Non-traumatic Thoracic Emergencies — MCQs
A 26 year old male patient was brought to the emergency department with abdominal pain and obstipation for 3 days. He gives a history of bull gore to the abdomen 3 days back. His chest X-ray is given below. What is the probable diagnosis?
Pulmonary embolism is most commonly produced by which of the following?
IOC for Acute Aortic Dissection in a Clinically Unstable patient is?
Which of the following statements about pulmonary embolism is false?
What is a key diagnostic criterion for acute respiratory distress syndrome (ARDS) in a child?
A patient with a known case of acute pancreatitis develops breathlessness and bilateral basal crepitations on day 4. What is the most likely diagnosis based on the chest radiography image?
A Patient presented to emergency with multiple rib fractures. He is conscious speaking single words. On examination, respiratory rate was 40/minute and BP was 90/40 mmHg. What is immediate next step?
Which of the following is shown in the image below?
What is the most likely diagnosis based on the chest radiographs shown below?
Radiological features of left ventricular heart failure are all, except -
Non-traumatic Thoracic Emergencies Indian Medical PG Practice Questions and MCQs
Question 1: A 26 year old male patient was brought to the emergency department with abdominal pain and obstipation for 3 days. He gives a history of bull gore to the abdomen 3 days back. His chest X-ray is given below. What is the probable diagnosis?
- A. Hemothorax
- B. Hollow viscus perforation (Correct Answer)
- C. Pneumothorax
- D. Intestinal obstruction
Explanation: ***Hollow viscus perforation*** - The chest X-ray clearly shows **free air under the diaphragm** (pneumoperitoneum), which is a hallmark sign of a perforated hollow viscus in the abdomen. - The history of **bull gore to the abdomen** and subsequent abdominal pain and obstipation further supports a traumatic perforation of a stomach or intestinal segment. *Hemothorax* - Hemothorax would present as **fluid in the pleural space**, typically seen as blunting of the costophrenic angles or an effusion on X-ray, which is not evident here. - While trauma can cause hemothorax, the prominent finding on this X-ray is intra-abdominal air, not intrathoracic fluid. *Pneumothorax* - Pneumothorax is characterized by the presence of **air in the pleural space**, leading to lung collapse and absence of lung markings in the affected area, which is not observed on this X-ray. - The air seen is clearly **below the diaphragm**, indicating intra-abdominal free air, not air in the chest cavity surrounding the lung. *Intestinal obstruction* - Intestinal obstruction typically presents with **dilated bowel loops** and **air-fluid levels** on an abdominal X-ray, along with abdominal pain and obstipation. - While the patient has obstipation, the primary X-ray finding is free air under the diaphragm, which is not characteristic of an uncomplicated intestinal obstruction.
Question 2: Pulmonary embolism is most commonly produced by which of the following?
- A. Trauma
- B. Atherosclerosis
- C. No significant cause
- D. Thrombosis of lower limb veins (Correct Answer)
Explanation: ***Thrombosis of lower limb veins*** - The vast majority of pulmonary emboli originate from **deep vein thromboses (DVTs)** in the lower extremities, particularly the proximal veins (popliteal, femoral, iliac) [1]. - These clots can detach and travel through the right side of the heart to lodge in the **pulmonary arterial system** [1]. - Many patients with suspected PE will have identifiable proximal thrombus in the leg veins [2]. *Trauma* - While severe trauma can increase the risk of DVT due to immobility and venous stasis, **trauma itself is not the direct cause** of the pulmonary embolism. - Trauma is a risk factor for DVT formation, which then leads to PE, rather than directly producing the embolism. *Atherosclerosis* - Atherosclerosis is a disease of arteries involving plaque formation and can lead to conditions like **myocardial infarction** or **stroke**, but it is not a direct source of pulmonary emboli. - While severe atherosclerosis can be a risk factor for DVT in some cases due to systemic inflammation or reduced mobility, it is not the primary mechanism. *No significant cause* - While up to 50% of deep vein thromboses can be asymptomatic, thereby making their "cause" seem insignificant to the patient, PE always has an underlying cause, most commonly **venous thrombosis** [1]. - PE is a serious medical condition with identifiable risk factors and origins, even if the patient is unaware of the initial thrombotic event.
Question 3: IOC for Acute Aortic Dissection in a Clinically Unstable patient is?
- A. NCCT
- B. TEE (Correct Answer)
- C. MRI
- D. CT-Angio
Explanation: ***TEE (Transesophageal Echocardiography)*** - **TEE is the investigation of choice** for acute aortic dissection in **hemodynamically unstable patients** due to its **portability and rapidity**. - Can be performed at the **bedside** without transporting the critically ill patient, minimizing risk. - Provides rapid diagnosis (5-10 minutes) with **>95% sensitivity and specificity** for detecting intimal flap and false lumen. - Simultaneously assesses **complications** such as aortic regurgitation, pericardial effusion/tamponade, and ventricular function. - Particularly excellent for visualizing the **ascending aorta** and aortic root. *CT-Angio* - **CT angiography** is the **investigation of choice** for acute aortic dissection in **hemodynamically STABLE patients**. - Provides excellent anatomical detail of the entire aorta, clearly showing the intimal flap, true and false lumens, and branch vessel involvement. - Requires **patient transport** to the radiology department, which is **unsafe in unstable patients**. - Best for comprehensive surgical planning in stable patients. *MRI* - **MRI** offers the highest anatomical detail and is considered the gold standard for **chronic dissection follow-up**. - Its lengthy acquisition time (30-60 minutes) and incompatibility with monitoring equipment make it **unsuitable for acutely unstable patients**. *NCCT* - **Non-contrast CT** may show indirect signs like the **hyperdense crescent sign** in the aortic wall. - Cannot reliably differentiate true and false lumens or assess the full extent of dissection. - Insufficient for definitive diagnosis or management planning.
Question 4: Which of the following statements about pulmonary embolism is false?
- A. Most commonly presents within 2 weeks (Correct Answer)
- B. Pulmonary embolism often arises from deep vein thrombosis in the legs.
- C. Dyspnea is the most common symptom
- D. Longer survival time generally indicates a better chance of recovery.
Explanation: Most commonly presents within 2 weeks - This statement is **false** because while pulmonary embolism can occur at any time, its onset is not restricted to or "most commonly presents" within a two-week period. - The timing of presentation can vary widely depending on the predisposing factors and the specific event leading to the embolus formation and migration. *Dyspnea is the most common symptom* - **Dyspnea** (shortness of breath) is indeed the **most frequent symptom** reported by patients experiencing pulmonary embolism. - This symptom often occurs acutely and can range from mild to severe, correlating with the size and location of the embolism. *Pulmonary embolism often arises from deep vein thrombosis in the legs.* - The vast majority of **pulmonary emboli (PEs)** originate from **deep vein thromboses (DVTs)**, particularly those located in the large veins of the legs and pelvis [1, 2]. - These clots can detach and travel through the venous system to the heart and then into the pulmonary arteries [2]. *Longer survival time generally indicates a better chance of recovery.* - Patients who survive longer after a pulmonary embolism are more likely to have received timely treatment and may have experienced a less severe embolic event or have better underlying health. - Prolonged survival after the initial acute phase suggests the patient has overcome the immediate life-threatening aspects and is on the path to recovery, potentially with less long-term sequelae.
Question 5: What is a key diagnostic criterion for acute respiratory distress syndrome (ARDS) in a child?
- A. Within 7 days of known clinical insult (Correct Answer)
- B. Respiratory failure not fully explained
- C. Left ventricular dysfunction
- D. All of the options
Explanation: ***Within 7 days of known clinical insult*** - A key diagnostic criterion for **Acute Respiratory Distress Syndrome (ARDS)** in children is the onset of respiratory symptoms within **7 days of a known clinical insult**. - This temporal relationship helps distinguish ARDS from other causes of respiratory failure that may have a more chronic or delayed onset. *Respiratory failure not fully explained* - **Respiratory failure not fully explained** by other conditions is a general characteristic but not a specific diagnostic criterion on its own. - ARDS requires the exclusion of cardiac failure as the primary cause of pulmonary edema, indicated by an absence of left atrial hypertension. *Left ventricular dysfunction* - **Left ventricular dysfunction** would suggest **cardiogenic pulmonary edema**, which needs to be excluded for a diagnosis of ARDS. - ARDS is characterized by **non-cardiogenic pulmonary edema**, meaning the fluid in the lungs is not due to heart failure. *All of the options* - This option is incorrect because **left ventricular dysfunction** is an *exclusion criterion* for ARDS, not a diagnostic criterion, as ARDS is defined by **non-cardiogenic pulmonary edema**. - While the other options relate to aspects of ARDS, only one is a key diagnostic criterion as formulated.
Question 6: A patient with a known case of acute pancreatitis develops breathlessness and bilateral basal crepitations on day 4. What is the most likely diagnosis based on the chest radiography image?
- A. Bilateral pneumonia
- B. Carcinogenic Pulmonary Embolism
- C. Lung collapse (atelectasis)
- D. Acute Respiratory Distress Syndrome (ARDS) (Correct Answer)
Explanation: ***Acute Respiratory Distress Syndrome (ARDS)*** - The chest radiograph shows **bilateral patchy infiltrates** and **diffuse alveolar opacities** consistent with ARDS, especially in the context of **acute pancreatitis** as a known risk factor. - The development of **breathlessness** and **bilateral basal crepitations** (rales) on day 4 further supports ARDS due to fluid accumulation in the lungs. *Bilateral pneumonia* - While pneumonia can cause bilateral infiltrates, the **symmetrical and widespread distribution** seen on this radiograph, combined with the context of acute pancreatitis, makes ARDS a more likely diagnosis. - Pneumonia typically presents with fever, productive cough, and lung consolidation, which are not specifically highlighted as primary symptoms over the breathlessness. *Carcinogenic Pulmonary Embolism* - Pulmonary embolism typically manifests with **sudden onset dyspnea**, pleuritic chest pain, and sometimes hemoptysis, and chest X-rays are often normal or show subtle findings like a **Westermark sign** or Hampton's hump. - The widespread bilateral infiltrates seen in the image are **not characteristic of pulmonary embolism**. *Lung collapse (atelectasis)* - Atelectasis usually appears as a ** localised area of increased opacification**, often with volume loss (e.g., tracheal deviation, elevated hemidiaphragm), and is often unilateral or segmental. - The **diffuse, bilateral, and often fluffy infiltrates** seen in this image are not consistent with typical atelectasis.
Question 7: A Patient presented to emergency with multiple rib fractures. He is conscious speaking single words. On examination, respiratory rate was 40/minute and BP was 90/40 mmHg. What is immediate next step?
- A. Urgent IV fluid administration
- B. Intubate the patient
- C. Needle insertion in 2nd intercostal space (Correct Answer)
- D. Chest X-ray
Explanation: ***Needle insertion in 2nd intercostal space*** - The patient's presentation with multiple rib fractures, **tachypnea (40/minute)**, **hypotension (90/40 mmHg)**, and speaking only single words suggests **tension pneumothorax**. - Speaking only single words indicates severe **respiratory distress** and inability to complete sentences due to dyspnea. - **Needle decompression** in the 2nd intercostal space at the midclavicular line is the immediate life-saving intervention for tension pneumothorax. - This is a **clinical diagnosis** in an emergency setting and does not require imaging confirmation before intervention. *Urgent IV fluid administration* - While fluid administration may be necessary for shock, the primary issue is likely **impaired ventilation** due to tension pneumothorax, which needs to be addressed first. - Delaying needle decompression to administer fluids could worsen the patient's respiratory and hemodynamic status. *Intubate the patient* - Intubation without addressing the cause of respiratory compromise, especially tension pneumothorax, can worsen the condition by increasing **intrathoracic pressure**. - Positive pressure ventilation in the presence of tension pneumothorax can be **life-threatening**. - **Relief of the tension pneumothorax** is the priority before considering definitive airway management. *Chest X-ray* - A chest X-ray is a diagnostic tool but should **not delay immediate life-saving interventions** in a patient with suspected tension pneumothorax. - Tension pneumothorax is a **clinical diagnosis** based on symptoms and immediate intervention takes precedence over imaging.
Question 8: Which of the following is shown in the image below?
- A. Westermark sign (Correct Answer)
- B. Palla sign
- C. Hampton hump
- D. Round pneumonia
Explanation: ***Westermark sign*** - This image displays a **dilated pulmonary artery proximal to an area of oligemia**, specifically noted in the upper right lung field, as indicated by the arrow. This finding is characteristic of the **Westermark sign**, which is suggestive of a **pulmonary embolism**. - The Westermark sign represents **distal collapse of the pulmonary vasculature** due to a reduction in blood flow, making the lung parenchyma appear unusually lucent compared to adjacent normal lung fields. *Palla sign* - The Palla sign refers to a **dilated right descending pulmonary artery** (interlobar artery) on a chest X-ray. While it is also associated with pulmonary embolism, the image prominently shows oligemia, the defining feature of the Westermark sign, not solely an enlarged artery. - This sign indicates **increased pulmonary artery pressure** due to the embolus, but the key feature in the provided image is the reduced vascularity distally, not just the proximal vessel size. *Hampton hump* - A Hampton hump is a **wedge-shaped pleural-based opacity** with a rounded convex border facing the hilum. - It results from a **pulmonary infarction** due to a large pulmonary embolus and is not visible in this image. *Round pneumonia* - Round pneumonia is a **circular or oval-shaped consolidation** that is typically seen in children and appears as a mass-like lesion. - It is an infectious process with consolidation of lung tissue and does not involve vascular abnormalities like oligemia, which is clearly depicted in the image.
Question 9: What is the most likely diagnosis based on the chest radiographs shown below?
- A. Lung abscess
- B. Lobar emphysema
- C. Segmental collapse (Correct Answer)
- D. Bronchiectasis
Explanation: ***Segmental collapse*** - The frontal image shows a **wedge-shaped opacity** in the right upper lobe, and the lateral view reveals a **triangular area of increased density** consistent with collapsed lung tissue. - This pattern, particularly the triangular density on the lateral view and volume loss indicated by the position of the **minor fissure (white arrow)**, points towards segmental collapse. *Lung abscess* - A lung abscess typically presents as a **cavity with an air-fluid level**, which is not depicted in these images. - The lesion shown is mostly **solid and dense**, unlike the characteristic appearance of an abscess. *Lobar emphysema* - Lobar emphysema involves **overinflation of a lung lobe**, characterized by increased lucency and vascular attenuation, which is the opposite of the findings here. - There is no evidence of **air trapping** or **hyperinflation** in the images provided. *Bronchiectasis* - Bronchiectasis is characterized by **permanent abnormal dilation of the bronchi**, often seen as "tram tracks" or "ring" opacities on imaging. - The images do not show these specific findings; instead, they indicate a loss of lung volume.
Question 10: Radiological features of left ventricular heart failure are all, except -
- A. Kerley B lines
- B. Cardiomegaly
- C. Increased flow in upper lobe veins
- D. Oligemic lung fields (Correct Answer)
Explanation: ***Oligemic lung fields*** - **Oligemic lung fields** are characteristic of conditions like severe **pulmonary hypertension** or **pulmonary embolism** post-embolus, leading to reduced blood flow to the lungs, not left ventricular heart failure. - In left ventricular heart failure, the primary issue is **pulmonary venous congestion** and **edema**, leading to increased, not decreased, pulmonary vascular markings. *Kerley B lines* - **Kerley B lines** are often seen in left ventricular heart failure, indicating **interstitial pulmonary edema**. - They represent thickened, edematous interlobular septa due to increased hydrostatic pressure in the pulmonary capillaries. *Cardiomegaly* - **Cardiomegaly** (enlarged heart) on chest X-ray is a common finding in left ventricular heart failure, reflecting ventricular dilation and/or hypertrophy due to chronic increased workload. - This enlargement is often due to the heart's compensatory mechanisms attempting to maintain cardiac output. *Increased flow in upper lobe veins* - **Increased flow in upper lobe veins** (cephalization of pulmonary vessels) is an early sign of pulmonary venous hypertension in left ventricular heart failure. - Due to elevated left atrial pressure, blood is preferentially shunted to the less gravitationally dependent upper lobes.
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