Cardiology Practice Questions

Q: A child after 4 weeks of age presents with an acyanotic ejection systolic murmur. Which of the following is the most likely cause?

VSD. ***VSD*** - A **ventricular septal defect (VSD)** typically presents with a **pansystolic (holosystolic) murmur** that becomes **audible after 4 weeks of age** when **pulmonary vascular resistance drops**. - It is the **most common acyanotic congenital heart disease** presenting at this age, with blood shunting from left to right ventricle. - The murmur is best heard at the **left lower sternal border** and increases pulmonary blood flow. - Small VSDs become clinically apparent around 4-6 weeks as PVR falls and the shunt increases. *PDA* - A **patent ductus arteriosus (PDA)** presents with a **continuous "machinery" murmur**, not an ejection systolic murmur. - While it's an **acyanotic lesion**, its characteristic continuous quality heard best at the left upper sternal border differentiates it from VSD. *Coarctation of aorta* - **Coarctation of the aorta** presents with a **systolic murmur** heard best over the **back/interscapular area**. - Characterized by **diminished or delayed femoral pulses** and **differential blood pressures** (higher in upper extremities). - May present earlier with heart failure in severe cases, but not typically with prominent murmur at 4 weeks. *TOF* - **Tetralogy of Fallot (TOF)** is a **cyanotic heart disease** due to right-to-left shunting, which contradicts the "acyanotic" presentation in the question. - The murmur is an **ejection systolic murmur** from pulmonary stenosis (RVOT obstruction), but the presence of cyanosis rules it out. - Presents with **cyanotic spells** and progressive cyanosis, not isolated murmur finding.

Q: Tetralogy of Fallot is characterized by following except –

AS. ***AS (Aortic Stenosis)*** - **Aortic stenosis (AS)** is characterized by a **narrowing of the aortic valve**, obstructing blood flow from the left ventricle to the aorta. - This is **NOT a component of Tetralogy of Fallot** and is a separate congenital or acquired cardiac condition. - The four main features of Tetralogy of Fallot are **ventricular septal defect**, **pulmonary stenosis** (typically infundibular), **overriding aorta**, and **right ventricular hypertrophy**. *VSD (Ventricular Septal Defect)* - A **ventricular septal defect (VSD)** is a communication between the right and left ventricles, allowing blood to shunt between chambers. - This is **one of the four essential components** of Tetralogy of Fallot, typically a large, non-restrictive VSD. *Over-riding of aorta* - An **overriding aorta** means the aortic root is positioned directly over the ventricular septal defect, straddling both ventricles instead of arising solely from the left ventricle. - This is a **hallmark feature of Tetralogy of Fallot**, leading to mixing of oxygenated and deoxygenated blood, contributing to cyanosis. *Infundibular constriction* - **Infundibular constriction**, also known as **pulmonary infundibular stenosis**, refers to the narrowing of the muscular outflow tract of the right ventricle (infundibulum) leading to the pulmonary artery. - This **subvalvular pulmonary stenosis** is a **critical component of Tetralogy of Fallot**, contributing to right ventricular hypertrophy, reduced pulmonary blood flow, and right-to-left shunting through the VSD.

Q: A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?

Echocardiography. ***Echocardiography*** - The constellation of symptoms (red eyes, cracked lips, rash on hands and feet, cervical lymphadenopathy in a 5-year-old) is highly suggestive of **Kawasaki disease**. - **Coronary artery aneurysms** are the most serious complication of Kawasaki disease, making echocardiography crucial for early detection and management. *Blood pressure* - While important in any pediatric assessment, **blood pressure measurement** is not specific for diagnosing or monitoring the most critical complication of Kawasaki disease. - Hypertensive or hypotensive episodes are not classic features and do not directly assess **coronary artery involvement**. *ECG* - An **ECG** can detect arrhythmias or signs of myocardial ischemia, which might occur with **coronary artery pathology**. - However, it is less sensitive and specific than **echocardiography** for directly visualizing and quantifying **coronary artery aneurysms**. *Blood tests for autoantibodies* - Kawasaki disease is not an autoimmune condition primarily diagnosed by **autoantibodies**; it is a **vasculitis** of unknown etiology. - Blood tests for autoantibodies would not be the most important investigation to rule out its most serious complication.

Q: Commonly associated in tetralogy of Fallot is:

Right sided aortic arch. ***Right sided aortic arch*** - A **right-sided aortic arch** is a known anomaly that frequently coexists with Tetralogy of Fallot, occurring in about 20-25% of cases. - This association is due to disturbances in the normal development of the **aortic arches** during embryonic life. *Coarctation of aorta* - **Coarctation of the aorta** is a narrowing of the aorta, most commonly found in the juxtaductal region. - While it can occur with other congenital heart defects, it is not particularly associated with Tetralogy of Fallot. *Aortopulmonary window* - An **aortopulmonary window** is a rare defect involving a communication between the aorta and the pulmonary artery, distinct from a patent ductus arteriosus. - It results from incomplete fusion of the aorticopulmonary septum and is not a common associated anomaly in Tetralogy of Fallot. *Aberrant right subclavian artery* - An **aberrant right subclavian artery** (also known as *arteria lusoria*) arises from the descending aorta and passes posterior to the esophagus. - While a congenital anomaly of the great vessels, it is not a characteristic or commonly associated finding with Tetralogy of Fallot.

Q: A 4 1/2- year-old girl always had to wear warm socks even is summer season. On physical examination, it was noticed that she had high blood pressure and her femoral pulse was weak as compared to radial and carotid pulse, a chest radiograph showed remarkable notching of ribs along with their lower borders. This was due to:

Coarctation of aorta. ***Coarctation of aorta*** - The combination of **hypertension**, diminished femoral pulses compared to radial/carotid, and **rib notching** on a chest radiograph is pathognomonic for **coarctation of the aorta**. - Rib notching occurs due to the dilation of **intercostal arteries** as they try to bypass the aortic obstruction and supply blood to the lower body. *Takayasu’s arteritis* - This is a form of **large vessel vasculitis** primarily affecting the aorta and its major branches, leading to **pulseless disease** in the upper extremities. - While it can cause hypertension and differential pulses, **rib notching** is not a characteristic feature, and it typically presents in older children or young adults. *Raynaud’s disease* - Characterized by **vasospasm** of the small arteries and arterioles, typically in the fingers and toes, in response to cold or stress. - It causes color changes (pallor, cyanosis, redness) and pain in the digits, but does not involve **hypertension**, **differential pulses**, or **rib notching**. *Femoral artery thrombosis* - This would cause a sudden onset of **pain, pallor, pulselessness, paresthesia, and paralysis** (5 Ps) in the affected limb, primarily affecting one leg. - It would not lead to generalized hypertension or **rib notching**, and the radial/carotid pulses would typically be normal.

Q: Most common cardiac defect seen in Rubella syndrome

PDA. ***Patent Ductus Arteriosus (PDA)*** - **PDA is the most common cardiac defect** associated with congenital rubella syndrome, occurring in 40-60% of cardiac cases. - Rubella virus infection during the **first trimester** causes failure of ductus arteriosus closure after birth. - The classic triad of congenital rubella syndrome includes **cardiac defects (PDA most common), cataracts, and deafness**. - PDA in rubella syndrome may be **isolated or combined** with other cardiac anomalies. *Pulmonary stenosis* - **Peripheral pulmonary artery stenosis (PPS)** is the second most common cardiac defect in rubella syndrome (20-30% of cases). - The option "pulmonary stenosis" typically refers to valvular PS, which is less specific to rubella. - PPS involves **multiple stenoses at branching points** of pulmonary arteries rather than valvular obstruction. *VSD* - **Ventricular Septal Defect** can occur in rubella syndrome but is **less common** than PDA or PPS. - VSD is more frequently associated with other congenital infections and genetic syndromes. *ASD* - **Atrial Septal Defect** is the least common cardiac defect among the listed options in congenital rubella syndrome. - While possible, ASD is not characteristically associated with maternal rubella infection during pregnancy.

Q: The most common paediatric cardiac tumour among the following is

Rhabdomyomas. ***Rhabdomyomas*** - **Rhabdomyomas** are the most common primary cardiac tumors in **infants and children**, accounting for over 50% of all pediatric cardiac tumors. - They are strongly associated with **tuberous sclerosis**, with up to 90% of children with cardiac rhabdomyomas having tuberous sclerosis. *Myxomas* - **Myxomas** are the most common primary cardiac tumors in **adults**, primarily found in the left atrium. - They are rare in children, making them an unlikely answer for the most common pediatric cardiac tumor. *Hemangiomas* - **Hemangiomas** are benign vascular tumors that can occur in various organs, including the heart, but they are **exceedingly rare as primary cardiac tumors**, especially compared to rhabdomyomas in children. - While they can be present at birth, cardiac hemangiomas are not the most common pediatric cardiac tumor. *Fibromas* - **Cardiac fibromas** are the **second most common primary cardiac tumor in children**, but they are significantly less common than rhabdomyomas. - They are typically single, large, and can cause symptoms due to their mass effect and potential for arrhythmias, but they do not outrank rhabdomyomas in frequency.

Q: In septum primum type of ASD overburden occurs in which chamber?

RA + RV. ***RA + RV*** - In a **septum primum ASD**, blood shunts from the left atrium to the right atrium due to higher left-sided pressures [3]. - This increased volume then flows into the **right ventricle**, causing **volume overload** in both the right atrium and right ventricle [1], [3]. *LA* - The left atrium experiences **decreased pressure** and **volume** as blood shunts out, not overload. - The primary burden is on the right side of the heart, not the left atrium. *LA + LV* - The left atrium and left ventricle do not experience **volume overload** in a typical ASD; instead, they may have reduced filling [2]. - The shunt primarily offloads the left side and creates overload on the right side [3]. *RA + LA* - While the **right atrium** is volume overloaded, the **left atrium** is not; it is actually under-filled. - The combination of right atrial overload and left atrial normal or slightly reduced volume does not accurately describe the overall burden.

Q: A 29-day-old child presents with features of congestive cardiac failure and left ventricular hypertrophy. Auscultation shows a short systolic murmur. The most likely diagnosis is:

Ventricular septal defect. ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** causes a left-to-right shunt, leading to increased pulmonary blood flow and can result in **congestive cardiac failure** and **left ventricular hypertrophy** as pulmonary vascular resistance drops in the first few weeks of life. - Large VSDs typically present with a **holosystolic murmur** best heard at the left lower sternal border; however, in the early neonatal period or with muscular VSDs, the murmur may be **shorter and less prominent** as pulmonary resistance is still relatively elevated. - Among the given options, VSD is the **most likely acyanotic heart defect** to present with CHF and LVH in this age group. *Rheumatic fever* - **Rheumatic fever** is an inflammatory disease following **Group A Streptococcal pharyngitis**, typically occurring in children **over 3 years of age**. - It is **extremely rare in infants** and would not explain CHF and LVH in a 29-day-old neonate. *Transposition of great arteries* - **Transposition of the great arteries (TGA)** is a cyanotic congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. - Infants with TGA present with **severe cyanosis within hours to days of birth**, not primarily CHF. - The murmur is often **absent or soft** unless there is an associated VSD or PDA. *Tetralogy of Fallot* - **Tetralogy of Fallot (ToF)** is a cyanotic heart disease with four components: VSD, pulmonary stenosis, overriding aorta, and **right ventricular hypertrophy** (not left). - Infants present with **cyanosis** (not CHF) and a **loud systolic ejection murmur** at the left upper sternal border due to pulmonary stenosis. - The pathophysiology leads to **RVH, not LVH**, making this inconsistent with the clinical findings.

Q: A child presents with LVH and pulmonary complications. ECG shows left axis deviation. Most likely diagnosis is:

Tricuspid atresia. ***Tricuspid atresia*** - **Left ventricular hypertrophy (LVH)** is common because the entire systemic venous return must pass from the right atrium through an atrial septal defect (ASD) into the left atrium and then to the left ventricle. The left ventricle then pumps blood through both the systemic circulation and, via a VSD, to the pulmonary circulation. - **Left axis deviation** is a classic ECG finding due to the hypoplastic right ventricle and the dominance of the left ventricle in pumping both systemic and pulmonary blood. *TOF* - **Tetralogy of Fallot** typically presents with **right ventricular hypertrophy (RVH)** due to the right ventricular outflow tract obstruction. - ECG usually shows **right axis deviation** and RVH, not LVH or left axis deviation. *TAPVC* - **Total anomalous pulmonary venous connection (TAPVC)** usually leads to **right ventricular volume overload** and **pulmonary hypertension**, resulting in right ventricular hypertrophy. - While it can cause pulmonary complications, **LVH and left axis deviation are not characteristic features**. *VSD* - A large **ventricular septal defect (VSD)** can cause **biventricular hypertrophy** or predominantly **left ventricular hypertrophy** due to increased pulmonary blood flow and left ventricular volume overload. - However, isolated, uncomplicated VSD does not typically present with **left axis deviation**; ECG findings are variable but often show an rsR' pattern in V1 or increased QRS voltages.

Question 1

A child after 4 weeks of age presents with an acyanotic ejection systolic murmur. Which of the following is the most likely cause?

Accepted Answer

VSD

Answer

PDA

Answer

Coarctation of aorta

Answer

TOF

Question 2

Tetralogy of Fallot is characterized by following except –

Accepted Answer

AS

Answer

VSD

Answer

Over–riding of aorta

Answer

Infundibular constriction

Question 3

A mother brings her 5-year-old boy to see you as a General Physician. On examination, he has red eyes, dry, cracked lips and a rash on his hands and feet. He also has cervical lymphadenopathy. What is the most important investigation to rule out a serious complication of this condition?

Accepted Answer

Echocardiography

Answer

Blood pressure

Answer

ECG

Answer

Blood tests for autoantibodies

Question 4

Commonly associated in tetralogy of Fallot is:

Accepted Answer

Right sided aortic arch

Answer

Coarctation of aorta

Answer

Aortopulmonary window

Answer

Aberrant right subclavian artery

Question 5

A 4 1/2- year-old girl always had to wear warm socks even is summer season. On physical examination, it was noticed that she had high blood pressure and her femoral pulse was weak as compared to radial and carotid pulse, a chest radiograph showed remarkable notching of ribs along with their lower borders. This was due to:

Accepted Answer

Coarctation of aorta

Answer

Takayasu’s arteritis

Answer

Raynaud’s disease

Answer

Femoral artery thrombosis

Question 6

Most common cardiac defect seen in Rubella syndrome

Accepted Answer

PDA

Answer

VSD

Answer

ASD

Answer

Pulmonary stenosis

Question 7

The most common paediatric cardiac tumour among the following is

Accepted Answer

Rhabdomyomas

Answer

Myxomas

Answer

Hemangiomas

Answer

Fibromas

Question 8

In septum primum type of ASD overburden occurs in which chamber?

Accepted Answer

RA + RV

Answer

LA

Answer

LA + LV

Answer

RA + LA

Question 9

A 29-day-old child presents with features of congestive cardiac failure and left ventricular hypertrophy. Auscultation shows a short systolic murmur. The most likely diagnosis is:

Accepted Answer

Ventricular septal defect

Answer

Rheumatic fever

Answer

Transposition of great arteries

Answer

Tetralogy of Fallot

Question 10

A child presents with LVH and pulmonary complications. ECG shows left axis deviation. Most likely diagnosis is:

Accepted Answer

Tricuspid atresia

Answer

TOF

Answer

TAPVC

Answer

VSD

Cardiology — MCQs

Cardiology — MCQs

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