Chest Radiology Practice Questions

Q: What is the investigation of choice for pleural effusion?

Contrast-Enhanced Computed Tomography (CECT). **Explanation:** The investigation of choice for pleural effusion is **Contrast-Enhanced Computed Tomography (CECT)** because it provides the most comprehensive evaluation of the pleural space, lung parenchyma, and mediastinum. While other modalities can detect fluid, CECT is superior in differentiating between transudates and exudates (based on pleural thickening/enhancement), identifying underlying causes (such as malignancy or pneumonia), and detecting loculated effusions or associated lung masses. **Analysis of Options:** * **A. Chest X-ray:** This is the **initial/screening investigation**. It requires approximately 175–200 ml of fluid to obliterate the costophrenic angle on a PA view (and ~50–75 ml on a lateral view). It cannot reliably distinguish between fluid, thickening, or underlying collapse. * **B. Ultrasound (USG):** This is the **most sensitive** modality for detecting small amounts of fluid (as little as 5–20 ml) and is the **investigation of choice for guiding thoracocentesis** (tapping). However, it lacks the anatomical detail of CECT for staging or diagnosing complex underlying pathologies. * **C. Magnetic Resonance Imaging (MRI):** MRI has a limited role in routine chest imaging due to motion artifacts and lung air interference. It is reserved for specific cases like chest wall invasion or when CT contrast is contraindicated. **High-Yield Clinical Pearls for NEET-PG:** * **Initial Investigation:** Chest X-ray (PA view). * **Most Sensitive for Detection:** Ultrasound. * **Investigation of Choice (Overall):** CECT. * **Gold Standard for Empyema/Complex Effusion:** CECT (shows the "Split Pleura Sign"). * **Minimum fluid for X-ray detection:** 175–200 ml (PA view); 50 ml (Lateral view); 5–10 ml (Lateral decubitus view).

Q: Kerley B lines are seen in which of the following conditions?

Mitral stenosis. **Explanation:** **Kerley B lines** are short (1–2 cm), thin, horizontal peripheral lines seen at the lung bases, perpendicular to the pleural surface. They represent **thickened interlobular septa** caused by fluid accumulation (edema) or cellular infiltration. **Why Mitral Stenosis is Correct:** In Mitral Stenosis, there is an obstruction to left atrial outflow, leading to increased left atrial pressure. This pressure is transmitted backward into the pulmonary veins and capillaries (**Pulmonary Venous Hypertension**). When the capillary hydrostatic pressure exceeds the oncotic pressure, fluid transudates into the pulmonary interstitium and interlobular septa, manifesting as Kerley B lines on a chest X-ray. **Analysis of Incorrect Options:** * **Pleural Effusion:** While often co-existing with heart failure, pleural effusion refers to fluid in the pleural space, not the interlobular septa. It typically presents as blunting of the costophrenic angles. * **Pericardial Effusion:** This involves fluid within the pericardial sac. On X-ray, it presents as a "water-bottle" or "money-bag" heart silhouette, but it does not directly cause septal thickening in the lungs. **High-Yield Clinical Pearls for NEET-PG:** * **Kerley A lines:** Longer (2–6 cm) lines radiating from the hila toward the periphery; represent distended anastomotic channels between peripheral and central lymphatics. * **Differential Diagnosis for Kerley B lines:** 1. **Left Ventricular Failure/Pulmonary Edema** (Most common cause). 2. **Mitral Valve Disease.** 3. **Lymphangitic Carcinomatosis** (Look for unilateral or asymmetric lines). 4. **Pneumoconiosis** (e.g., Silicosis). * **Staging of Pulmonary Edema:** Kerley B lines appear during the **interstitial phase** (PCWP 18–25 mmHg), following cephalization (PCWP 13–18 mmHg) but before alveolar edema (PCWP >25 mmHg).

Q: What is the investigation of choice for evaluating pleural diseases?

CT scan. **Explanation:** **CT scan (Contrast-Enhanced CT)** is the investigation of choice for evaluating pleural diseases because it provides superior anatomical detail and can distinguish between pleural thickening, fluid, and solid masses. It is highly sensitive for detecting pleural calcification, plaques, and nodules, and is the gold standard for differentiating a lung abscess from an empyema. Its ability to visualize the entire pleural space, including the mediastinal and diaphragmatic surfaces, makes it indispensable for staging pleural malignancies like mesothelioma. **Why other options are incorrect:** * **Chest X-ray:** Usually the initial screening tool. While it can detect pleural effusion (blunting of costophrenic angles), it lacks the sensitivity to characterize the nature of the disease or detect small lesions. * **Ultrasound (USG):** Excellent for detecting small effusions, identifying loculations, and guiding thoracocentesis. However, it cannot visualize the entire pleura (due to rib shadows) or evaluate the lung parenchyma as effectively as CT. * **MRI:** Reserved for specific cases, such as evaluating chest wall invasion or diaphragmatic involvement in mesothelioma when CT is inconclusive. It is not the primary choice due to cost and motion artifacts. **High-Yield Clinical Pearls for NEET-PG:** * **Split Pleura Sign:** Seen on CECT; it indicates an empyema (thickened visceral and parietal pleura separated by fluid). * **Pleural Calcification:** Often associated with old TB or Asbestosis (Holly leaf sign on CXR). * **Sensitivity for Effusion:** USG can detect as little as 5–10 ml of fluid, whereas a PA view CXR requires ~200 ml to show blunting of the costophrenic angle.

Q: Which of the following chest x-ray findings is a common feature of ARDS and cardiogenic pulmonary edema?

Alveolar and interstitial opacities. ### Explanation The correct answer is **D. Alveolar and interstitial opacities.** Both **Acute Respiratory Distress Syndrome (ARDS)** and **Cardiogenic Pulmonary Edema (CPE)** represent forms of pulmonary edema, though their underlying mechanisms differ. In both conditions, fluid accumulates within the lung parenchyma (interstitium) and eventually spills into the air sacs (alveoli). On a chest X-ray, this manifests as bilateral, patchy, or confluent opacities. While the distribution may vary—CPE often shows a "bat-wing" perihilar pattern and ARDS is often more peripheral—the presence of alveolar and interstitial opacities is the fundamental radiographic hallmark shared by both. #### Analysis of Incorrect Options: * **A. Cardiomegaly:** This is a classic feature of **CPE** (due to heart failure). In ARDS (non-cardiogenic edema), the heart size is typically normal. * **B. Pleural effusions:** These are common and often bilateral in **CPE**. While they can occur in ARDS, they are usually absent or very small. Their prominent presence strongly favors a cardiac etiology. * **C. Pulmonary vascular redistribution:** Also known as "cephalization" (prominent upper lobe vessels), this is an early sign of increased pulmonary venous pressure seen in **CPE**. It is not a feature of ARDS. #### High-Yield Clinical Pearls for NEET-PG: * **PCWP (Pulmonary Capillary Wedge Pressure):** The gold standard to differentiate the two. In CPE, PCWP is **>18 mmHg**; in ARDS, it is **≤18 mmHg**. * **Air Bronchograms:** More commonly seen in ARDS due to the dense alveolar consolidation. * **Kerley B Lines:** Horizontal lines at the lung bases indicating interstitial edema; these are characteristic of **CPE**, not ARDS. * **Key Differentiator:** If the CXR shows a normal heart size, no pleural effusion, and peripheral opacities, think **ARDS**.

Q: What is the investigation of choice for the detection and characterization of interstitial lung disease?

High resolution CT. **Explanation:** **High-Resolution Computed Tomography (HRCT)** is the gold standard and investigation of choice for Interstitial Lung Disease (ILD). The underlying medical concept relies on HRCT’s ability to provide ultra-thin sections (1–2 mm) using a high-spatial-frequency reconstruction algorithm. This allows for the visualization of the secondary pulmonary lobule—the smallest functional unit of the lung—enabling clinicians to identify specific patterns such as ground-glass opacities, honeycombing, reticular patterns, and traction bronchiectasis, which are essential for differentiating between types of ILD (e.g., IPF vs. NSIP). **Why other options are incorrect:** * **Chest X-ray:** While often the initial screening tool, it lacks sensitivity. Up to 10–15% of patients with biopsy-proven ILD may have a normal chest radiograph. It cannot characterize the specific pattern or extent of the disease. * **MRI:** Due to low proton density in the lungs and artifacts caused by respiratory motion and air-tissue interfaces, MRI has a limited role in parenchymal lung evaluation compared to CT. * **Ventilation-Perfusion (V/Q) Scan:** This is primarily used to diagnose Pulmonary Embolism (by detecting mismatch) or to evaluate lung function prior to surgery, not for parenchymal characterization. **Clinical Pearls for NEET-PG:** * **HRCT Technique:** Uses thin slices (1-2mm) and a "bone algorithm" for edge enhancement. * **Prone HRCT:** Used to differentiate early interstitial changes from dependent basal atelectasis. * **Expiratory HRCT:** The investigation of choice to detect **air trapping**, a hallmark of small airway diseases like Bronchiolitis Obliterans. * **Honeycombing:** The radiological hallmark of Usual Interstitial Pneumonia (UIP).

Q: A patient presented with a history of blunt trauma to the chest and abdomen. On USG examination in M mode the following finding is seen. What is the likely diagnosis?

Pneumothorax. ***Pneumothorax*** - In M-mode ultrasound, pneumothorax shows the **"barcode sign"** or **"stratosphere sign"** - horizontal parallel lines without the normal lung sliding motion due to air between chest wall and lung. - Following **blunt chest trauma**, pneumothorax is common and the absence of **lung sliding** on ultrasound is highly sensitive for detecting it. *Pleural effusion* - Would show **anechoic fluid collection** in the pleural space with **respiratory variation** and possible **atelectatic lung** floating within. - M-mode would demonstrate **fluid movement** and **compressed lung tissue**, not the static barcode pattern seen here. *Bronchial obstruction* - Ultrasound has **limited utility** in diagnosing bronchial obstruction as **air-filled bronchi** cannot be well visualized on USG. - Would require **CT scan** or **bronchoscopy** for diagnosis, and wouldn't produce the characteristic M-mode findings described. *Lung abscess* - Appears as a **thick-walled cavity** with **internal echoes** representing pus and debris, often with **air-fluid levels**. - M-mode would show **complex echogenic patterns** within the abscess cavity, distinctly different from the uniform barcode sign of pneumothorax.

Q: The following CT chest shows the presence of?

Pneumoconiosis. ***Pneumoconiosis*** - CT chest shows **bilateral small nodular opacities** with **upper lobe predominance**, characteristic of pneumoconiosis from occupational dust exposure. - May progress to **progressive massive fibrosis (PMF)** and show **eggshell calcification** of hilar lymph nodes, pathognomonic for silicosis. *Primary carcinoma of lung* - Typically presents as a **solitary pulmonary nodule** or **mass lesion** rather than bilateral small nodules. - Shows **irregular margins**, **spiculation**, and may have **pleural effusion** or **mediastinal lymphadenopathy**. *Bronchiectasis* - CT demonstrates **bronchial wall thickening** and **bronchial dilatation** with the classic **"tram-track" sign**. - Shows **"signet ring" appearance** where dilated bronchi appear larger than accompanying pulmonary arteries. *Chronic bronchitis* - CT findings include **bronchial wall thickening** and **peribronchial cuffing** without the nodular pattern seen here. - May show **mosaic attenuation** and **air trapping** on expiratory images, but lacks bilateral small nodules.

Q: Atelectasis with reverse S sign is seen in which of the following conditions?

Bronchogenic carcinoma. **Explanation:** The **Golden S-sign** (also known as the **Reverse S-sign of Golden**) is a classic radiological sign seen on a chest X-ray or CT scan. It is formed by the collapse of the **Right Upper Lobe (RUL)**. The "S" shape is created by two distinct components: 1. **Superior/Lateral limb:** Formed by the upward displacement of the minor fissure due to RUL atelectasis (concave appearance). 2. **Inferior/Medial limb:** Formed by a **central mass** (usually Bronchogenic Carcinoma) obstructing the RUL bronchus, which creates a convex bulge. **Why Bronchogenic Carcinoma is correct:** The sign specifically indicates a central obstructing mass. In an elderly patient or a smoker, the Golden S-sign is highly suggestive of **Bronchogenic Carcinoma** (most commonly Squamous Cell Carcinoma) obstructing the right upper lobe bronchus. **Why other options are incorrect:** * **Asthma:** Typically presents with hyperinflation and air trapping, not lobar collapse with a central mass. * **Tuberculosis:** While TB can cause collapse due to endobronchial spread or lymph node compression, it rarely presents with the classic S-sign unless there is a specific endobronchial tuberculoma mimicking a mass. * **Sarcoidosis:** Usually presents with bilateral hilar lymphadenopathy (Garland’s triad) and interstitial lung disease, rather than isolated lobar collapse with a mass effect. **NEET-PG High-Yield Pearls:** * **Luftsichel Sign:** Seen in Left Upper Lobe (LUL) collapse; it is a crescent of air around the aortic arch. * **Sail Sign:** Seen in Right Middle Lobe collapse or a normal neonatal thymus. * **Flat Waist Sign:** Seen in Left Lower Lobe collapse due to rotation of the heart. * **Golden S-sign** can also be seen in the collapse of other lobes, but it is most classically described and easily recognized in the **Right Upper Lobe**.

Q: Perihilar fluffy opacities on chest X-ray are typically seen in which of the following conditions?

Pulmonary edema. **Explanation:** **1. Why Pulmonary Edema is Correct:** Perihilar fluffy opacities, often described as a **"Bat-wing" or "Butterfly" pattern**, are a hallmark of **acute alveolar pulmonary edema**. This occurs when fluid leaks from the pulmonary capillaries into the alveolar spaces, primarily in the central (medullary) portion of the lungs, while sparing the peripheral (cortical) zones. The "fluffy" nature of the opacities indicates an alveolar filling process rather than interstitial thickening. **2. Analysis of Incorrect Options:** * **Sarcoidosis:** Typically presents with **bilateral hilar lymphadenopathy** (Stage I) or reticular opacities (Stage II). The nodes are discrete and well-defined, not "fluffy" alveolar opacities. * **Silicosis:** Characterized by small, discrete nodules (2–5 mm) predominantly in the upper lobes. Advanced stages show **"Eggshell calcification"** of hilar nodes, not perihilar fluffiness. * **Lung Carcinoma:** Usually presents as a solitary pulmonary nodule, a focal mass, or obstructive atelectasis. While a central tumor can cause hilar enlargement, it is typically unilateral and well-demarcated. **3. High-Yield Clinical Pearls for NEET-PG:** * **Stages of Pulmonary Edema on CXR:** 1. **Stage 1 (Cephalization):** Redistribution of blood flow to upper lobes (PCWP 13–18 mmHg). 2. **Stage 2 (Interstitial Edema):** Kerley B lines, peribronchial cuffing, and hazy hila (PCWP 18–25 mmHg). 3. **Stage 3 (Alveolar Edema):** Bat-wing opacities and pleural effusion (PCWP >25 mmHg). * **Differential for Bat-wing appearance:** Pulmonary edema (most common), Alveolar proteinosis, PJP pneumonia, and Pulmonary hemorrhage.

Question 1

A 30-year-old male presents with a 3-week history of right-sided chest pain and cough. Examination reveals decreased breath sounds in the right lower lung. Chest X-ray shows blunting of the costophrenic angles. A contrast-enhanced CT scan of the chest is performed. What is the most probable diagnosis?

Accepted Answer

Empyema

Answer

Loculated pleural effusion

Answer

Pulmonary abscess

Answer

Mesothelioma

Question 2

What is the investigation of choice for pleural effusion?

Accepted Answer

Contrast-Enhanced Computed Tomography (CECT)

Answer

Chest X-ray

Answer

Ultrasound (USG)

Answer

Magnetic Resonance Imaging (MRI)

Question 3

Kerley B lines are seen in which of the following conditions?

Accepted Answer

Mitral stenosis

Answer

Pleural effusion

Answer

Pericardial effusion

Answer

All of the above

Question 4

What is the investigation of choice for evaluating pleural diseases?

Accepted Answer

CT scan

Answer

Ultrasound (USG)

Answer

Chest X-ray

Answer

MRI

Question 5

Which of the following chest x-ray findings is a common feature of ARDS and cardiogenic pulmonary edema?

Accepted Answer

Alveolar and interstitial opacities

Answer

Cardiomegaly

Answer

Pleural effusions

Answer

Pulmonary vascular redistribution

Question 6

What is the investigation of choice for the detection and characterization of interstitial lung disease?

Accepted Answer

High resolution CT

Answer

MRI

Answer

Chest x-ray

Answer

Ventilation perfusion scan

Question 7

A patient presented with a history of blunt trauma to the chest and abdomen. On USG examination in M mode the following finding is seen. What is the likely diagnosis?

Accepted Answer

Pneumothorax

Answer

Pleural effusion

Answer

Bronchial obstruction

Answer

Lung abscess

Question 8

The following CT chest shows the presence of?

Accepted Answer

Pneumoconiosis

Answer

Primary carcinoma of lung

Answer

Bronchiectasis

Answer

Chronic bronchitis

Question 9

Atelectasis with reverse S sign is seen in which of the following conditions?

Accepted Answer

Bronchogenic carcinoma

Answer

Asthma

Answer

Tuberculosis

Answer

Sarcoidosis

Question 10

Perihilar fluffy opacities on chest X-ray are typically seen in which of the following conditions?

Accepted Answer

Pulmonary edema

Answer

Sarcoidosis

Answer

Silicosis

Answer

Lung carcinoma

Chest Radiology — MCQs

Chest Radiology — MCQs

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