Cardiology Practice Questions

Q: A 62-year-old man with carcinoma of the lung presented to the emergency department with respiratory distress. His ECG showed electrical alternans. What is the most likely diagnosis?

Cardiac tamponade. ### Explanation **Correct Option: C. Cardiac Tamponade** The clinical presentation of respiratory distress in a patient with lung cancer, combined with the classic ECG finding of **electrical alternans**, is pathognomonic for cardiac tamponade [1]. * **Pathophysiology:** In cardiac tamponade, a large pericardial effusion causes the heart to "swing" back and forth within the fluid-filled pericardial sac [1]. This physical movement changes the heart's axis relative to the ECG electrodes with every beat, resulting in beat-to-beat variations in the amplitude of the QRS complexes (electrical alternans) [1]. * **Clinical Context:** Malignancy (especially lung and breast cancer) is a leading cause of rapidly accumulating pericardial effusions that progress to tamponade [1]. **Why other options are incorrect:** * **A. Pneumothorax:** While it causes respiratory distress and can shift the mediastinum, it does not cause electrical alternans. ECG might show low voltage or T-wave inversions, but not beat-to-beat variation. * **B. Pleural Effusion:** Large effusions cause respiratory distress and "stony dull" percussion notes, but they do not cause the heart to swinging; thus, electrical alternans is absent. * **D. Constrictive Pericarditis:** This is a chronic scarring process. While it shares some clinical features with tamponade (like Kussmaul’s sign), it does not involve a large fluid collection or a swinging heart. **NEET-PG High-Yield Pearls:** 1. **Beck’s Triad:** Hypotension, Jugular Venous Distention (JVD), and Muffled heart sounds (classic for tamponade). 2. **Pulsus Paradoxus:** An inspiratory drop in systolic BP >10 mmHg. 3. **ECG Findings:** Low voltage QRS complexes + Electrical alternans [1]. 4. **CXR:** "Water bottle" or "Money bag" heart appearance [1]. 5. **Treatment:** Immediate ultrasound-guided pericardiocentesis [1].

Q: Which electrolyte imbalance is shown in the following ECG?

Hyperkalemia. ***Hyperkalemia*** - Classic ECG features include **peaked T-waves**, **widened QRS complexes**, and **prolonged PR intervals** as potassium levels rise. - Severe hyperkalemia can progress to **loss of P-waves** and a characteristic **sine-wave pattern** that can be life-threatening. *Hypokalemia* - Characterized by **flattened T-waves**, **prominent U-waves**, and **ST depression** on ECG. - May also show **prolonged QT intervals** and increased susceptibility to **arrhythmias** like torsades de pointes. *Hyponatremia* - Does not produce **specific ECG changes** as sodium primarily affects neurological function and fluid balance. - Clinical manifestations include **confusion**, **seizures**, and **cerebral edema** rather than cardiac conduction abnormalities. *Hypernatremia* - Also does not cause **characteristic ECG abnormalities** since sodium imbalances primarily affect **osmotic gradients** and cellular hydration. - Symptoms are predominantly **neurological** including altered mental status, restlessness, and in severe cases, coma.

Q: Prominent x descent in JVP is seen in all EXCEPT?

Tricuspid regurgitation. **Explanation:** The **x descent** in the Jugular Venous Pulse (JVP) represents atrial relaxation and the downward displacement of the tricuspid valve during ventricular systole. **Why Tricuspid Regurgitation (TR) is the correct answer:** In TR, blood leaks backward from the right ventricle into the right atrium during systole. This retrograde flow counteracts the normal drop in pressure, leading to the **obliteration or reversal of the x descent**. Instead, it is replaced by a prominent **'v' wave** (systolic filling) or a fused 'cv' wave. **Analysis of other options:** * **Cardiac Tamponade:** Characterized by a **prominent x descent** and an absent or diminished y descent. The high intrapericardial pressure prevents diastolic filling, making the x descent the dominant downward deflection. * **Constrictive Pericarditis:** Features **both prominent x and y descents**. The rapid ventricular filling in early diastole leads to a sharp y descent (Friedreich’s sign), but the x descent remains preserved and often exaggerated. * **Atrial Septal Defect (ASD):** Typically presents with a prominent x descent due to increased right-sided stroke volume and enhanced atrial emptying [1]. These shunts can be identified by the increased flow across the tricuspid valve visible on echocardiography [2]. **NEET-PG High-Yield Pearls:** 1. **Prominent 'a' wave:** Tricuspid stenosis, Pulmonary stenosis, Right ventricular hypertrophy (Non-compliant RV). 2. **Cannon 'a' waves:** Complete heart block (AV dissociation), Ventricular tachycardia. 3. **Absent 'a' wave:** Atrial fibrillation. 4. **Prominent 'y' descent:** Constrictive pericarditis, Tricuspid regurgitation. 5. **Absent/Slow 'y' descent:** Cardiac tamponade, Tricuspid stenosis.

Q: A 50-year-old man presents to the emergency department with chest pain and shortness of breath. He smokes 2 packs of cigarettes daily. His BP is 150/90 mmHg and HR is 110 bpm. An ECG is performed. What is your diagnosis?

Right ventricular hypertrophy. ***Right ventricular hypertrophy*** - Heavy smoking history with chest pain and dyspnea suggests **chronic obstructive pulmonary disease (COPD)** leading to **cor pulmonale** and subsequent RVH. - ECG findings would show **right axis deviation**, **dominant R wave in V1**, and **deep S waves in V5-V6**, consistent with RVH pattern. *Left ventricular hypertrophy* - While hypertension (150/90 mmHg) can cause LVH, the ECG would show **left axis deviation** and **tall R waves in V5-V6**. - LVH typically presents with **increased voltage in lateral leads** (V5, V6, I, aVL), not the pattern seen in chronic smokers with pulmonary disease. *Torsades de pointes* - This **polymorphic ventricular tachycardia** requires **prolonged QTc interval** as a prerequisite, which is not mentioned. - Presents with **twisting QRS complexes** around the baseline and is associated with **electrolyte imbalances** or **QT-prolonging medications**. *Inferior wall MI* - Would show **ST elevation in leads II, III, and aVF** with possible **reciprocal depression** in lateral leads. - Typically presents with **acute onset chest pain** and **elevated cardiac enzymes**, not chronic symptoms in a smoker.

Q: Postural hypotension can be a consequence of which of the following?

Autonomic dysfunction. **Explanation:** Postural (orthostatic) hypotension is defined as a sustained reduction in systolic blood pressure of at least **20 mmHg** or diastolic blood pressure of at least **10 mmHg** within 3 minutes of standing. **Why Option A is Correct:** The physiological response to standing involves venous pooling in the lower extremities, which triggers a baroreceptor reflex to increase sympathetic outflow (vasoconstriction and increased heart rate). In **Autonomic Dysfunction** (seen in Diabetes Mellitus, Parkinson’s disease, or Multiple System Atrophy), this reflex arc is damaged [1]. The body fails to compensate for the gravity-induced drop in venous return, leading to a significant fall in blood pressure [1]. **Why Options B and C are Incorrect:** While **Retroperitoneal bleeding** and **Entry site bleeds** (common post-cardiac catheterization) cause hypovolemia, they typically lead to **acute hemorrhagic shock** or compensatory tachycardia rather than "postural hypotension" as a primary diagnostic feature. While severe volume depletion *can* cause orthostatic changes, in the context of standard medical examinations, postural hypotension is classically associated with the failure of the autonomic nervous system to regulate vascular tone. **High-Yield Clinical Pearls for NEET-PG:** * **The "3-Minute Rule":** Always measure BP after the patient has been standing for 3 minutes. * **Common Causes:** Drugs (Alpha-blockers, Diuretics), Neurodegenerative diseases (Shy-Drager Syndrome), and Peripheral Neuropathies (Diabetes, Amyloidosis). * **Management:** Initial steps include lifestyle modifications (increased salt/water intake, compression stockings). Pharmacological options include **Fludrocortisone** (first-line) or **Midodrine**. * **Bedside Test:** A heart rate increase of >30 bpm upon standing suggests hypovolemia; a lack of heart rate compensation suggests autonomic failure [1].

Q: Kussmaul's sign is seen in all of the following except?

Cardiac tamponade. **Explanation:** **Kussmaul’s sign** is a paradoxical rise (or failure to fall) in Jugular Venous Pressure (JVP) during inspiration. Normally, inspiration creates negative intrathoracic pressure, increasing venous return to the right heart and causing JVP to drop. **Why Cardiac Tamponade is the correct answer:** In **Cardiac Tamponade**, Kussmaul’s sign is characteristically **absent** [1]. Although the heart is compressed by fluid, the intrapericardial pressure is transmitted equally to all chambers. During inspiration, the negative intrathoracic pressure is still transmitted to the pericardial space, allowing the heart to accommodate the increased venous return (often at the expense of the left ventricle—the mechanism behind *Pulsus Paradoxus*). Therefore, the JVP still falls normally. **Analysis of Incorrect Options:** * **Constrictive Pericarditis:** This is the classic cause [2]. A rigid, calcified pericardium prevents the right ventricle from expanding to accommodate inspiratory venous return, forcing the pressure back into the jugular veins. * **Right Ventricular (RV) Infarct:** A non-compliant, "stunned" RV cannot handle the increased preload during inspiration, leading to a backup of pressure [3]. * **Restrictive Cardiomyopathy:** Similar to constriction, the stiff myocardium limits diastolic filling, resulting in a positive Kussmaul’s sign. **High-Yield Clinical Pearls for NEET-PG:** * **The "Big Three" for Kussmaul’s Sign:** Constrictive Pericarditis, RV Infarct, and Tricuspid Stenosis/Regurgitation. * **Differentiating Factor:** Cardiac Tamponade presents with **Pulsus Paradoxus** but **NOT** Kussmaul’s sign. Constrictive Pericarditis presents with **Kussmaul’s sign** but rarely Pulsus Paradoxus. * **JVP Waveform:** In Tamponade, there is a prominent *x* descent and absent/blunted *y* descent. In Constriction, there is a sharp *y* descent (Friedreich’s sign).

Question 1

A 62-year-old man with carcinoma of the lung presented to the emergency department with respiratory distress. His ECG showed electrical alternans. What is the most likely diagnosis?

Accepted Answer

Cardiac tamponade

Answer

Pneumothorax

Answer

Pleural effusion

Answer

Constrictive pericarditis

Question 2

Which electrolyte imbalance is shown in the following ECG?

Accepted Answer

Hyperkalemia

Answer

Hypokalemia

Answer

Hyponatremia

Answer

Hypernatremia

Question 3

Which of the following increases the susceptibility to coronary artery disease?

Accepted Answer

Nephrotic syndrome

Answer

Von Willebrand disease

Answer

Type V hyperlipoproteinemia

Answer

Systemic lupus erythematosus

Question 4

Which one of the following statements is true regarding Stokes-Adams attack?

Accepted Answer

It is usually caused by a high degree of atrioventricular block.

Answer

It is usually preceded by an aura.

Answer

Focal neurological signs are commonly observed during the attack.

Answer

It is caused by recurrent paroxysmal tachyarrhythmias.

Question 5

Prominent x descent in JVP is seen in all EXCEPT?

Accepted Answer

Tricuspid regurgitation

Answer

Cardiac tamponade

Answer

Atrial septal defect

Answer

Constrictive pericarditis

Question 6

A 50-year-old man presents to the emergency department with chest pain and shortness of breath. He smokes 2 packs of cigarettes daily. His BP is 150/90 mmHg and HR is 110 bpm. An ECG is performed. What is your diagnosis?

Accepted Answer

Right ventricular hypertrophy

Answer

Left ventricular hypertrophy

Answer

Torsades de pointes

Answer

Inferior wall MI

Question 7

Which of the following statements is NOT true regarding myocardial ischemia?

Accepted Answer

An akinetic area of the myocardium does not benefit from revascularization.

Answer

Late enhancement on Gd-enhanced MRI is suggestive of scar tissue.

Answer

Low-dose dobutamine can be used to assess hibernating myocardium.

Answer

Rest reinfection thallium scintigraphy is used to evaluate hibernating myocardium.

Question 8

Postural hypotension can be a consequence of which of the following?

Accepted Answer

Autonomic dysfunction

Answer

Retroperitoneal bleeding

Answer

Entry site bleed

Answer

All of the above

Question 9

Kussmaul's sign is seen in all of the following except?

Accepted Answer

Cardiac tamponade

Answer

Constrictive pericarditis

Answer

Right ventricular infarct

Answer

Restrictive cardiomyopathy

Question 10

Where is pulsatile liver and ascites found?

Accepted Answer

Tricuspid regurgitation

Answer

Critical pulmonary stenosis

Answer

Mitral regurgitation

Answer

Mitral stenosis

Cardiology — MCQs

Cardiology — MCQs

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