margin on the right mid-clavicular line, and then asking the patient to inhale deeply [1]. - A positive sign is indicated by a sudden cessation of inspiration due to pain, which is specific for **acute cholecystitis** and not referred shoulder pain [1]. *Gray Turner sign* - The **Gray Turner sign** involves ecchymosis or discoloration of the flanks. - It is a severe indicator of **retroperitoneal hemorrhage**, often associated with acute pancreatitis, not cholecystitis [2]. *Cullen's sign* - **Cullen's sign** presents as periumbilical ecchymosis or discoloration around the navel. - This sign is also indicative of **retroperitoneal hemorrhage**, typically seen in serious conditions like ruptured ectopic pregnancy or acute pancreatitis.
Question 2: Which of the following is the most appropriate initial test for the diagnosis of ascites?
- A. CT scan of the abdomen
- B. Abdominal X-ray
- C. Abdominal ultrasound (Correct Answer)
- D. Paracentesis
Explanation: ***Abdominal ultrasound*** - An abdominal ultrasound is the **most appropriate initial test** for diagnosing ascites due to its high sensitivity for detecting fluid, non-invasiveness, and cost-effectiveness [1]. - It can identify even small amounts of **peritoneal fluid** and often helps determine the underlying cause by evaluating the liver and other abdominal organs [1]. *CT scan of the abdomen* - While a CT scan can detect ascites, it is generally **not the initial diagnostic test of choice** due to higher cost and radiation exposure [1]. - It is typically reserved for cases where ultrasound findings are equivocal or when further characterization of abdominal pathology is needed [1]. *Abdominal X-ray* - An abdominal X-ray has **poor sensitivity** for detecting ascites, especially small to moderate amounts of fluid. - It primarily identifies features like **bowel gas patterns** or calcifications and is not adequate for confirming fluid accumulation. *Paracentesis* - Paracentesis is a **diagnostic and therapeutic procedure** used to analyze ascitic fluid, not the initial imaging test for diagnosis. - It is performed after ascites has been detected (often by ultrasound) to determine its **etiology** (e.g., infection, malignancy) or to relieve symptoms.
Question 3: The imaging modality primarily used in FAST (Focused Assessment with Sonography for Trauma) exam is:
- A. X-ray
- B. CT
- C. MRI
- D. USG (Correct Answer)
Explanation: **USG** - **Focused Assessment with Sonography for Trauma (FAST)** exam specifically uses **ultrasound (USG)** to rapidly detect free fluid (blood) in pericardial, perihepatic, perisplenic, and pelvic spaces. - Its quick, non-invasive nature and portability make it ideal for **point-of-care assessment** in trauma settings. *X-ray* - While X-rays are useful in trauma for detecting **fractures** and some pneumothoraces, they are not the primary modality for detecting free fluid in the peritoneal or pericardial cavities during a FAST exam. - X-rays do not provide real-time, dynamic imaging of soft tissues and fluid accumulation as effectively as ultrasound. *CT* - **Computed Tomography (CT)** is a highly detailed imaging modality used in trauma for comprehensive assessment of injuries to organs, bones, and vessels. - However, it involves **radiation exposure**, takes longer to perform, and is typically reserved for hemodynamically stable patients after initial resuscitation and FAST exam. *MRI* - **Magnetic Resonance Imaging (MRI)** provides excellent soft tissue contrast, but its use in acute trauma is very limited due to its **long scan times**, high cost, and incompatibility with many metallic medical devices. - MRI is not suitable for rapid assessment of free fluid in hemodynamically unstable trauma patients.
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
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.
Question 5: A 25-year-old patient presents in emergency with abdominal trauma. Why is FAST done?
- A. Detection of aortic injury
- B. Detection of mesenteric injury
- C. Detection of bowel perforation
- D. Detection of free fluid in the abdomen (hemoperitoneum) (Correct Answer)
Explanation: ***Detection of free fluid in the abdomen (hemoperitoneum)*** - **FAST (Focused Assessment with Sonography for Trauma)** is primarily used to rapidly identify the presence of **free fluid**, typically blood, within the peritoneal, pericardial, or pleural spaces. - In abdominal trauma, the detection of **hemoperitoneum** guides immediate management decisions, such as the need for surgical intervention. *Detection of aortic injury* - While FAST can sometimes identify large pericardial effusions or mediastinal hematomas which might suggest aortic injury, it is **not sensitive or specific enough** to definitively diagnose an aortic injury. - **CT angiography** is the gold standard for diagnosing aortic injuries. *Detection of mesenteric injury* - **Mesenteric injuries** involve damage to the blood supply of the intestines and are difficult to detect with FAST. - These injuries might cause **intraperitoneal bleeding** detectable by FAST, but FAST cannot directly visualize the mesenteric damage itself. *Detection of bowel perforation* - **Bowel perforations** release air and contents into the peritoneal cavity, but FAST is generally **poor at detecting free air**. - While it might indirectly show some free fluid as a result of inflammation, it is not the primary diagnostic tool for perforation; **plain radiographs** or **CT scans** are more effective.
Question 6: All the following are true about acute cholecystitis, except
- A. Gall bladder thickness >3 mm on USG
- B. Murphy's sign positive
- C. Preferential visualization of gall bladder in HIDA scan (Correct Answer)
- D. Leukocytosis
Explanation: ***Preferential visualization of gall bladder in HIDA scan*** - In acute cholecystitis, the **cystic duct** becomes obstructed, preventing bile flow into the gallbladder. - A **HIDA scan** (hepatobiliary iminodiacetic acid scan) would show **non-visualization of the gallbladder** due to this obstruction, not preferential visualization. *Gall bladder thickness >3 mm on USG* - An **ultrasound (USG)** finding of gallbladder wall thickening **greater than 3 mm** is a common indicator of inflammation in acute cholecystitis. - This thickening is due to **edema** and inflammation of the gallbladder wall. *Murphy's sign positive* - A **positive Murphy's sign** involves tenderness and an inspiratory arrest upon palpation of the right upper quadrant, specifically over the gallbladder. - This clinical sign is a **classic indicator** of acute cholecystitis. *Leukocytosis* - **Leukocytosis**, an elevated white blood cell count, is a common systemic inflammatory response seen in acute cholecystitis. - It reflects the body's reaction to the **inflammation and possible infection** within the gallbladder.
Question 7: Best advantage of doing transcranial Doppler ultrasound?
- A. Detect brain blood vessels stenosis
- B. Detect AV malformation
- C. Detect emboli
- D. Detect vasospasm (Correct Answer)
Explanation: ***Detect vasospasm*** - **Transcranial Doppler (TCD) ultrasound** is highly effective for monitoring and detecting **cerebral vasospasm**, particularly after a **subarachnoid hemorrhage**. - It allows for non-invasive, continuous, and dynamic assessment of **blood flow velocities** in the **intracranial arteries**, which increase significantly during vasospasm. *Detect brain blood vessels stenosis* - While TCD can indicate increased flow velocities suggestive of **stenosis**, it is less accurate for precise anatomical localization and quantification compared to **CTA** or **MRA**. - Its ability to directly visualize the vessel lumen and the degree of stenosis is limited by its reliance on **flow dynamics**. *Detect AV malformation* - TCD can sometimes detect altered flow patterns associated with **arteriovenous malformations (AVMs)**, but it lacks the spatial resolution to definitively diagnose or characterize these complex vascular structures. - **Cerebral angiography** or **MRA** are the gold standards for diagnosing and mapping **AVMs**. *Detect emboli* - TCD can detect **microembolic signals (MES)**, which are transient high-intensity signals indicating the passage of emboli through the cerebral circulation. - However, while it can detect emboli, it is not its *best* or primary advantage compared to its utility in monitoring **vasospasm**, which directly impacts patient management and prognosis in certain acute conditions.
Question 8: A female patient presents to you with six weeks of amenorrhea, associated with abdominal pain and vaginal bleeding with normal blood pressure. Investigations revealed beta-hCG to be 1400 mIU/mL. An ultrasound scan was done which showed a trilaminar endometrium with normal adnexa. What is the next best step in the management of this patient?
- A. Repeat beta – hCG after 48 hours (Correct Answer)
- B. Laparoscopy
- C. Repeat ultrasound after 5 days
- D. Measurement of serum progesterone
Explanation: ***Repeat beta – hCG after 48 hours*** - With a beta-hCG of 1400 mIU/mL and no intrauterine pregnancy visible on ultrasound, repeating **beta-hCG after 48 hours** is crucial to assess its doubling time, which helps differentiate between a normal intrauterine pregnancy, ectopic pregnancy, or miscarriage. - An hCG level of 1400 mIU/mL is below the discriminatory zone (typically 1500-2000 mIU/mL) where an intrauterine gestational sac should be visible, making serial measurements essential. *Repeat ultrasound after 5 days* - While a repeat ultrasound may eventually be necessary, waiting 5 days without an interim hCG measurement could delay diagnosis and management, especially if the hCG levels are rising rapidly or are in a concerning range. - The current beta-hCG level is below the **discriminatory zone**, meaning a gestational sac would likely still not be visible even after 5 days, making hCG follow-up a more immediate and informative step. *Measurement of serum progesterone* - **Serum progesterone** levels can indicate overall pregnancy viability, but they do not specifically localize the pregnancy or differentiate between an intrauterine pregnancy and an ectopic pregnancy as effectively as serial hCG levels. - A single low progesterone level could indicate a non-viable pregnancy (either intrauterine or ectopic), but it does not guide immediate management for distinguishing between locations. *Laparoscopy* - **Laparoscopy** is an invasive surgical procedure and is not the first diagnostic step unless there are signs of ruptured ectopic pregnancy or hemodynamic instability, which are not present in this patient (normal blood pressure, mild symptoms). - It would be premature to proceed with laparoscopy without further biochemical or sonographic evidence of an ectopic pregnancy or clear signs of clinical deterioration.
Question 9: A pregnant female presents with pain in abdomen. On examination, tenderness is found in right lumbar region. TLC is 12000/cmm and urine examination is normal. The most appropriate diagnostic test is:
- A. Laparoscopy
- B. Non contrast CT abdomen
- C. Chest Xray with abdominal shield
- D. Ultrasound abdomen (Correct Answer)
Explanation: ***Ultrasound abdomen*** - This is the **safest and preferred initial imaging modality** for abdominal pain in pregnant women, as it avoids **ionizing radiation**. - It can effectively visualize the **appendix**, **gallbladder**, **kidneys**, and **uterus/adnexa**, helping to identify common causes of right lumbar pain like **appendicitis**, **pyelonephritis**, or **adnexal pathology**. *Laparoscopy* - While diagnostic, laparoscopy is an **invasive surgical procedure** and is typically reserved for cases where non-invasive imaging is inconclusive or if a **therapeutic intervention** is required. - It carries risks such as **anesthesia complications** and **uterine injury** in pregnancy, making it unsuitable as a primary diagnostic test. *Non-contrast CT abdomen* - **CT scans** involve **ionizing radiation**, which should be avoided in pregnancy due to potential risks to the **fetus**, especially if a less harmful alternative is available. - While it offers detailed anatomical information, the risk-benefit ratio for a **pregnant patient with a normal urine analysis** does not justify its initial use over ultrasound. *Chest X-ray with abdominal shield* - A **chest X-ray** primarily evaluates the **lungs and heart** and would not provide adequate visualization of the abdominal organs responsible for the right lumbar pain. - While a shield minimizes fetal exposure, the information gained would be **irrelevant to the presenting abdominal symptoms**, making it an inappropriate diagnostic choice.
Question 10: To differentiate pancreatic ascites from ascites secondary to cirrhosis of the liver, the most important test is :
- A. Abdominal ultrasound
- B. Endoscopic retrograde cholangio pancreatography (ERCP)
- C. Computed tomogram (CT) scan
- D. Abdominal paracentesis (Correct Answer)
Explanation: ***Abdominal paracentesis*** - This procedure involves analyzing the **ascitic fluid**, which is crucial for distinguishing between pancreatic ascites and cirrhosis-related ascites [1]. - In **pancreatic ascites**, the fluid will have a very high **amylase** content and often a high protein level (>2.5 g/dL), whereas in **cirrhosis**, the amylase is typically normal and the protein is usually low (<2.5 g/dL) [1]. *Abdominal ultrasound* - While useful for detecting ascites and underlying liver disease (cirrhosis), it cannot definitively determine the **cause of ascites** or the specific content of the ascitic fluid [2]. - Ultrasound can visualize the pancreas but cannot reliably differentiate pancreatic ascites from other causes without **fluid analysis**. *Endoscopic retrograde cholangiopancreatography (ERCP)* - This is an **invasive procedure** primarily used for diagnosing and treating disorders of the bile ducts and pancreatic duct, such as strictures or stones. - It is not the most important or initial test for differentiating the cause of ascites, as its main role is in identifying **ductal leaks** that might lead to pancreatic ascites, rather than direct fluid analysis. *Computed tomogram (CT) scan* - CT can confirm the presence of ascites, evaluate the **pancreas** for inflammation or pseudocysts, and assess the **liver** for signs of cirrhosis [2]. - However, like ultrasound, a CT scan cannot provide the definitive **biochemical analysis** of the ascitic fluid that is necessary to distinguish pancreatic ascites from other causes.
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