Chest Radiology — MCQs

Chest Radiology Indian Medical PG Practice Questions and MCQs

Question 151: Perihilar fluffy opacities on chest X-ray is seen in?

A. Pulmonary embolism
B. Pericardial effusion
C. Pulmonary arterial hypertension
D. Pulmonary venous hypertension (Correct Answer)

Explanation: **Explanation:** **1. Why Pulmonary Venous Hypertension (PVH) is correct:** Pulmonary venous hypertension (most commonly due to left-sided heart failure) leads to an increase in pulmonary capillary hydrostatic pressure. When this pressure exceeds the oncotic pressure of plasma, fluid leaks into the interstitium and alveoli. On a chest X-ray, this manifests as **perihilar fluffy opacities**, often described as the **"Bat-wing" or "Butterfly" appearance**. This represents alveolar edema concentrated in the central lung zones, sparing the peripheral cortex. **2. Why the other options are incorrect:** * **Pulmonary Embolism (PE):** Typically presents with a normal X-ray. Specific signs include **Westermark sign** (focal oligemia) or **Hampton’s hump** (wedge-shaped peripheral opacity), not central fluffy opacities. * **Pericardial Effusion:** Characterized by a symmetric enlargement of the cardiac silhouette, often described as a **"Water-bottle" or "Money-bag" heart**, with clear lung fields. * **Pulmonary Arterial Hypertension (PAH):** Shows enlargement of the central pulmonary arteries with **"peripheral pruning"** (abrupt narrowing of distal vessels), but lacks the fluffy alveolar exudates seen in venous congestion. **3. High-Yield Clinical Pearls for NEET-PG:** * **Stages of Pulmonary Edema on CXR:** 1. **Stage I (Cephalization):** Redistribution of blood flow to upper lobes (PCWP 13–18 mmHg). 2. **Stage II (Interstitial Edema):** Kerley B lines, peribronchial cuffing, and hazy hila (PCWP 18–25 mmHg). 3. **Stage III (Alveolar Edema):** Bat-wing opacities and pleural effusion (PCWP >25 mmHg). * **Differential for Bat-wing appearance:** Pulmonary edema (cardiogenic), alveolar hemorrhage, and Pneumocystis jirovecii pneumonia (PJP).

Question 152: Popcorn calcification is characteristically seen in which of the following?

A. Tuberculosis
B. Metastasis
C. Fungal invagination
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Popcorn calcification** refers to a specific radiological pattern characterized by amorphous, disorganized, and coarse calcified clusters resembling popcorn kernels. While classically associated with **Pulmonary Hamartomas** (the most common benign lung tumor), it is a non-specific finding that can occur in several pulmonary pathologies. 1. **Tuberculosis (Option A):** Healed granulomatous diseases like TB often result in dystrophic calcification. When multiple small granulomas coalesce and calcify, they can present as a "popcorn" pattern within a calcified nodule or lymph node. 2. **Metastasis (Option B):** Certain slow-growing or treated metastatic lesions can calcify. Specifically, **osteosarcoma** or **chondrosarcoma** metastases often produce osteoid or chondroid matrices that result in a popcorn-like appearance. 3. **Fungal Infection (Option C):** Similar to TB, fungal infections (e.g., **Histoplasmosis**) lead to granuloma formation. Upon healing, these lesions undergo dystrophic calcification, frequently manifesting this pattern. **Why "All of the above" is correct:** The term "popcorn calcification" is a morphological description rather than a pathognomonic sign. Since TB, specific metastases, and fungal granulomas can all produce coarse, irregular calcifications, all three options are clinically valid. **High-Yield Clinical Pearls for NEET-PG:** * **Pulmonary Hamartoma:** The most classic association for popcorn calcification in a solitary pulmonary nodule. * **Breast Radiology:** Popcorn calcification on a mammogram is pathognomonic for a **degenerated fibroadenoma**. * **Bone Radiology:** This pattern is also seen in **enchondromas** or **chondrosarcomas** (chondroid matrix). * **Benign vs. Malignant:** Generally, popcorn, central, diffuse, or laminated calcifications in a lung nodule suggest a benign etiology, whereas eccentric or stippled calcifications are more concerning for malignancy.

Question 153: A patient with breathlessness shows Kerley B-lines in chest X-ray. What do these lines represent?

A. Linear fibrosis
B. Haemosiderin deposits
C. Small focal atelectasis
D. Thickened interlobular septa (Correct Answer)

Explanation: **Explanation:** **Kerley B-lines** are short (1–2 cm), thin, horizontal lines seen at the lung periphery, most commonly at the costophrenic angles. They represent **thickened interlobular septa**. These septa contain pulmonary veins and lymphatics; when fluid, cells, or connective tissue accumulate here, the septa become visible on a chest X-ray. The most common cause is **pulmonary edema** (secondary to congestive heart failure), where increased pulmonary venous pressure leads to fluid transudation into the interstitium. **Analysis of Incorrect Options:** * **A. Linear fibrosis:** While fibrosis can cause linear opacities, Kerley B-lines specifically refer to the septal pattern. Fibrosis is usually more irregular and permanent, whereas Kerley B-lines can disappear with diuretic treatment. * **B. Haemosiderin deposits:** These typically present as fine, diffuse punctate nodular opacities (miliary pattern), often seen in chronic mitral stenosis, rather than peripheral horizontal lines. * **C. Small focal atelectasis:** This is represented by **Fleischner lines** (discoid or plate-like atelectasis), which are usually thicker, longer, and more random in orientation than Kerley B-lines. **High-Yield Pearls for NEET-PG:** * **Kerley A-lines:** Longer (2–6 cm) lines radiating from the hila toward the periphery; represent thickening of the deep central interlobular septa. * **Kerley C-lines:** Short, reticular lines forming a "mesh" appearance at the base; represent thickening of anastomotic lymphatics. * **Differential Diagnosis for Kerley B-lines:** Remember the mnemonic **"CHAL"**: **C**HF (most common), **H**ypervolemia, **A**lveolar cell carcinoma (or Lymphangitic carcinomatosis), and **L**ymphoma/Left-sided heart disease.

Question 154: What is the investigation of choice for the diagnosis of pulmonary embolism?

A. MRI chest
B. CT scan chest (Correct Answer)
C. X-ray chest
D. Radioisotope scan

Explanation: **Explanation:** **CT Pulmonary Angiography (CTPA)**, which is a specialized contrast-enhanced CT scan of the chest, is currently the **investigation of choice (Gold Standard)** for diagnosing pulmonary embolism (PE). It allows for direct visualization of the pulmonary arteries and can identify filling defects (thrombi) up to the segmental and subsegmental levels. Its high sensitivity, specificity, and ability to provide alternative diagnoses (like pneumonia or aortic dissection) make it the preferred first-line imaging modality. **Analysis of Options:** * **MRI Chest (Option A):** While MRI can detect PE without ionizing radiation, it is technically difficult, time-consuming, and has lower resolution for distal vessels compared to CT. It is generally reserved for patients with contraindications to CT contrast or radiation (e.g., pregnancy). * **X-ray Chest (Option C):** Chest X-rays are often **normal** in PE. While they help rule out other causes of chest pain and may show classic signs like *Hampton’s Hump* (wedge-shaped opacity) or *Westermark sign* (oligemia), they are not diagnostic. * **Radioisotope Scan (V/Q Scan) (Option D):** Formerly the investigation of choice, it is now a second-line option. It is used primarily when CTPA is contraindicated (e.g., severe renal failure or contrast allergy). **High-Yield Clinical Pearls for NEET-PG:** * **Initial Investigation:** Chest X-ray (to rule out other pathologies). * **Most Accurate/Gold Standard:** CT Pulmonary Angiography (CTPA). * **Traditional Gold Standard (Historical):** Invasive Catheter Pulmonary Angiography (rarely used now). * **Best Screening/Initial Lab Test:** D-dimer (High negative predictive value; used to rule out PE in low-risk patients). * **ECG Finding:** Most common is Sinus Tachycardia; most specific is the **S1Q3T3** pattern.

Question 155: Inferior rib notching is seen in all except?

A. Aortic thrombosis
B. Taussing Blalock operation
C. Pulmonary atresia
D. Marfan's syndrome (Correct Answer)

Explanation: **Explanation:** **Inferior rib notching** is a classic radiological sign caused by the pressure erosion of the lower borders of the ribs. This occurs due to the dilation and tortuosity of the **intercostal arteries**, which act as collateral pathways when there is an obstruction to normal blood flow. **Why Marfan’s Syndrome is the correct answer:** Marfan’s syndrome is a connective tissue disorder primarily associated with aortic root dilation, dissection, and mitral valve prolapse. It does **not** cause obstruction of major vessels or the development of intercostal collaterals; therefore, it does not result in rib notching. **Analysis of Incorrect Options:** * **Aortic Thrombosis:** Chronic occlusion of the abdominal aorta (e.g., Leriche syndrome) or descending aorta forces blood to bypass the obstruction via the internal mammary and intercostal arteries to reach the lower extremities, causing notching. * **Taussig-Blalock (BT) Shunt:** This surgical procedure involves anastomosing the subclavian artery to the pulmonary artery. This reduces blood flow to the distal subclavian, leading to compensatory collateral flow through the intercostal arteries on the **ipsilateral** side. * **Pulmonary Atresia:** In conditions with reduced pulmonary blood flow, the bronchial and intercostal arteries enlarge significantly to provide collateral circulation to the lungs, leading to rib notching. **NEET-PG High-Yield Pearls:** 1. **Most Common Cause:** Coarctation of the aorta (usually involves 3rd to 9th ribs; 1st and 2nd ribs are spared as they don't participate in the collateral pathway). 2. **Unilateral Notching:** Seen in Blalock-Taussig shunts or if the coarctation is proximal to the left subclavian artery. 3. **Superior Rib Notching:** A rarer finding associated with connective tissue diseases (SLE, RA), hyperparathyroidism, or restrictive lung disease (Polio). 4. **Roesler’s Sign:** Another name for the radiological appearance of inferior rib notching.

Question 156: Which radiographic view is best for recognizing collapse of the lingula?

A. PA view
B. Right anterior oblique view
C. Left anterior oblique view
D. Lordotic view (Correct Answer)

Explanation: **Explanation:** The **lingula** is the anatomical equivalent of the middle lobe in the left lung. When the lingula collapses, it moves anteriorly and medially, often silhouetting the left heart border on a standard PA view. However, the **Lordotic view** (or Apical Lordotic view) is the most sensitive radiographic projection for recognizing this collapse. In the lordotic position, the patient leans backward, projecting the anterior structures (like the lingula) superiorly and the posterior structures inferiorly. This maneuver removes the overlapping shadows of the ribs and clavicles and projects the collapsed, wedge-shaped lingular segment more clearly against the heart border, making the density more apparent. **Analysis of Options:** * **PA View:** While it may show a "blurring" of the left heart border (Silhouette sign), the collapse is often subtle and easily missed due to overlying rib shadows and the heart's density. * **Right/Left Anterior Oblique Views:** These views are primarily used to visualize the heart, great vessels, and specific lung segments without mediastinal overlap, but they are not the standard or most effective choice for isolated lingular collapse. * **Lordotic View (Correct):** By angling the X-ray beam relative to the patient, it provides the best visualization of anteriorly located pathologies, specifically middle lobe and lingular collapses. **High-Yield Clinical Pearls for NEET-PG:** * **Silhouette Sign:** Loss of the left heart border on a PA view indicates pathology in the **lingula**. * **Golden S-Sign:** Typically associated with Right Upper Lobe collapse due to a central mass, but can occur in other lobes. * **Lordotic View Uses:** Best for visualizing **apical lung tumors (Pancoast)**, **middle lobe syndrome**, and **lingular collapse**.

Question 157: Unilateral hyperlucency of the lung is seen in all of the following conditions except?

A. Pneumothorax
B. Resection of mammary gland
C. Pulmonary artery obstruction
D. Pneumonectomy (Correct Answer)

Explanation: **Explanation:** The core concept in this question is understanding the difference between **hyperlucency** (increased blackness/transparency) and **opacity** (increased whiteness/density) on a chest X-ray. **Why Pneumonectomy is the correct answer:** In a **pneumonectomy**, the entire lung is surgically removed. The resulting empty space eventually fills with fluid and organized tissue, leading to a **complete opacification (white-out)** of that hemithorax, often accompanied by an ipsilateral mediastinal shift. Since the area becomes opaque rather than lucent, it is the "except" in this list. **Analysis of incorrect options (Causes of Unilateral Hyperlucency):** * **Pneumothorax:** Air in the pleural space lacks lung markings and appears more lucent (blacker) than the normal lung. * **Resection of Mammary Gland (Mastectomy):** The removal of overlying soft tissue (breast) reduces X-ray attenuation. This results in a "false" hyperlucency of the underlying lung field on the affected side. * **Pulmonary Artery Obstruction (Westermark Sign):** In conditions like massive Pulmonary Embolism, decreased perfusion to a lung segment leads to localized oligemia, appearing as a focal area of hyperlucency. **NEET-PG High-Yield Pearls:** 1. **Swyer-James Syndrome:** A classic cause of unilateral hyperlucency due to post-infectious bronchiolitis obliterans leading to air trapping and small vessel hypoplasia. 2. **Poland Syndrome:** Congenital absence of the pectoralis major muscle, causing unilateral hyperlucency. 3. **Macleod’s Syndrome:** Another name for Swyer-James; look for a small, hyperlucent lung with diminished vascular markings. 4. **Checklist for Hyperlucency:** Always check for (a) Technical factors (rotation), (b) Chest wall issues (mastectomy/muscles), (c) Pleural issues (pneumothorax), and (d) Lung parenchyma/vascular issues (PE/Emphysema).

Question 158: Which condition presents with ipsilateral homogeneous opacification and contralateral mediastinal shift?

A. Collapse
B. Consolidation
C. Hydrothorax (Correct Answer)
D. Hemothorax

Explanation: **Explanation:** The key to solving chest radiology questions involving opacification is assessing the **position of the mediastinum**. **1. Why Hydrothorax is Correct:** Hydrothorax (pleural effusion) represents an accumulation of fluid within the pleural space. As fluid occupies volume outside the lung parenchyma, it exerts **positive pressure**, leading to **ipsilateral homogeneous opacification** (due to fluid density) and a **contralateral (away) shift** of the mediastinum and trachea. This is a classic "space-occupying" lesion effect. **2. Why the other options are incorrect:** * **Collapse (A):** While it causes opacification, collapse is a "volume-losing" process. It results in an **ipsilateral (towards)** shift of the mediastinum as the remaining lung and structures move to fill the void. * **Consolidation (B):** This occurs when air in the alveoli is replaced by fluid/pus (e.g., pneumonia). Crucially, there is **no change in lung volume**, so the mediastinum remains **central**. * **Hemothorax (D):** While hemothorax also causes a contralateral shift, it is clinically distinguished by history (trauma). In the context of standard radiologic descriptions for exams, "Hydrothorax" is the broader term for pleural fluid causing mass effect. **High-Yield NEET-PG Pearls:** * **White-out Hemithorax Rule:** * Shift **Towards** opacity = Collapse/Pneumonectomy. * Shift **Away** from opacity = Large Pleural Effusion/Hydrothorax/Large Diaphragmatic Hernia. * **No Shift** = Consolidation or Mesothelioma (which "fixes" the mediastinum). * **Air Bronchogram:** Characteristically seen in **Consolidation**, but notably absent in Pleural Effusion and obstructive Collapse. * **Meniscus Sign:** The classic radiological appearance of a moderate pleural effusion.

Question 159: Which of the following does NOT form the shadow of the right side of the mediastinum?

A. Superior vena cava
B. Right innominate vein
C. Right atrium
D. Right ventricle (Correct Answer)

Explanation: To answer this question, one must understand the **radiographic anatomy of the cardiac silhouette** on a standard Postero-Anterior (PA) chest X-ray. ### **Why Right Ventricle is the Correct Answer** The **Right Ventricle (RV)** forms the majority of the **anterior surface** of the heart. On a frontal (PA) view, it sits centrally and does not contribute to either the right or left lateral borders. It only forms the heart's border on a **lateral view** (anterior border, behind the sternum). Therefore, it does not form the right mediastinal shadow. ### **Analysis of Incorrect Options (Right Border Components)** The right border of the mediastinum is formed by structures that lie most laterally on the right side: * **Right Innominate (Brachiocephalic) Vein:** Forms the uppermost part of the right mediastinal shadow. * **Superior Vena Cava (SVC):** Forms the straight vertical segment of the right border above the heart. * **Right Atrium (RA):** Forms the prominent lower convex segment of the right heart border. * **Inferior Vena Cava (IVC):** May occasionally be seen as a small vertical notch at the cardiophrenic angle. ### **High-Yield Clinical Pearls for NEET-PG** * **Left Heart Border:** Formed by the Left Subclavian Artery, Aortic Arch (Aortic Knuckle), Pulmonary Trunk, Left Auricle (only the appendage), and the Left Ventricle. * **Right Ventricular Enlargement:** On a PA view, this causes **elevation of the apex** (due to the RV pushing the LV upward), often described as a "boot-shaped heart" (Coeur-en-sabot) in Tetralogy of Fallot. * **Left Atrium:** This is the most **posterior** chamber. It does not form a border on a normal PA view but, when enlarged, creates a "double atrial shadow" on the right side.

Question 160: A middle-aged patient presents with a complaint of right hypochondrial pain. On plain chest X-ray, an elevated right hemidiaphragm is seen. Which of the following is NOT a possible diagnosis?

A. Acute cholecystitis (Correct Answer)
B. Subphrenic abscess
C. Amebic liver abscess
D. Pyogenic liver abscess

Explanation: **Explanation:** The elevation of a hemidiaphragm on a chest X-ray is typically caused by either a decrease in lung volume above it (atelectasis), a phrenic nerve palsy, or an **inflammatory/occupying process** immediately below it that causes irritation or mass effect. **1. Why Acute Cholecystitis is the Correct Answer:** While acute cholecystitis causes significant right hypochondrial pain, it is a localized inflammation of the gallbladder. It generally **does not** cause enough mass effect or widespread diaphragmatic irritation to result in a radiological elevation of the hemidiaphragm. Therefore, it is the least likely diagnosis among the choices provided. **2. Analysis of Incorrect Options (Causes of Elevation):** * **Amebic & Pyogenic Liver Abscess:** These are space-occupying lesions in the liver parenchyma. Large abscesses (especially in the superior segments) push the diaphragm upward. Furthermore, the associated peri-hepatic inflammation causes diaphragmatic irritation and reactive changes. * **Subphrenic Abscess:** This is a collection of infected fluid between the liver and the diaphragm. It directly displaces the diaphragm superiorly and is a classic cause of an elevated hemidiaphragm accompanied by a reactive pleural effusion. **High-Yield Clinical Pearls for NEET-PG:** * **Eventration:** A congenital condition where the diaphragm is thin and weak, leading to permanent elevation (usually on the left). * **Phrenic Nerve Palsy:** Suspect this if the diaphragm is elevated and shows **paradoxical movement** on a Sniff Test (fluoroscopy). * **Liver Abscess Triad:** Fever, right hypochondrial pain, and an elevated right hemidiaphragm on X-ray. * **Right vs. Left:** Normally, the right hemidiaphragm is 1.5–2 cm higher than the left due to the liver. Elevation is considered pathological if the displacement is significantly exaggerated.

Practice by Chapter

Normal Chest Radiographic Anatomy

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Radiographic Signs in Chest Imaging

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Pulmonary Infections

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Chronic Obstructive Pulmonary Disease

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Interstitial Lung Diseases

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Pulmonary Neoplasms

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Pleural Diseases

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Mediastinal Pathology

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Congenital and Developmental Chest Anomalies

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Pulmonary Vascular Diseases

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Chest Trauma Imaging

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Post-Surgical Chest Imaging

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