Cardiology Practice Questions

Q: A 8-month-old infant presents with severe dyspnea on exertion, clubbing of digits, and bluish sclera. What is the most likely diagnosis based on these findings?

Tetralogy of Fallot. **Explanation:** The clinical triad of **cyanosis** (implied by bluish sclera/clubbing), **clubbing**, and **dyspnea on exertion** in an 8-month-old infant is classic for **Tetralogy of Fallot (TOF)**. 1. **Why TOF is correct:** TOF is the most common cyanotic congenital heart disease (CCHD) beyond infancy. The "bluish sclera" is a clinical sign of chronic systemic desaturation (cyanosis), and clubbing signifies chronic hypoxia. Dyspnea on exertion in infants often manifests during feeding or crying (cyanotic spells/Tet spells). The pathophysiology involves a right-to-left shunt due to a large VSD and right ventricular outflow tract obstruction (RVOTO). 2. **Why other options are incorrect:** * **TGA:** Typically presents with severe cyanosis in the **neonatal period** (first days of life). Without a large mixing lesion, it is incompatible with life beyond the immediate newborn stage. * **Ebstein’s Anomaly:** While it causes cyanosis, it is characterized by massive cardiomegaly ("wall-to-wall heart") and arrhythmias. It is less likely to present with this specific exertional profile at 8 months compared to TOF. * **Coarctation of the Aorta:** This is an acyanotic condition. It presents with upper limb hypertension, radio-femoral delay, and heart failure, not chronic cyanosis or clubbing. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray finding:** Boot-shaped heart (Coeur en sabot) due to RVH and upturned apex. * **Murmur:** A harsh systolic ejection murmur at the left mid-to-upper sternal border (due to pulmonary stenosis, NOT the VSD). * **Management of Tet Spell:** Knee-chest position (increases systemic vascular resistance), Oxygen, Morphine, and Beta-blockers (Propranolol). * **Most common associated anomaly:** Right-sided aortic arch (seen in 25% of cases).

Q: Which one of the following is the most common cause of cyanotic heart disease?

Fallot's tetralogy. **Explanation:** **Tetralogy of Fallot (TOF)** is the most common cause of **cyanotic congenital heart disease (CCHD)** beyond the neonatal period. It consists of four classic features: pulmonary stenosis (the primary determinant of severity), right ventricular hypertrophy, overriding of the aorta, and a large ventricular septal defect (VSD). The cyanosis results from a right-to-left shunt across the VSD due to increased resistance at the pulmonary outflow tract. **Analysis of Options:** * **Dextrocardia (Option A):** This refers to the heart being positioned in the right side of the chest. While it can be associated with complex anomalies, it is a positional diagnosis, not a primary cause of cyanosis. * **Atrial Septal Defect (Option C):** This is an **acyanotic** heart disease characterized by a left-to-right shunt. Cyanosis only occurs if Eisenmenger syndrome develops (reversal of shunt), which is a late complication. * **Coarctation of Aorta (Option D):** This is an acyanotic obstructive lesion. It typically presents with upper limb hypertension and diminished lower limb pulses, rather than central cyanosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common CCHD overall:** Tetralogy of Fallot. * **Most common CCHD in the newborn period (first week):** Transposition of the Great Arteries (TGA). * **X-ray finding in TOF:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex from RVH and a concave pulmonary segment. * **Management of "Tet Spells":** Knee-chest position (increases systemic vascular resistance), oxygen, and morphine.

Q: Which type of Atrial Septal Defect (ASD) is most common?

Ostium secundum. **Explanation:** **Ostium secundum** is the most common type of Atrial Septal Defect (ASD), accounting for approximately **75% of all cases**. It results from the excessive resorption of the septum primum or the inadequate growth of the septum secundum. It is typically located in the region of the fossa ovalis (mid-septal). **Analysis of Options:** * **Ostium secundum (Correct):** The most frequent variety. It is usually a sporadic finding but can be associated with Holt-Oram syndrome (heart-hand syndrome). * **Patent Foramen Ovale (PFO):** While common in the general population (up to 25%), a PFO is technically a "flap-valve" opening rather than a true deficiency of septal tissue. Therefore, it is not classified as a true ASD. * **Ostium primum:** The second most common type (15-20%). It occurs low in the septum and is a form of Atrioventricular Septal Defect (AVSD). It is classically associated with **Down Syndrome** and often presents with a cleft mitral valve. * **Sinus venosus:** A rare type (5-10%) located near the entry of the Superior Vena Cava (most common) or Inferior Vena Cava. It is frequently associated with **Partial Anomalous Pulmonary Venous Connection (PAPVC)**. **High-Yield Clinical Pearls for NEET-PG:** * **Physical Exam:** Characterized by a **wide, fixed split S2** and a mid-systolic flow murmur at the upper left sternal border. * **ECG Findings:** Ostium secundum typically shows **Right Axis Deviation (RAD)** and RBBB, whereas Ostium primum shows **Left Axis Deviation (LAD)**. * **Complication:** Paradoxical embolism (stroke) is a known risk. Eisenmenger syndrome occurs much later in ASD compared to VSD or PDA.

Q: A 3-year-old child presented with a 15-day history of high-grade fever, polymorphous exanthem, rhinorrhea, vomiting, diarrhea, and abdominal pain. On examination, bilateral conjunctival injection with limbal sparing, erythema of oral and pharyngeal mucosa, edema of hands and feet, and mild cervical lymphadenopathy at III and IV levels were noted. Laboratory findings included leucocytosis with neutrophilia and immature forms, elevated erythrocyte sedimentation rate, elevated C-reactive protein, anemia, abnormal plasma lipids, hypoalbuminemia, and hyponatremia. Coronary angiogram findings are also available. What is the most important next step in the management of this child?

Start on both IVIg and aspirin. **Explanation:** The clinical presentation is a classic case of **Kawasaki Disease (KD)**, a medium-vessel vasculitis. The child meets the diagnostic criteria: fever >5 days plus at least four out of five clinical features (polymorphous rash, bilateral non-purulent conjunctival injection with limbal sparing, oral mucosal changes like "strawberry tongue," extremity changes like edema, and cervical lymphadenopathy). The laboratory findings (elevated ESR/CRP, anemia, hypoalbuminemia, and hyponatremia) and the mention of coronary angiogram findings further support this diagnosis. **Why Option C is correct:** The standard of care for acute Kawasaki Disease is the combination of **Intravenous Immunoglobulin (IVIg)** and **Aspirin**. * **IVIg (2 g/kg):** Reduces the incidence of coronary artery aneurysms from 25% to <5% if administered within the first 10 days of illness. * **Aspirin:** Used initially at high doses (80–100 mg/kg/day) for its anti-inflammatory effect, then switched to low doses (3–5 mg/kg/day) for its anti-platelet effect once the fever subsides. **Why other options are incorrect:** * **Options A & B:** Monotherapy is insufficient. IVIg is the primary disease-modifying agent, but Aspirin is essential to manage inflammation and prevent thrombotic complications in the coronary arteries. * **Option D:** Clopidogrel is only indicated in children with giant aneurysms or those who cannot tolerate aspirin; it is not the first-line acute management. **Clinical Pearls for NEET-PG:** * **Most common cause** of acquired heart disease in children in developed countries. * **Cardiac complication:** Coronary artery aneurysms (most common in the proximal LAD and RCA). * **Incomplete KD:** Suspect in infants or children with prolonged fever and fewer than 4 criteria but elevated inflammatory markers. * **Echo:** Should be performed at diagnosis, at 2 weeks, and at 6–8 weeks.

Q: Which congenital heart disease is associated with the defect shown in the diagram below?

Endocardial cushion defect. ***Endocardial cushion defect*** - Characterized by **primum atrial septal defect**, **inlet ventricular septal defect**, and **common atrioventricular valve**, creating the classic "gooseneck" appearance on chest X-ray. - Strongly associated with **Down syndrome** (trisomy 21) and presents with early **congestive heart failure** and **failure to thrive**. *Tricuspid atresia* - Involves **absence or imperforation of the tricuspid valve**, causing blood to bypass the right ventricle entirely. - Results in **cyanosis** from birth and requires blood flow through **atrial septal defect** and **patent ductus arteriosus** for survival. *Hypoplastic left ventricle* - Features **underdevelopment of the left ventricle**, **mitral valve**, and **ascending aorta**, not involving septal defects. - Presents with severe **cyanosis** and **cardiogenic shock** in the first days of life, requiring immediate intervention. *Aortic stenosis* - Involves **narrowing of the aortic valve** or **subvalvular/supravalvular areas**, not septal abnormalities. - Typically presents with **exercise intolerance**, **chest pain**, and **syncope** in older children, not early heart failure.

Q: Which of the following is NOT a sign of congestive cardiac failure in infants?

Large volume pulse. In infants, congestive cardiac failure (CCF) is primarily a clinical diagnosis characterized by sympathetic overactivity and systemic/pulmonary venous congestion. ### **Why "Large Volume Pulse" is the Correct Answer** In CCF, the heart is unable to maintain an adequate cardiac output. This leads to a **low stroke volume**, which clinically manifests as a **small volume (thready) pulse** and tachycardia. A **large volume (bounding) pulse** is characteristic of conditions with a wide pulse pressure, such as Patent Ductus Arteriosus (PDA), Aortic Regurgitation, or high-output states—not heart failure itself. ### **Explanation of Other Options** * **Gallop Rhythm (S3):** This is a hallmark sign of ventricular dysfunction in infants. The S3 occurs during the rapid ventricular filling phase and signifies a dilated, non-compliant ventricle. * **Lack of Weight Gain:** This is often the earliest sign of CCF in infants (Failure to Thrive). It occurs due to a combination of hypermetabolism (increased work of breathing/heart) and poor caloric intake (suck-rest-suck cycle/interrupted feeding). * **Peripheral Cyanosis:** In CCF, low cardiac output leads to increased oxygen extraction by peripheral tissues and poor cutaneous perfusion, resulting in cold extremities and peripheral cyanosis (acrocyanosis). ### **High-Yield Clinical Pearls for NEET-PG** * **Most common cause of CCF in the first week of life:** Hypoplastic Left Heart Syndrome. * **Most common cause of CCF in the first month:** Coarctation of Aorta or large PDA. * **Clinical Triad of CCF in Infants:** Tachycardia, Tachypnea, and Hepatomegaly (tender). * **Note on Edema:** Unlike adults, peripheral pedal edema is rare in infants; instead, they present with **periorbital edema** or excessive weight gain due to fluid retention before it becomes clinically visible.

Q: Which of the following is NOT a cause of Long QT syndrome in children?

Holt-Oram Syndrome. **Explanation:** The correct answer is **Holt-Oram Syndrome** because it is a "Heart-Hand" syndrome characterized by upper limb radial ray defects and structural cardiac defects (most commonly **Secundum ASD**), but it does **not** involve the cardiac conduction system's repolarization phase (QT interval). **Why the other options are causes of Long QT Syndrome (LQTS):** * **Romano-Ward Syndrome (Option A):** This is the most common **autosomal dominant** form of congenital LQTS. It involves only cardiac manifestations (prolonged QT interval and risk of Torsades de Pointes) without associated deafness. * **Jervell and Lange-Nielsen Syndrome (Option B):** This is a rare **autosomal recessive** form of congenital LQTS. It is characterized by a very long QT interval and is uniquely associated with **sensorineural deafness**. * **Macrolide Antibiotics (Option C):** These are a classic cause of **acquired LQTS**. Drugs like Erythromycin and Azithromycin block the delayed rectifier potassium channels (IKr), delaying repolarization. **High-Yield NEET-PG Pearls:** 1. **Holt-Oram Syndrome:** Look for "triphalangeal thumbs" or absent radii + ASD/VSD in the clinical stem. It is associated with the **TBX5 gene** mutation. 2. **LQTS Management:** The first-line treatment for congenital LQTS is **Beta-blockers** (Propranolol or Nadolol). 3. **Torsades de Pointes:** This is the life-threatening polymorphic ventricular tachycardia seen in LQTS; the acute treatment of choice is **Magnesium Sulfate**. 4. **Electrolyte triggers:** Hypokalemia, hypomagnesemia, and hypocalcemia can all trigger or worsen QT prolongation.

Q: All are true in Kawasaki disease except?

Exudative conjunctivitis. **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. Diagnosis is primarily clinical, based on the **CRASH and Burn** mnemonic (Fever for ≥5 days + 4 out of 5 clinical criteria). **Why Option A is the correct answer:** The conjunctivitis in Kawasaki disease is classically **bilateral, non-exudative (dry), and bulbar**, often with limbic sparing. The presence of pus or exudate should prompt a clinician to look for alternative diagnoses, such as Adenovirus or Stevens-Johnson Syndrome. **Analysis of Incorrect Options:** * **B. Pedal edema:** This is a classic feature of the "Extremity changes" criterion. In the acute phase, patients present with erythema and painful edema of the hands and feet. (In the subacute phase, periungual desquamation occurs). * **C. Strawberry tongue:** This is a hallmark of the "Oral mucosal changes" criterion, which also includes cracked, erythematous lips and oropharyngeal injection. * **D. Thrombocytosis:** While not a diagnostic criterion, a high platelet count (often >4.5 lakh/µL) is a characteristic laboratory finding that typically appears in the **second week** (subacute phase) of the illness. **NEET-PG High-Yield Pearls:** * **Most common cause** of acquired heart disease in children in developed nations. * **Cardiac Complication:** Coronary artery aneurysms (most common in the subacute phase). * **Treatment:** High-dose IVIG (2g/kg) + Aspirin. (Note: This is one of the few pediatric conditions where Aspirin is used despite the risk of Reye syndrome). * **Incomplete Kawasaki:** Suspect in infants with prolonged fever; requires Echo and inflammatory markers (ESR/CRP) for diagnosis.

Q: What is the most common manifestation of rheumatic fever?

Arthritis. Acute Rheumatic Fever (ARF) is a multisystem autoimmune response following a Group A Streptococcal (GAS) pharyngeal infection. Diagnosis is based on the **Revised Jones Criteria**, which categorizes clinical features into Major and Minor manifestations. ### Why Arthritis is the Correct Answer **Arthritis** is the **most common** major manifestation of ARF, occurring in approximately **75% of patients**. It typically presents as a "migratory polyarthritis," involving large joints (knees, ankles, elbows, wrists) in succession. A hallmark of this arthritis is its dramatic response to salicylates (aspirin) within 24–48 hours. ### Analysis of Incorrect Options * **B. Carditis:** This is the **most serious** manifestation and the only one that leads to permanent disability (chronic rheumatic heart disease). It occurs in about 50–60% of cases. * **C. Chorea (Sydenham’s):** This occurs in about 10–15% of patients. It is characterized by purposeless, involuntary movements and emotional lability. It has a long latent period (months) after the initial infection. * **D. Nodules (Subcutaneous):** These are rare (<1–5%) and are almost always associated with severe carditis. They are firm, painless, and located over bony prominences. ### NEET-PG High-Yield Pearls * **Most common manifestation:** Migratory Polyarthritis. * **Most common valve involved:** Mitral Valve (Mitral Regurgitation in acute phase; Mitral Stenosis in chronic phase). * **Most specific finding:** Aschoff bodies (pathognomonic on histology). * **Least common major criteria:** Subcutaneous nodules. * **Erythema Marginatum:** The characteristic rash of ARF (evanescent, non-pruritic, pink rings).

Question 1

A 8-month-old infant presents with severe dyspnea on exertion, clubbing of digits, and bluish sclera. What is the most likely diagnosis based on these findings?

Accepted Answer

Tetralogy of Fallot

Answer

Transposition of Great Arteries (TGA)

Answer

Ebstein's anomaly

Answer

Coarctation of the aorta

Question 2

Which one of the following is the most common cause of cyanotic heart disease?

Accepted Answer

Fallot's tetralogy

Answer

Dextrocardia

Answer

Atrial septal defect

Answer

Coarctation of aorta

Question 3

Which type of Atrial Septal Defect (ASD) is most common?

Accepted Answer

Ostium secundum

Answer

Patent foramen ovale

Answer

Ostium primum

Answer

Sinus venosus

Question 4

A 3-year-old child presented with a 15-day history of high-grade fever, polymorphous exanthem, rhinorrhea, vomiting, diarrhea, and abdominal pain. On examination, bilateral conjunctival injection with limbal sparing, erythema of oral and pharyngeal mucosa, edema of hands and feet, and mild cervical lymphadenopathy at III and IV levels were noted. Laboratory findings included leucocytosis with neutrophilia and immature forms, elevated erythrocyte sedimentation rate, elevated C-reactive protein, anemia, abnormal plasma lipids, hypoalbuminemia, and hyponatremia. Coronary angiogram findings are also available. What is the most important next step in the management of this child?

Accepted Answer

Start on both IVIg and aspirin

Answer

Start on IVIg only

Answer

Start on aspirin only

Answer

Start on Clopidogrel only

Question 5

Which of the following statements regarding Atrial Septal Defect (ASD) is true?

Accepted Answer

Large ASDs are typically surgically corrected between 1 to 3 years of age.

Answer

Ostium primum is the most common type of ASD.

Answer

Children with ASD always exhibit growth retardation.

Answer

ASD is commonly affected by infective endocarditis.

Question 6

Which congenital heart disease is associated with the defect shown in the diagram below?

Accepted Answer

Endocardial cushion defect

Answer

Tricuspid atresia

Answer

Hypoplastic left ventricle

Answer

Aortic stenosis

Question 7

Which of the following is NOT a sign of congestive cardiac failure in infants?

Accepted Answer

Large volume pulse

Answer

Gallop rhythm (S3)

Answer

Lack of weight gain

Answer

Peripheral cyanosis

Question 8

Which of the following is NOT a cause of Long QT syndrome in children?

Accepted Answer

Holt-Oram Syndrome

Answer

Romano Ward syndrome

Answer

Jervell and Lange-Nielsen Syndrome

Answer

Macrolide antibiotics

Question 9

All are true in Kawasaki disease except?

Accepted Answer

Exudative conjunctivitis

Answer

Pedal edema

Answer

Strawberry tongue

Answer

Thrombocytosis

Question 10

What is the most common manifestation of rheumatic fever?

Accepted Answer

Arthritis

Answer

Carditis

Answer

Chorea

Answer

Nodules

Cardiology — MCQs

Cardiology — MCQs

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