Chest Radiology Practice Questions

Q: A 45-year-old male presents to the emergency department at 1 AM after binge drinking, complaining of severe chest pain following an episode of vomiting. A chest radiograph of this patient demonstrates which of the following signs?

Naclerio V sign. ### **Explanation** **Correct Answer: B. Naclerio V sign** The clinical presentation describes **Boerhaave Syndrome** (spontaneous esophageal perforation), typically occurring after forceful vomiting or retching (often post-alcohol binge). When the esophagus ruptures, air escapes into the mediastinum (**pneumomediastinum**). The **Naclerio V sign** is a classic radiologic finding in Boerhaave syndrome. It represents air outlining the lower lateral margin of the descending aorta and the left hemidiaphragm, forming a "V" shape. This occurs because gas tracks between the parietal pleura and the mediastinal fascia. --- ### **Analysis of Incorrect Options** * **A. Silhouette Sign:** This occurs when two structures of similar radiographic density are in anatomical contact, causing the border between them to disappear (e.g., right middle lobe pneumonia obscuring the right heart border). It is not specific to esophageal rupture. * **C. Spinnaker Sign (Angel Wing Sign):** This refers to the elevation of the thymic lobes by air in the mediastinum. While it is a sign of pneumomediastinum, it is primarily seen in **neonates** and infants, not adults. * **D. Hilum Overlay Sign:** This is used to differentiate a hilar mass from an enlarged heart or a mass in the anterior/posterior mediastinum. If hilar vessels are visible through the mass, the lesion is not in the hilum. --- ### **High-Yield Clinical Pearls for NEET-PG** * **Mackler’s Triad:** Vomiting, chest pain, and subcutaneous emphysema (pathognomonic for Boerhaave syndrome). * **Most Common Site of Rupture:** Left posterolateral aspect of the distal esophagus (2–3 cm above the gastroesophageal junction). * **Hamman’s Crunch:** A crunching sound heard over the precordium synchronous with the heartbeat, indicating pneumomediastinum. * **Gold Standard Investigation:** Gastrografin (water-soluble contrast) swallow study. Avoid Barium initially due to the risk of mediastinitis.

Q: Which one of the following diagnostic techniques is most specific for pulmonary embolism?

Pulmonary angiography. **Explanation:** **Pulmonary Angiography** is considered the **"Gold Standard"** and the most specific diagnostic technique for pulmonary embolism (PE). It involves the direct injection of radiopaque contrast into the pulmonary arteries via a catheter. A definitive diagnosis is made by the direct visualization of an intraluminal filling defect or the abrupt "cutoff" of a vessel. While highly specific, it is an invasive procedure and has largely been replaced in clinical practice by CT Pulmonary Angiography (CTPA). **Why other options are incorrect:** * **Ventilation (V) and Perfusion (Q) Lung Scanning:** These are functional imaging tests. While a "mismatch" (normal ventilation with a perfusion defect) suggests PE, these tests are often non-specific. Conditions like pneumonia, COPD, or old scars can cause defects, leading to "intermediate" or "low probability" results that are not definitive. * **Arterial Blood Gas (ABG) Analysis:** ABG typically shows hypoxemia, hypocapnia, and respiratory alkalosis in PE. However, these findings are highly non-specific and can be seen in numerous other cardiac and pulmonary conditions. A normal ABG does not rule out PE. **High-Yield Clinical Pearls for NEET-PG:** * **Investigation of Choice (IOC):** CT Pulmonary Angiography (CTPA) is the current IOC due to its high sensitivity and non-invasive nature. * **Gold Standard:** Invasive Pulmonary Angiography (as per the question). * **Initial Screening Test:** Chest X-ray (usually normal, but look for *Hampton’s Hump* or *Westermark Sign*). * **Best Initial Bedside Test:** ECG (most common finding is Sinus Tachycardia; most specific is S1Q3T3). * **D-Dimer:** High negative predictive value (useful to rule out PE in low-risk patients).

Q: A 25-year-old man presented with fever, cough, expectoration, and breathlessness of 2 months' duration. Contrast-enhanced computed tomography of the chest showed bilateral upper lobe fibrotic lesions and mediastinal enlarged necrotic nodes with peripheral rim enhancement. Which one of the following is the most probable diagnosis?

Tuberculosis. ### Explanation The clinical and radiological presentation is classic for **Post-primary (Reactivation) Tuberculosis**. **Why Tuberculosis is correct:** In a young patient with a chronic history (2 months) of constitutional symptoms (fever, cough, expectoration), the presence of **bilateral upper lobe fibrotic lesions** is highly suggestive of TB, as the organism (*Mycobacterium tuberculosis*) prefers the high oxygen tension found in the lung apices. The pathognomonic CT finding here is **mediastinal lymphadenopathy with peripheral rim enhancement and central necrosis**. This "rim sign" represents granulomatous inflammation with central caseous necrosis, which is the hallmark of tubercular lymphadenitis. **Why other options are incorrect:** * **Sarcoidosis:** Typically presents with bilateral symmetrical hilar lymphadenopathy and perilymphatic nodules. While it can cause upper lobe fibrosis in Stage IV, the nodes are usually "potato-like" (well-defined, non-matted) and **homogeneously enhancing**, not necrotic. * **Lymphoma:** Usually presents with a large anterior mediastinal mass. While nodes can be bulky, they typically show **homogeneous enhancement**. Necrosis is rare unless the tumor is very large or post-treatment. * **Silicosis:** Characterized by multiple small, well-defined nodules in the upper lobes and "eggshell calcification" of hilar nodes. It does not typically present with necrotic nodes or acute febrile illness. **NEET-PG High-Yield Pearls:** * **Rim-enhancing necrotic nodes:** Think Tuberculosis first (especially in the Indian context). * **Eggshell calcification:** Classic for Silicosis; also seen in Sarcoidosis (rarely). * **1-2-3 Sign (Garland’s Triad):** Right paratracheal, right hilar, and left hilar lymphadenopathy—characteristic of Sarcoidosis. * **Tree-in-bud appearance:** On CT, this signifies endobronchial spread of infection (highly suggestive of active TB).

Q: Which of the following is NOT typically seen in congestive cardiac failure?

Prominent lower lobe vessels. In Congestive Cardiac Failure (CCF), the hallmark finding on a chest X-ray is **Cephalization** (also known as the Antler sign). This refers to the redistribution of blood flow to the upper lobes. **Explanation of the Correct Answer:** * **Prominent lower lobe vessels (Option B):** In a normal upright chest X-ray, gravity causes the lower lobe vessels to be more prominent than the upper lobe vessels. However, in CCF, increased pulmonary venous pressure leads to perivascular edema, which compresses the lower lobe vessels. This causes a redistribution of blood flow to the upper lobes. Therefore, **prominent lower lobe vessels are a normal finding**, while their absence (cephalization) is a sign of heart failure. **Explanation of Incorrect Options:** * **Kerley B lines (Option A):** These are short (1-2 cm), horizontal peripheral lines seen at the lung bases. They represent thickened interlobular septa due to fluid accumulation and are a classic sign of pulmonary edema. * **Pleural effusions (Option C):** Increased hydrostatic pressure leads to fluid transudation into the pleural space. In CCF, effusions are typically bilateral; if unilateral, they are more common on the right side. * **Cardiomegaly (Option D):** Defined as a cardiothoracic ratio >0.5 on a PA view, this is a common finding in chronic heart failure, indicating ventricular enlargement. **High-Yield Clinical Pearls for NEET-PG:** * **Stages of Pulmonary Edema on CXR:** 1. **Stage 1 (PCWP 13-18 mmHg):** Cephalization (Upper lobe diversion). 2. **Stage 2 (PCWP 18-25 mmHg):** Interstitial edema (Kerley B lines, peribronchial cuffing). 3. **Stage 3 (PCWP >25 mmHg):** Alveolar edema (Bat-wing appearance). * **Vanishing Tumor:** A localized pleural effusion in the interlobar fissures (usually the minor fissure) that disappears with diuretic therapy is called a "pseudotumor" or "phantom tumor."

Q: Pruned tree appearance of pulmonary circulation is a feature of which condition?

Pulmonary artery hypertension. **Explanation:** The **"Pruned Tree Appearance"** is a classic radiological sign of **Pulmonary Artery Hypertension (PAH)**. It occurs due to the marked dilation of the central pulmonary arteries (the "trunk") followed by a rapid, abrupt narrowing (tapering) of the peripheral pulmonary vessels. This peripheral tapering is caused by increased pulmonary vascular resistance and obliterative changes in the small distal vessels, making the lungs look like a tree with its outer branches cut off. **Analysis of Options:** * **Pulmonary Artery Hypertension (Correct):** High pressure leads to proximal vessel distension and distal vasoconstriction/obliteration, creating the characteristic "pruned" look on a chest X-ray or CT. * **Pulmonary Stenosis:** Typically results in **post-stenotic dilation** of the main pulmonary artery (especially the left branch) and *decreased* pulmonary vascular markings (oligemia), but not the specific pruned-tree pattern. * **Pulmonary Regurgitation:** Usually leads to right ventricular enlargement and potentially dilated central arteries due to volume overload, but it lacks the abrupt peripheral tapering seen in PAH. * **Pulmonary Embolism:** Acute PE may show **Westermark’s sign** (focal oligemia) or **Fleischner sign** (distended central artery), but "pruning" is a chronic feature of vascular remodeling. **High-Yield Clinical Pearls for NEET-PG:** * **Westermark Sign:** Focal area of lucency (oligemia) distal to an embolus in Pulmonary Embolism. * **Hampton’s Hump:** Wedge-shaped opacity at the periphery indicating pulmonary infarction. * **Knuckle Sign:** Abrupt tapering of a pulmonary artery branch due to an embolus. * **PAH on X-ray:** Right descending pulmonary artery diameter **>16 mm** in males or **>15 mm** in females is a strong indicator of PAH.

Q: Which of the following conditions is best investigated with a non-contrast CT scan?

Interstitial lung disease. **Explanation:** The primary goal of a CT scan in **Interstitial Lung Disease (ILD)** is to visualize the fine structural details of the lung parenchyma, such as reticulations, ground-glass opacities, and honeycombing. This is achieved through **High-Resolution Computed Tomography (HRCT)**, which uses thin slices (1–2 mm) and a high-spatial-frequency reconstruction algorithm. Since the natural contrast between air-filled alveoli and the lung interstitium is high, intravenous contrast is unnecessary and may even obscure subtle parenchymal details. **Analysis of Incorrect Options:** * **A. Mediastinal mass:** Contrast (CECT) is essential to differentiate the mass from adjacent vascular structures, identify the degree of vascularity, and check for invasion into the heart or great vessels. * **B. Lung mass:** CECT is required to evaluate the vascularity of the lesion, its relationship with the hilum, and to identify mediastinal lymphadenopathy (staging). * **C. Nodular thickening of pleura:** Contrast helps distinguish between simple pleural fluid and pleural thickening/masses. It also highlights "pleural enhancement," which is a key sign of inflammation or malignancy (e.g., Mesothelioma). **Clinical Pearls for NEET-PG:** * **HRCT** is the "Gold Standard" for diagnosing ILD and Bronchiectasis. * **Non-Contrast CT (NCCT)** is also the investigation of choice for **Ureteric Calculi** (KUB) and **Acute Head Injury** (to rule out hemorrhage). * **Contrast (CECT)** is generally mandatory for evaluating **malignancies, infections (abscesses), and vascular pathologies** (Aortic dissection/PE).

Q: The following X-ray was taken after Staph. aureus pneumonia. What is the diagnosis?

Pneumothorax. ***Pneumothorax*** - **Staph. aureus pneumonia** can lead to **pneumatocele formation**, which may rupture and cause pneumothorax as a complication. - X-ray shows a **pleural line** with absent lung markings peripherally, indicating air in the pleural space. *Lung abscess* - Presents as a **thick-walled cavity** with an **air-fluid level** on X-ray, not the findings described here. - While **Staph. aureus** can cause lung abscesses, the X-ray appearance would show a loculated collection within lung parenchyma. *Empyema* - Appears as **homogeneous opacity** in the pleural space with a **meniscus sign** on X-ray. - Represents infected pleural fluid collection, not the radiological pattern suggested in this case. *Increased bronchovascular markings* - This is a **non-specific finding** seen in early stages of pneumonia or inflammatory conditions. - Does not represent a specific complication following **Staph. aureus pneumonia** as described in the question.

Q: A 45-year-old man presents with a 3-day history of breathlessness, fever, and dry cough. He recently traveled to China. Nasal and throat swabs have been collected, and a chest CT scan has been performed. Which of the following CT chest findings is most likely to be observed in this patient?

Ground-glass opacification. **Explanation:** The clinical presentation (fever, dry cough, breathlessness) and travel history suggest a viral pneumonia, specifically **COVID-19** (SARS-CoV-2). In the early to peak stages of viral pneumonias, the hallmark radiological finding is **Ground-Glass Opacification (GGO)**. **Why Option A is Correct:** GGO represents partial filling of air spaces or interstitial thickening without obscuring the underlying bronchovascular structures. In COVID-19, GGOs are typically **bilateral, peripheral, and subpleural** in distribution, predominantly involving the lower lobes. This occurs due to the inflammatory exudate within the alveolar spaces during the early phase of the infection. **Why Other Options are Incorrect:** * **B. Consolidation:** While seen in COVID-19, it usually indicates a later stage of the disease or secondary bacterial infection. It is characterized by the obscuration of underlying vessels. * **C. Traction Bronchiectasis:** This is a sign of **lung fibrosis** (chronic stage). It involves the irreversible dilatation of bronchi due to the pulling effect of surrounding fibrotic tissue. * **D. Subpleural Bands:** These are linear opacities often seen during the **organizing/healing phase** of the infection, representing architectural distortion rather than the acute presenting pathology. **High-Yield Clinical Pearls for NEET-PG:** * **CO-RADS Scale:** Used to categorize the level of suspicion for COVID-19 on CT (CO-RADS 5 is highly suggestive). * **Crazy Paving Pattern:** GGO with superimposed interlobular septal thickening; common as the disease progresses. * **Reverse Halo Sign (Atoll Sign):** A central area of GGO surrounded by a ring of consolidation; seen in organizing pneumonia. * **CT Severity Index:** Calculated out of a score of 25 (5 lobes × 5 points each) to predict prognosis.

Q: A cruise ship passenger who is a known smoker presents with fever, cough, and shortness of breath for the last 4 days. What do the provided CT chest findings suggest?

Ground glass opacities. ***Ground glass opacities*** - **Ground glass opacities** are the hallmark CT finding in **viral pneumonia**, especially COVID-19, which commonly spreads in closed environments like cruise ships. - These bilateral, peripheral **hazy opacities** preserve underlying vascular markings and are characteristic of **acute inflammatory processes** affecting alveoli. *Tree in bud pattern* - Represents **bronchiolar spread** of infection, typically seen in **bacterial pneumonia** or **tuberculosis**, not viral pneumonia. - Appears as **branching linear opacities** resembling a budding tree, indicating **endobronchial spread** rather than alveolar involvement. *Traction bronchiectasis* - Indicates **chronic pulmonary fibrosis** with **scarring and distortion** of bronchi, not acute pneumonia. - Develops over **months to years** and represents **end-stage lung disease**, not an acute 4-day illness. *Hyperinflation with air trapping* - Classic finding in **obstructive lung diseases** like **COPD** or **emphysema**, common in chronic smokers. - Represents **chronic structural changes** with **increased lung volumes**, not acute infectious consolidation.

Question 1

A 45-year-old male presents to the emergency department at 1 AM after binge drinking, complaining of severe chest pain following an episode of vomiting. A chest radiograph of this patient demonstrates which of the following signs?

Accepted Answer

Naclerio V sign

Answer

Silhouette Sign

Answer

Spinnaker Sign

Answer

Hilum Overlay Sign

Question 2

Which one of the following diagnostic techniques is most specific for pulmonary embolism?

Accepted Answer

Pulmonary angiography

Answer

Ventilation lung scanning

Answer

Perfusion lung scanning

Answer

Arterial blood gas analysis

Question 3

Consolidation of which part of the lung is likely to obliterate the aortic knuckle on a chest X-ray?

Accepted Answer

Left upper lobe (posterior segment)

Answer

Left Lingula

Answer

Right Upper lobe

Answer

Apex of the lower lobe

Question 4

A 25-year-old man presented with fever, cough, expectoration, and breathlessness of 2 months' duration. Contrast-enhanced computed tomography of the chest showed bilateral upper lobe fibrotic lesions and mediastinal enlarged necrotic nodes with peripheral rim enhancement. Which one of the following is the most probable diagnosis?

Accepted Answer

Tuberculosis

Answer

Sarcoidosis

Answer

Lymphoma

Answer

Silicosis

Question 5

Which of the following is NOT typically seen in congestive cardiac failure?

Accepted Answer

Prominent lower lobe vessels

Answer

Kerley B lines

Answer

Pleural effusions

Answer

Cardiomegaly

Question 6

Pruned tree appearance of pulmonary circulation is a feature of which condition?

Accepted Answer

Pulmonary artery hypertension

Answer

Pulmonary stenosis

Answer

Pulmonary regurgitation

Answer

Pulmonary embolism

Question 7

Which of the following conditions is best investigated with a non-contrast CT scan?

Accepted Answer

Interstitial lung disease

Answer

Mediastinal mass

Answer

Lung mass

Answer

Nodular thickening of pleura

Question 8

The following X-ray was taken after Staph. aureus pneumonia. What is the diagnosis?

Accepted Answer

Pneumothorax

Answer

Lung abscess

Answer

Empyema

Answer

Increased bronchovascular markings

Question 9

A 45-year-old man presents with a 3-day history of breathlessness, fever, and dry cough. He recently traveled to China. Nasal and throat swabs have been collected, and a chest CT scan has been performed. Which of the following CT chest findings is most likely to be observed in this patient?

Accepted Answer

Ground-glass opacification

Answer

Consolidation

Answer

Traction bronchiectasis

Answer

Subpleural bands

Question 10

A cruise ship passenger who is a known smoker presents with fever, cough, and shortness of breath for the last 4 days. What do the provided CT chest findings suggest?

Accepted Answer

Ground glass opacities

Answer

Tree in bud pattern

Answer

Traction bronchiectasis

Answer

Hyperinflation with air trapping

Chest Radiology — MCQs

Chest Radiology — MCQs

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