Chest Radiology Practice Questions

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

Pulmonary venous hypertension. **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).

Q: A 40-year-old man is seen for an insurance assessment. He has no past medical history and feels well. His complete physical examination is normal. His biochemistry, complete blood count (CBC), ECG, and urinalysis are also normal. His CXR is abnormal. Which of the following is the most likely diagnosis?

Tuberculous granuloma of the left apex. ***Tuberculous granuloma of the left apex*** - **Calcified apical nodule** (Ghon focus/Simon focus) from healed tuberculosis is the most common incidental finding on CXR in asymptomatic adults, especially in **TB-endemic regions**. - Presents as a **well-defined calcified lesion** in the upper lobe apex, representing old healed primary tuberculosis infection. *Hamartoma of the lung* - Typically shows characteristic **popcorn calcification** pattern on imaging, which is different from the uniform calcification of TB granuloma. - Usually located in the **lower lobes** rather than the typical apical location of TB lesions. *Osteochondroma of the left 4th rib* - Appears as a **bony exostosis** arising from the rib surface with characteristic **cartilaginous cap**, not as a lung parenchymal lesion. - Would be **rib-based** and extend outward from the bone, easily distinguishable from intrapulmonary lesions. *Bronchogenic carcinoma* - Typically presents as an **irregular, spiculated mass** with poorly defined borders, not a well-circumscribed calcified nodule. - More commonly occurs in **older patients** with smoking history and would be unlikely to remain completely asymptomatic with normal physical examination.

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

Thickened interlobular septa. **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.

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

Lordotic view. **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**.

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

Pneumonectomy. **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).

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

Hydrothorax. **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.

Q: 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?

Acute cholecystitis. **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.

Q: On barium swallow, which of the following causes a posterior impression?

Aberrant right subclavian artery. **Explanation:** The correct answer is **Aberrant right subclavian artery (Arteria Lusoria)**. This is the most common congenital anomaly of the aortic arch. In this condition, the right subclavian artery arises as the last branch of the aortic arch (distal to the left subclavian) and crosses from left to right to reach the right arm. In 80% of cases, it passes **posterior to the esophagus**, creating a characteristic oblique indentation on the posterior wall during a barium swallow. Clinically, this can lead to "Dysphagia Lusoria." **Analysis of Incorrect Options:** * **Left Atrium:** Causes an **anterior** impression on the mid-to-lower esophagus when enlarged (Mitral Stenosis). * **Aortic Knuckle:** Causes a **left lateral** impression on the esophagus. * **Pulmonary Sling:** Occurs when the left pulmonary artery arises from the right pulmonary artery. It is the only vascular anomaly that passes **between the trachea and the esophagus**, causing an **anterior** impression on the esophagus and a posterior impression on the trachea. **High-Yield Clinical Pearls for NEET-PG:** * **Double Aortic Arch:** Causes a "vascular ring" that encircles both the trachea and esophagus, resulting in **bilateral and posterior** indentations. * **Right-sided Aortic Arch:** Causes a **right lateral** indentation. * **Key Distinction:** If a question mentions a posterior impression, think **Aberrant Right Subclavian** or **Double Aortic Arch**. If it mentions an impression *between* the trachea and esophagus, it is always a **Pulmonary Sling**.

Q: A 44-year-old man presents with dyspnea, cough, and mild pyrexia. Which lobe of the lung is most likely involved?

Right middle lobe. ***Right middle lobe*** - The **right middle lobe** is most commonly affected in pneumonia presenting with dyspnea, cough, and pyrexia, often showing **silhouette sign** with obliteration of the **right heart border** on chest X-ray. - On **lateral chest X-ray**, right middle lobe consolidation appears as opacity in the **anterior-inferior portion** of the thorax, helping differentiate from other lobes. *Right upper lobe* - Right upper lobe pneumonia typically shows consolidation **above the horizontal fissure** and would obliterate the **right paratracheal stripe**, not the heart border. - On lateral view, opacity would be located in the **anterior-superior** portion, distinctly different from middle lobe involvement. *Left lower lobe* - Left lower lobe consolidation would obliterate the **left hemidiaphragm** and **descending aorta** silhouette, not affecting the right heart border. - Symptoms would be similar, but radiological findings show **retrocardiac opacity** on PA view and **posterior-inferior** opacity on lateral view. *Left upper lobe* - Left upper lobe pneumonia would cause loss of the **left heart border** and **aortic knob** silhouette, with opacity in the **upper left thorax**. - On lateral chest X-ray, consolidation appears in the **anterior-superior** region, similar to right upper lobe but on the opposite side.

Question 1

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

Accepted Answer

Pulmonary venous hypertension

Answer

Pulmonary embolism

Answer

Pericardial effusion

Answer

Pulmonary arterial hypertension

Question 2

A 40-year-old man is seen for an insurance assessment. He has no past medical history and feels well. His complete physical examination is normal. His biochemistry, complete blood count (CBC), ECG, and urinalysis are also normal. His CXR is abnormal. Which of the following is the most likely diagnosis?

Accepted Answer

Tuberculous granuloma of the left apex

Answer

Hamartoma of the lung

Answer

Osteochondroma of the left 4th rib

Answer

Bronchogenic carcinoma

Question 3

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

Accepted Answer

Thickened interlobular septa

Answer

Linear fibrosis

Answer

Haemosiderin deposits

Answer

Small focal atelectasis

Question 4

Inferior rib notching is seen in all except?

Accepted Answer

Marfan's syndrome

Answer

Aortic thrombosis

Answer

Taussing Blalock operation

Answer

Pulmonary atresia

Question 5

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

Accepted Answer

Lordotic view

Answer

PA view

Answer

Right anterior oblique view

Answer

Left anterior oblique view

Question 6

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

Accepted Answer

Pneumonectomy

Answer

Pneumothorax

Answer

Resection of mammary gland

Answer

Pulmonary artery obstruction

Question 7

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

Accepted Answer

Hydrothorax

Answer

Collapse

Answer

Consolidation

Answer

Hemothorax

Question 8

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?

Accepted Answer

Acute cholecystitis

Answer

Subphrenic abscess

Answer

Amebic liver abscess

Answer

Pyogenic liver abscess

Question 9

On barium swallow, which of the following causes a posterior impression?

Accepted Answer

Aberrant right subclavian artery

Answer

Left atrium

Answer

Aortic knuckle

Answer

Pulmonary sling

Question 10

A 44-year-old man presents with dyspnea, cough, and mild pyrexia. Which lobe of the lung is most likely involved?

Accepted Answer

Right middle lobe

Answer

Right upper lobe

Answer

Left lower lobe

Answer

Left upper lobe

Chest Radiology — MCQs

Chest Radiology — MCQs

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