Cardiology Practice Questions

Q: Which of the following is NOT a component of Kawasaki disease?

Purulent conjunctivitis. **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. The diagnosis is clinical, based on the presence of high-grade fever for at least 5 days plus 4 out of 5 principal criteria. **Why "Purulent Conjunctivitis" is the correct answer:** The hallmark ocular finding in Kawasaki disease is **bilateral non-exudative (bulbar) conjunctival injection**. It is typically painless and, crucially, **spares the limbus** (the area around the iris). The presence of pus or discharge (purulent conjunctivitis) points away from KD and suggests a viral or bacterial etiology. **Analysis of Incorrect Options:** * **Pedal Edema:** This is a classic component 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). * **Truncal Rash:** A polymorphous exanthema (usually maculopapular or morbilliform) that primarily involves the trunk and extremities is a core diagnostic criterion. * **Pharyngeal Congestion:** This falls under "Oropharyngeal Changes," which include erythema of the pharynx, "strawberry tongue," and cracked, erythematous lips. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic (CRASH and Burn):** **C**onjunctivitis (non-purulent), **R**ash, **A**denopathy (cervical, >1.5cm, usually unilateral), **S**trawberry tongue, **H**ands/feet (edema/erythema), and **Burn** (Fever >5 days). * **Most Common Complication:** Coronary artery aneurysms (occurs in 20-25% of untreated cases). * **Treatment:** High-dose IVIG (2g/kg) plus Aspirin. This is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye syndrome. * **Echocardiography:** Should be performed at diagnosis, at 2 weeks, and at 6-8 weeks to monitor for coronary involvement.

Q: A 2-year-old known case of Rheumatic Heart Disease (RHD) presents with a 3-week history of fever, hematuria, and palpitations. What is the most likely diagnosis?

Staphylococcal endocarditis. **Explanation:** The clinical presentation of a child with pre-existing **Rheumatic Heart Disease (RHD)** presenting with a prolonged fever (3 weeks), hematuria (suggestive of embolic phenomena or glomerulonephritis), and palpitations strongly points towards **Infective Endocarditis (IE)**. 1. **Why Staphylococcal endocarditis is correct:** While *Viridans group Streptococci* are common causes of subacute IE, **Staphylococcus aureus** is the most common cause of acute and subacute infective endocarditis worldwide, especially in children with underlying structural heart disease like RHD. The presence of hematuria indicates systemic embolization or immune-complex mediated damage, which are classic peripheral stigmata of IE. 2. **Why other options are incorrect:** * **Streptococcal endocarditis:** Though a frequent cause, *S. aureus* has overtaken it in many clinical settings as the primary pathogen. In the context of NEET-PG, if a specific organism must be chosen for IE in a damaged valve, *Staphylococcus* is often the preferred answer unless "Viridans" is specified for a post-dental procedure scenario. * **Collagen vascular disease:** While conditions like SLE can cause fever and hematuria (lupus nephritis), they do not typically present as a complication of known RHD. * **Reactivation:** Acute Rheumatic Fever (ARF) reactivation would present with Jones criteria (migratory polyarthritis, carditis, chorea). While fever and palpitations occur, hematuria is not a feature of ARF; it is a hallmark of IE. **Clinical Pearls for NEET-PG:** * **Most common cause of IE (Overall):** *Staphylococcus aureus*. * **Most common cause of IE (Subacute/Native Valve):** *Streptococcus viridans*. * **Duke’s Criteria:** Used for diagnosis (2 Major, 1 Major + 3 Minor, or 5 Minor). * **Classic Signs:** Roth spots (retina), Osler nodes (painful, fingers), Janeway lesions (painless, palms/soles), and Splinter hemorrhages.

Q: What percentage of patients with Down's syndrome have congenital cardiovascular disease?

50%. **Explanation:** **1. Understanding the Correct Answer (C - 50%):** Down’s syndrome (Trisomy 21) is the most common chromosomal disorder associated with congenital heart disease (CHD). Epidemiological studies and standard pediatric textbooks (like Nelson) establish that approximately **40% to 50%** of newborns with Down’s syndrome have a cardiac malformation. The high prevalence is attributed to the overexpression of genes on chromosome 21 that influence endocardial cushion development during embryogenesis. **2. Analysis of Incorrect Options:** * **A (10%) & B (30%):** These figures significantly underestimate the prevalence. While 10-30% might represent the prevalence in other chromosomal anomalies (like Turner syndrome, which is ~25-30%), it is too low for Down’s syndrome. * **D (70%):** While the association is strong, 70% is an overestimation. However, it is important to note that if a patient with Down’s syndrome has CHD, the complexity is often high, requiring early surgical intervention. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Lesion:** The **Atrioventricular Septal Defect (AVSD)**, specifically the canal type, is the most common CHD in Down’s syndrome (approx. 45% of their cardiac cases). * **Second Most Common:** Ventricular Septal Defect (VSD) is the second most frequent. * **Clinical Management:** All infants diagnosed with Down’s syndrome must undergo a screening **Echocardiogram** regardless of clinical findings, as murmurs may not be audible in the neonatal period due to high pulmonary vascular resistance. * **Eisenmenger Syndrome:** Patients with Down’s syndrome and large left-to-right shunts (like AVSD) tend to develop pulmonary hypertension much earlier than non-syndromic children.

Q: What is true about Ventricular Septal Defect (VSD)?

Third heart sound (S3) is left-sided.. **Explanation:** Ventricular Septal Defect (VSD) is the most common congenital heart disease. It is characterized by a left-to-right shunt, leading to increased pulmonary blood flow and subsequent volume overload of the left heart chambers. **Why Option C is correct:** In a large VSD, the increased pulmonary venous return leads to **volume overload of the Left Atrium (LA) and Left Ventricle (LV)**. During the rapid filling phase of diastole, this excessive volume hitting the dilated LV wall produces a **left-sided S3**. Additionally, the high flow across the mitral valve often produces a mid-diastolic flow murmur at the apex. **Analysis of Incorrect Options:** * **Option A:** The intensity of S2 depends on pulmonary artery pressure. In a simple VSD, S2 is typically normal. It becomes loud (specifically the P2 component) only if **Pulmonary Arterial Hypertension (PAH)** or Eisenmenger syndrome develops. * **Option B:** While a mid-diastolic flow murmur can occur (as mentioned above), the *characteristic* murmur of VSD is a **pansystolic murmur** heard best at the left lower sternal border. A primary diastolic murmur is not a defining feature of VSD itself. * **Option D:** A **wide, fixed split of S2** is the hallmark of an **Atrial Septal Defect (ASD)**, not VSD. In VSD, the split is usually wide but remains **variable** (moves with respiration) because the LV takes longer to empty, delaying A2. **Clinical Pearls for NEET-PG:** * **Small VSD (Roger’s Disease):** Loud, harsh murmur but clinically asymptomatic. * **Large VSD:** Leads to heart failure, frequent chest infections, and Eisenmenger syndrome (reversal of shunt). * **Murmur Intensity:** The smaller the hole, the louder the murmur (due to higher turbulence). * **Closing:** Small muscular VSDs have the highest rate of spontaneous closure.

Q: All of the following are true regarding tetralogy of Fallot except:

Left ventricular hypertrophy. **Explanation:** Tetralogy of Fallot (TOF) is characterized by four classic anatomical features: **VSD, Overriding of the aorta, Right Ventricular Outflow Tract Obstruction (RVOTO), and Right Ventricular Hypertrophy (RVH).** **Why Option D is the correct answer (False statement):** In TOF, the primary hemodynamic burden is on the right side of the heart due to subpulmonic stenosis (RVOTO). This leads to **Right Ventricular Hypertrophy (RVH)**, not left. The left ventricle is typically normal in size or even small because it receives less blood flow due to the right-to-left shunt across the VSD. **Analysis of other options:** * **Option A (Boot-shaped heart):** On X-ray, the "Coeur en sabot" appearance is a classic finding. It is caused by the upturning of the cardiac apex (due to RVH) and a concave pulmonary segment (due to pulmonary hypoplasia). * **Option B (Most common cyanotic heart disease):** TOF is the most common cyanotic congenital heart disease (CCHD) presenting **after infancy**. (Note: TGA is the most common CCHD at birth). * **Option C (Severity depends on subpulmonic stenosis):** The degree of cyanosis and the clinical severity are directly proportional to the degree of RVOTO. If the stenosis is mild, it is called "Acyanotic" or "Pink Fallot." **NEET-PG High-Yield Pearls:** * **Squatting position:** Increases systemic vascular resistance (SVR), which decreases the right-to-left shunt and improves oxygenation during a "Tet spell." * **Murmur:** The murmur in TOF is due to **pulmonary stenosis**, not the VSD (the VSD is large and non-restrictive). * **Drug of choice for Tet spell:** Morphine (calms the child) and Phenylephrine (increases SVR). Beta-blockers (Propranolol) are used for long-term prevention.

Q: Which of the following manifestations of rheumatic fever disappears completely?

Arthritis. **Explanation:** The correct answer is **Arthritis**. In Acute Rheumatic Fever (ARF), the arthritis is typically a **migratory polyarthritis** involving large joints (knees, ankles, elbows, wrists). The hallmark of this manifestation is that it is **exquisitely responsive to salicylates** and, most importantly, it **leaves no residual deformity**. It resolves completely within weeks, making it the most transient major manifestation. **Analysis of Options:** * **Carditis (Option A):** This is the most serious manifestation and the only one that can lead to **permanent chronic damage**, specifically Rheumatic Heart Disease (RHD). It can result in lifelong valvular scarring (most commonly the mitral valve). * **Chorea (Option B):** Sydenham’s chorea (St. Vitus dance) is a delayed manifestation. While it usually resolves, it can persist for several months and may occasionally recur. It does not leave "permanent" damage like carditis, but arthritis is the classic textbook answer for "disappearing completely" without sequelae. * **Subcutaneous Nodules (Option D):** These are firm, painless nodules over bony prominences. While they eventually disappear, they are strongly associated with severe carditis and are not the defining "reversible" feature compared to the dramatic resolution of arthritis. **High-Yield Clinical Pearls for NEET-PG:** * **Jones Criteria:** Arthritis is the most common major manifestation, while Carditis is the most specific/serious. * **Salicylate Response:** If a patient suspected of ARF does not show dramatic improvement in joint pain within 48–72 hours of starting Aspirin, the diagnosis of ARF should be reconsidered. * **Jaccoud Arthropathy:** A rare, non-erosive chronic joint deformity that can occur after repeated episodes of ARF, but the standard teaching remains that rheumatic arthritis is non-deforming.

Q: What is the characteristic murmur differentiating Patent Ductus Arteriosus (PDA) from Atrial Septal Defect (ASD)?

Continuous murmur in PDA. **Explanation:** The hallmark of **Patent Ductus Arteriosus (PDA)** is a **continuous machinery-type murmur**, best heard at the left infraclavicular area. This occurs because the pressure in the aorta remains higher than the pressure in the pulmonary artery during both systole and diastole, resulting in a continuous left-to-right shunt. In contrast, an **Atrial Septal Defect (ASD)** typically presents with a **midsystolic flow murmur** (due to increased flow across the pulmonary valve) and a characteristic **fixed, wide splitting of S2**. **Analysis of Options:** * **Option D (Correct):** The continuous nature of the murmur is the pathognomonic clinical feature that distinguishes PDA from most other simple congenital heart defects like ASD or VSD. * **Option A & B (Incorrect):** A wide split of S2 and delayed P2 are classic findings in **ASD**, not PDA. In PDA, the S2 is often obscured by the loud continuous murmur, or there may be "paradoxical splitting" if the shunt is large enough to delay aortic closure. * **Option C (Incorrect):** Accentuation of S1 is typically associated with Mitral Stenosis. In ASD, the S1 is usually normal or split, but not specifically "accentuated" as a differentiating feature from PDA. **High-Yield Clinical Pearls for NEET-PG:** * **PDA Murmur:** Also known as **Gibson’s murmur**. * **ASD S2:** The "Fixed Wide Split S2" in ASD occurs because the respiratory variations in venous return are equalized between the two atria. * **Management:** Indomethacin or Ibuprofen (NSAIDs) are used to close a PDA in preterms; Prostaglandin E1 (Alprostadil) is used to keep it open in duct-dependent lesions. * **Pulse:** PDA is associated with a **bounding pulse** and wide pulse pressure due to diastolic runoff into the pulmonary artery.

Q: What is the most frequent chromosomal abnormality found in individuals with congenital heart defects?

Trisomy 21. **Explanation:** **Trisomy 21 (Down Syndrome)** is the most common chromosomal abnormality associated with congenital heart defects (CHD). Approximately **40–50%** of children with Down Syndrome are born with a cardiac malformation. The most characteristic lesion is the **Atrioventricular Septal Defect (AVSD)**, specifically the endocardial cushion defect. Due to the high prevalence of Down Syndrome in the general population compared to other trisomies, it remains the leading genetic contributor to CHD. **Analysis of Incorrect Options:** * **Trisomy 13 (Patau Syndrome):** While ~80% of these infants have CHD (most commonly VSD, ASD, or PDA), the condition is much rarer and associated with high neonatal mortality, making it less frequent overall than Trisomy 21. * **Trisomy 18 (Edwards Syndrome):** Similar to Trisomy 13, over 90% have CHD (typically VSD or Polyvalvular disease), but the low live-birth prevalence makes it a less frequent cause than Trisomy 21. * **Monosomy X (Turner Syndrome):** Associated with CHD in about 25–30% of cases. The classic lesion is **Bicuspid Aortic Valve** (most common) or **Coarctation of the Aorta**. **High-Yield Clinical Pearls for NEET-PG:** * **Most common CHD in Down Syndrome:** AVSD (Endocardial cushion defect). * **Most common CHD in Turner Syndrome:** Bicuspid Aortic Valve (Note: Coarctation is the most common *obstructive* lesion). * **Noonan Syndrome:** Associated with **Pulmonary Stenosis** and Hypertrophic Cardiomyopathy. * **DiGeorge Syndrome (22q11.2 deletion):** Associated with Conotruncal anomalies (Truncus Arteriosus, Tetralogy of Fallot). * **Williams Syndrome:** Associated with **Supravalvular Aortic Stenosis**.

Q: Which of the following is NOT a feature of arthritis in acute rheumatic fever?

Joint deformities are common sequels. The arthritis of Acute Rheumatic Fever (ARF) is characteristically **non-deforming**. Even without treatment, the inflammation typically resolves within 1–5 weeks without leaving any residual joint damage or chronic sequelae. This distinguishes it from other inflammatory conditions like Rheumatoid Arthritis, which leads to joint erosion and permanent deformity. ### **Analysis of Options** * **A. Elevated ASO titer:** This is a diagnostic requirement [1]. According to the **Jones Criteria**, evidence of a preceding Group A Streptococcal (GAS) infection (e.g., elevated/rising Antistreptolysin O titer) is essential for diagnosis [1]. * **C. Dramatic response to aspirin:** The response to salicylates (Aspirin) or NSAIDs is so rapid and complete (usually within 48 hours) that if a patient does not respond, the diagnosis of ARF should be reconsidered. * **D. Involvement of large joints:** ARF typically presents as a **migratory polyarthritis** affecting large joints such as the knees, ankles, elbows, and wrists. Small joints are rarely involved. ### **High-Yield Clinical Pearls for NEET-PG** * **Jaccoud’s Arthropathy:** While ARF is non-deforming, a rare condition called Jaccoud’s arthropathy (painless loosening of ligaments) can occur after recurrent attacks, but it is functional rather than erosive. * **Jones Criteria (Revised):** Arthritis is a **Major Criterion**. In high-risk populations, even monoarthritis or polyarthralgia can be considered a major criterion. * **Inverse Relationship:** There is often an inverse relationship between the severity of arthritis and the severity of carditis; patients with severe arthritis often have milder carditis [1]. * **Treatment:** Aspirin remains the drug of choice for arthritis, while corticosteroids are reserved for severe carditis.

Question 1

Which of the following is NOT a component of Kawasaki disease?

Accepted Answer

Purulent conjunctivitis

Answer

Pedal edema

Answer

Truncal rash

Answer

Pharyngeal congestion

Question 2

A 2-year-old known case of Rheumatic Heart Disease (RHD) presents with a 3-week history of fever, hematuria, and palpitations. What is the most likely diagnosis?

Accepted Answer

Staphylococcal endocarditis

Answer

Streptococcal endocarditis

Answer

Collagen vascular disease

Answer

Reactivation

Question 3

In children, which of the following congenital heart diseases presents with absence of sinus arrhythmia?

Accepted Answer

Atrial Septal Defect (ASD)

Answer

Fallot's tetralogy

Answer

Patent Ductus Arteriosus (PDA)

Answer

Ebstein's anomaly

Question 4

What percentage of patients with Down's syndrome have congenital cardiovascular disease?

Accepted Answer

50%

Answer

10%

Answer

30%

Answer

70%

Question 5

What is true about Ventricular Septal Defect (VSD)?

Accepted Answer

Third heart sound (S3) is left-sided.

Answer

Second heart sound (S2) is loud.

Answer

A diastolic murmur is heard.

Answer

The split of the second heart sound (S2) is wide and fixed.

Question 6

All of the following are true regarding tetralogy of Fallot except:

Accepted Answer

Left ventricular hypertrophy

Answer

Boot shaped heart

Answer

Most common cyanotic heart disease

Answer

Clinical consequences depend on severity of subpulmonic stenosis

Question 7

Which of the following manifestations of rheumatic fever disappears completely?

Accepted Answer

Arthritis

Answer

Carditis

Answer

Chorea

Answer

Subcutaneous nodules

Question 8

What is the characteristic murmur differentiating Patent Ductus Arteriosus (PDA) from Atrial Septal Defect (ASD)?

Accepted Answer

Continuous murmur in PDA

Answer

Delayed P2 in PDA

Answer

Wide split of S2 in PDA

Answer

Accentuation of S1 in ASD

Question 9

What is the most frequent chromosomal abnormality found in individuals with congenital heart defects?

Accepted Answer

Trisomy 21

Answer

Trisomy 13

Answer

Trisomy 18

Answer

Monosomy X

Question 10

Which of the following is NOT a feature of arthritis in acute rheumatic fever?

Accepted Answer

Joint deformities are common sequels

Answer

Elevated ASO titer

Answer

Dramatic response to aspirin

Answer

Involvement of large joints

Cardiology — MCQs

Cardiology — MCQs

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