Chest X-ray and CT interpretation

30 NEET-PG practice questions on Chest X-ray and CT interpretation, part of Radiology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Hard

   A 63-year-old man who has smoked bidis for 40 years has had haemoptysis and weight loss for 2 months; he has never had chest surgery. Chest X-ray shows a uniformly opaque left hemithorax with no air bronchogram, and the trachea and mediastinum are pulled to the left; the left hemidiaphragm is not visible. What is the most likely cause of the opacity?

   1. APrevious left pneumonectomy
   2. BConsolidation of the whole left lung
   3. CCollapse of the left lung
   4. DMassive left pleural effusion

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   Answer: C · Collapse of the left lung

   A white hemithorax is read by the position of the mediastinum. A shift towards the opacity means volume loss, and with no surgery that is collapse; here a central bronchogenic carcinoma blocking the left main bronchus is likely in an older smoker with haemoptysis. Absent air bronchograms fit an obstructed bronchus. A massive effusion pushes the mediastinum away, and consolidation keeps it central with air bronchograms. CECT chest followed by bronchoscopy and biopsy is the next step.

   • A: He has never had chest surgery, so pneumonectomy is excluded.
   • B: Consolidation does not shift the mediastinum and usually shows air bronchograms.
   • D: A massive effusion pushes the trachea and mediastinum away from the opaque side.

2. Question 2 · Easy

   A 35-year-old woman in a Visakhapatnam OPD has fever and productive cough. Her chest X-ray shows a homogeneous opacity in the left upper zone through which branching dark tubular lucencies can be traced. Where does this sign place the disease?

   1. AIn the alveolar air spaces
   2. BIn the pleural space
   3. CIn the mediastinum
   4. DIn the chest wall

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   Answer: A · In the alveolar air spaces

   Dark branching tubes inside an opacity are an air bronchogram: air-filled bronchi made visible because the alveoli around them are filled with fluid, pus, blood or cells. It proves that the opacity lies within the lung parenchyma and that the airways leading to it are open. Pneumonia is the commonest cause, but oedema, haemorrhage and some tumours such as adenocarcinoma with a lepidic pattern can also show it. A pleural, mediastinal or chest wall lesion lies outside the lung and therefore cannot contain an air bronchogram.

   • B: Pleural fluid or masses lie outside the lung and contain no bronchi.
   • C: Mediastinal masses displace the airways but do not show branching bronchi within them.
   • D: Chest wall lesions lie outside the lung and contain no bronchi.

3. Question 3 · Easy

   A 45-year-old man in a Patna hospital has pleuritic pain after pneumonia, but his erect PA chest X-ray shows sharp costophrenic angles. The resident wants a plain radiograph view that can show the smallest amount of free pleural fluid. Which view should be requested?

   1. AErect lateral view
   2. BLateral decubitus, affected side down
   3. CLateral decubitus, affected side up
   4. DApical lordotic view

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   Answer: B · Lateral decubitus, affected side down

   Free fluid moves to the most dependent part of the pleural space, so with the affected side down it layers along the lateral chest wall, where even a small volume shows as a band. This is the most sensitive plain film view; an erect PA film needs roughly 200 mL before the lateral angle blunts, and the lateral view shows smaller amounts at the posterior angle. Ultrasound is more sensitive than any plain film and also guides aspiration. The affected-side-up view is used instead to look at the lung under a large effusion.

   • A: The erect lateral view is more sensitive than PA but less than a decubitus film.
   • C: With the affected side up the fluid falls towards the mediastinum and is not well seen.
   • D: The apical lordotic view shows the apices and the right middle lobe, not small effusions.

4. Question 4 · Medium

   A 47-year-old man with diabetes in Hubli still has fever 10 days into treatment for right lower lobe pneumonia. Contrast CT shows a lens-shaped fluid collection along the posterior chest wall that meets it at an obtuse angle and compresses the adjacent lung; the thickened visceral and parietal pleura both enhance and are separated by the fluid. What is the most likely diagnosis?

   1. ALung abscess
   2. BEmpyema
   3. CInfected bulla
   4. DPulmonary infarct

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   Answer: B · Empyema

   Enhancing, thickened visceral and parietal pleura separated by fluid is the split pleura sign of an empyema. Pleural collections are lenticular, meet the chest wall at obtuse angles and compress and displace the lung. A lung abscess, in contrast, is a rounded cavity within the lung with a thick irregular wall, an acute angle with the chest wall and no displacement of vessels. The distinction matters because an empyema needs drainage with an intercostal tube, while most lung abscesses settle with antibiotics and postural drainage.

   • A: A lung abscess is spherical, lies within the lung, meets the chest wall at an acute angle and has no split pleura.
   • C: An infected bulla is an air-containing space within lung, often with a thin wall and fluid level.
   • D: A pulmonary infarct is a wedge-shaped, pleura-based opacity in lung, not an enhancing pleural collection.

5. Question 5 · Medium

   A 44-year-old woman who works in a garment unit in Tiruppur has had fever and cough for 5 days. On her PA chest X-ray an ill-defined opacity sits in the left mid and lower zone, blurring the outline of the left ventricle, while the aortic knuckle and the left dome of the diaphragm stay crisp. Where does the consolidation lie?

   1. ASuperior segment of the left lower lobe
   2. BApicoposterior segment of the left upper lobe
   3. CLateral basal segment of the left lower lobe
   4. DLingula of the left upper lobe

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   Answer: D · Lingula of the left upper lobe

   An opacity that touches a soft-tissue structure of the same density wipes out its edge, the silhouette sign. The left heart border, formed mainly by the left ventricle, lies against the lingula, so lingular consolidation blurs it. Disease of the left lower lobe lies posteriorly and blurs the left hemidiaphragm and descending aorta instead, while the heart border stays sharp; upper lobe apical disease blurs the aortic knuckle. A lateral view then confirms the anterior position of the opacity, in front of the oblique fissure.

   • A: The superior segment lies posteriorly behind the hilum and does not touch the heart border.
   • B: Apicoposterior disease lies high and blurs the aortic knuckle, which is sharp here.
   • C: Lateral basal disease lies against the diaphragm, which is sharp here, not the heart border.

6. Question 6 · Hard

   A 62-year-old man who has smoked for 35 years was treated in Bhopal for right upper lobe pneumonia with two antibiotic courses. Eight weeks later he feels better, but the chest X-ray still shows the same right upper lobe consolidation. Two sputum CBNAAT tests are negative for M. tuberculosis. What is the most appropriate next step?

   1. ARepeat chest X-ray after another 8 weeks
   2. BContrast CT chest followed by bronchoscopy
   3. CA third course of broader antibiotics
   4. DEmpirical anti-tubercular treatment

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7. Question 7 · Hard

   A 38-year-old man in Chennai has had progressive breathlessness and dry cough for 8 months, with SpO2 87% on room air. HRCT shows patchy, geographic ground-glass areas with smooth thickened interlobular septa, giving a crazy-paving pattern. Bronchoalveolar lavage returns milky fluid that is PAS-positive, and serum anti-GM-CSF antibody is positive. Sputum CBNAAT is negative. What is the standard treatment for his hypoxaemia?

   1. ALong-term azithromycin
   2. BAnti-tubercular treatment
   3. CWhole-lung lavage
   4. DHigh-dose oral prednisolone

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8. Question 8 · Easy

   A 56-year-old man with uncontrolled hypertension is brought to casualty in Delhi with acute breathlessness. His chest X-ray shows bilateral perihilar haziness and short horizontal lines, 1-2 cm long, reaching the pleural surface just above both costophrenic angles. What do these short lines represent?

   1. AFluid in the oblique fissures
   2. BBronchial walls seen end-on
   3. CAreas of plate-like atelectasis
   4. DThickened interlobular septa

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9. Question 9 · Medium

   A 34-year-old man with HIV in Mumbai, CD4 count 70 cells/µL, has fever and cough for 3 weeks, and sputum CBNAAT detects M. tuberculosis. The chest physician lists four statements about the chest X-ray in TB with advanced HIV: 1. Cavitation is less frequent than in people without HIV. 2. Hilar or mediastinal lymphadenopathy is more frequent. 3. A normal chest X-ray rules out pulmonary TB. 4. Most lesions are in the apical segments of the upper lobes. Which statements are correct?

   1. A1 and 4 only
   2. B1 and 2 only
   3. C1, 2 and 3 only
   4. D2 and 3 only

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10. Question 10 · Medium

    A 9-year-old boy with nephrotic syndrome in a Kolkata paediatric ward has an erect PA chest X-ray. The left hemidiaphragm appears raised, its highest point lies more laterally than usual, and the gap between the stomach gas bubble and the lung base is about 4 cm. The costophrenic angle is sharp, and he is afebrile with a soft abdomen. What is the most likely explanation?

    1. AEventration of the left hemidiaphragm
    2. BLeft phrenic nerve palsy
    3. CLeft subphrenic abscess
    4. DSubpulmonic pleural effusion

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11. Question 11 · Medium

    A 70-year-old man with long-standing heart failure is admitted to a Madurai hospital with breathlessness and raised JVP. Chest X-ray shows cardiomegaly, bilateral small effusions and a sharply marginated, lens-shaped 6 cm opacity lying along the line of the right horizontal fissure. A chest X-ray from 6 months ago, taken when he was well, was clear. What is the most appropriate next step for the opacity?

    1. ABronchoscopy with lavage cytology
    2. BContrast CT to stage a lung tumour
    3. CTreat the failure and repeat the X-ray
    4. DCT-guided biopsy of the opacity

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12. Question 12 · Easy

    A 40-year-old woman at a PHC in Wayanad has fever for 3 weeks and dullness at the right base. On her erect PA chest X-ray, what is the typical upper border of a moderate free pleural effusion?

    1. AA concave meniscus rising higher laterally
    2. BA convex border bulging towards the lung
    3. CA straight horizontal line across the chest
    4. DA sharp line along the horizontal fissure

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13. Question 13 · Medium

    A 7-month-old girl in a paediatric ward in Bareilly had infected skin boils a week ago and now has high fever and fast breathing. Within 48 hours her chest X-ray progresses from patchy right-sided consolidation to several thin-walled air-filled cysts within it, and a small right effusion. Which organism is the most likely cause?

    1. AStreptococcus pneumoniae
    2. BMycoplasma pneumoniae
    3. CRespiratory syncytial virus
    4. DStaphylococcus aureus

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14. Question 14 · Medium

    A 68-year-old man with severe COPD from 40 years of bidi smoking is admitted in Jaipur with worsening breathlessness. Chest X-ray shows a large hyperlucent area without lung markings in the right upper and mid zone; it is unclear whether its curved margin is a pleural line or the wall of a bulla. He is stable with SpO2 90% on 2 L of oxygen. What is the most appropriate next step?

    1. AImmediate intercostal drain in the 5th space
    2. BAn expiratory chest X-ray to see the lung edge
    3. CCT of the chest before any drain is placed
    4. DNeedle aspiration in the 2nd intercostal space

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15. Question 15 · Medium

    A 66-year-old man in Lucknow has a 5 cm cavitating lesion in the right lower lobe. The pulmonologist teaches four points about cavities: 1. A wall thicker than 15 mm favours malignancy. 2. Squamous cell carcinoma is the primary lung cancer that most often cavitates. 3. An air-fluid level in the cavity excludes malignancy. 4. A wall thinner than 4 mm favours a benign cause. Which statements are correct?

    1. A2, 3 and 4 only
    2. B1, 2 and 4 only
    3. C2 and 3 only
    4. D1 and 2 only

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16. Question 16 · Hard

    A 30-year-old shepherd from Anantnag, Kashmir, coughed up a gush of salty fluid followed by fever and cough. Chest X-ray shows a 7 cm well-defined right lower lobe cavity with an air-fluid level, on which an irregular wavy membrane floats. Ultrasound of the abdomen is normal, and his eosinophil count is 9%. What is the most appropriate management?

    1. ASurgical removal with albendazole cover
    2. BAntibiotics and postural drainage alone
    3. CAnti-tubercular treatment
    4. DCT-guided percutaneous aspiration

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17. Question 17 · Medium

    A 5-year-old boy is brought to a district hospital in Thrissur with high fever and cough for 3 days, with crackles at the left base. Chest X-ray shows a well-defined round opacity about 4 cm across in the left lower zone, with air bronchograms within it. There is no history of TB contact, and he is well nourished. What is the most appropriate management?

    1. AAntibiotics for pneumonia, then a repeat X-ray
    2. BCECT chest to exclude a lung tumour
    3. CEmpirical anti-tubercular treatment
    4. DBronchoscopy to look for a foreign body

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18. Question 18 · Medium

    A 42-year-old man in Indore has had nasal crusting and blood-stained nasal discharge for 4 months, and now haemoptysis. Chest X-ray shows several nodules in both lungs, some of them cavitating. Urine shows red cells with RBC casts and creatinine is 2.1 mg/dL. Sputum CBNAAT is negative. Which blood test is most useful for the likely diagnosis?

    1. ASerum ACE level
    2. BAnti-double-stranded DNA
    3. CAnti-GBM antibody
    4. DPR3-ANCA (c-ANCA)

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19. Question 19 · Hard

    A 34-year-old woman, a non-smoker, comes to the pulmonology OPD in Bengaluru after her third right-sided pneumothorax in 18 months. Each episode began within two days of the start of her menstrual period, and she has long-standing dysmenorrhoea. After re-expansion, high-resolution CT shows normal lung parenchyma with no cysts or blebs, and her chest X-rays have never shown a pleural effusion. What is the most likely underlying cause?

    1. ALymphangioleiomyomatosis
    2. BBirt-Hogg-Dube syndrome
    3. CThoracic endometriosis
    4. DRuptured apical subpleural bleb

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20. Question 20 · Medium

    A 55-year-old man in a Nashik hospital has fever and left-sided pleuritic pain, but his PA chest X-ray is reported as nearly normal. On the lateral view the lower thoracic vertebral bodies look denser than the upper ones instead of becoming darker towards the diaphragm. What does this finding suggest?

    1. ALower lobe consolidation
    2. BRight middle lobe consolidation
    3. CAnterior mediastinal mass
    4. DUpper lobe collapse

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21. Question 21 · Medium

    A 2-day-old preterm baby ventilated for respiratory distress syndrome in a NICU in Chennai suddenly needs more oxygen. On the frontal chest X-ray both lobes of the thymus are lifted upwards and outwards away from the heart, with a band of air beneath them; the lungs are expanded to the chest wall on both sides. What does this appearance indicate?

    1. ABilateral medial pneumothoraces
    2. BPneumomediastinum
    3. CPneumopericardium
    4. DA normal thymic sail shadow

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22. Question 22 · Medium

    A 26-year-old man is brought to casualty in Coimbatore after a two-wheeler crash, with pain over the left chest wall. During bedside ultrasound of the left anterior chest, lung sliding is absent and, at one point in the mid-axillary line, the normal sliding pattern appears and disappears with breathing. On M-mode the area without sliding shows parallel horizontal lines throughout. What does the point where sliding appears and disappears indicate?

    1. AThe edge of a pneumothorax
    2. BA pleural adhesion
    3. CA main bronchus intubation
    4. DA rib fracture

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23. Question 23 · Medium

    A 47-year-old man in Guwahati completed treatment for pulmonary TB 6 years ago and now has recurrent small haemoptysis. Chest X-ray shows a rounded opacity inside a thin-walled left upper lobe cavity, with a crescent of air between the opacity and the cavity wall. On CT taken in the prone position, the opacity has moved to the dependent side of the cavity. Sputum CBNAAT is negative. What is the most likely diagnosis?

    1. ARelapse of tuberculosis
    2. BAspergilloma
    3. CRuptured hydatid cyst
    4. DCavitating squamous carcinoma

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24. Question 24 · Medium

    A 24-year-old man on induction chemotherapy for AML in a Vellore haematology ward has had fever for 5 days despite piperacillin-tazobactam; his neutrophil count is 100/µL. CT of the chest shows a 2 cm nodule in the right upper lobe surrounded by a rim of ground-glass attenuation. Serum galactomannan is raised. Which drug should be started?

    1. ACaspofungin
    2. BFlucytosine
    3. CFluconazole
    4. DVoriconazole

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25. Question 25 · Easy

    A 28-year-old construction worker in Surat has had cough, evening fever and weight loss for 2 months, and his sputum CBNAAT detects M. tuberculosis. In this adult with post-primary (reactivation) TB, where on the chest X-ray is a cavity most likely to be seen?

    1. AApical or posterior segment of an upper lobe
    2. BAnterior segment of an upper lobe
    3. CAnterior basal segment of a lower lobe
    4. DMedial segment of the middle lobe

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