Cardiology Practice Questions

Q: A patient presents with elevated total cholesterol, subcutaneous xanthomas, and a positive family history of similar findings. Triglyceride levels are normal (<140 mg/dL). What is the most likely type of familial dyslipidemia?

Type IIa. ***Type IIa*** - This type, also known as **Familial Hypercholesterolemia**, is characterized by severely elevated **Total (LDL) Cholesterol** and **normal triglyceride** levels (<140 mg/dL) [1]. - The presence of **subcutaneous xanthomas** (often reflecting tendon xanthomas) and a strong family history are classic findings associated with defective **LDL receptors** [1]. *Type I* - This type (Familial Hyperchylomicronemia) is characterized by extremely high **Triglyceride** levels and chylomicrons due to **Lipoprotein Lipase (LPL) deficiency** or C-II deficiency. - The key clinical feature is usually recurrent **pancreatitis** and **eruptive xanthomas**, contrary to the normal TGs seen in this patient. *Type IIb* - This type is defined by elevated levels of both **Total/LDL Cholesterol** and **Triglycerides** (as VLDL) [1]. - An elevated triglyceride level would be mandatory for a Type IIb classification, differentiating it from the patient's normal triglyceride levels. *Type II* - Type II is the broad classification covering all dyslipidemias with elevated **LDL cholesterol** (both IIa and IIb). - For a precise diagnosis in the Fredrickson system, the specific subtype (**IIa** based on normal TGs) is required.

Q: The murmur of mitral regurgitation is best heard at

Cardiac apex. ***Cardiac apex*** - The **mitral valve** is located at the cardiac apex, and the murmur of **mitral regurgitation** is typically loudest at this point [1]. - Mitral regurgitation creates a **holosystolic murmur** that radiates to the axilla [1]. *Tricuspid area* - This area is located at the **lower left sternal border** and is where murmurs originating from the **tricuspid valve** are best heard, such as tricuspid regurgitation [2]. - Murmurs heard here are not characteristic of mitral valve dysfunction. *Aortic area* - The aortic area is at the **right upper sternal border**, primarily for auscultation of the **aortic valve**. - Conditions like **aortic stenosis** or **aortic regurgitation** are best heard here [3]. *Pulmonary area* - This area is located at the **left upper sternal border** and is where murmurs related to the **pulmonic valve** are best heard. - Examples include **pulmonic stenosis** or **pulmonic regurgitation**.

Q: Which of the following statements is correct regarding the Opening Snap (OS) in a patient of mitral stenosis?

OS moves closer to the second sound (S2) as the stenosis becomes more severe. ***OS moves closer to the second sound (S2) as the stenosis becomes more severe*** - As **mitral stenosis** worsens, the **left atrial pressure** increases, causing the mitral valve to open earlier in diastole. - This earlier opening effectively shortens the **isovolumic relaxation time**, bringing the **opening snap (OS)** closer to the **second heart sound (S2)** [1]. *OS is best heard at the second left intercostal space* - The **opening snap** in **mitral stenosis** is typically best heard at the **apex** (4th or 5th intercostal space, midclavicular line) or the **lower left sternal border** [2]. - The **second left intercostal space** is where pulmonary components of S2 are best heard, and where murmurs of pulmonary regurgitation might be audible, not the OS. *OS is best heard with the bell of stethoscope* - The **opening snap** is a **high-pitched sound** resulting from the abrupt halting of the valve leaflets during opening [1]. - High-pitched sounds are best heard with the **diaphragm** of the stethoscope, not the bell, which is used for low-pitched sounds. *Intensity of OS becomes louder when the valve is calcified* - The **intensity of the opening snap** is directly related to the **mobility of the mitral valve leaflets**. - When the valve becomes heavily **calcified** and stiff, its mobility is reduced, which can cause the **opening snap to become softer or even disappear entirely** [1].

Q: Which one of the following is correct with regard to Carey Coombs murmur?

Soft mid-diastolic murmur due to mitral valvulitis. ***Soft mid-diastolic murmur due to mitral valvulitis*** - The **Carey Coombs murmur** is a soft, mid-diastolic murmur heard in acute rheumatic fever, characterized by inflammation of the mitral valve (mitral valvulitis) [4]. - It is distinct from the Austin Flint murmur and indicates active **rheumatic carditis** [4]. *Harsh early diastolic murmur due to aortic regurgitation* - An early diastolic murmur, especially a harsh one, typically indicates **aortic regurgitation**, which is a different valvular pathology [3]. - The Carey Coombs murmur is described as soft and mid-diastolic, not harsh and early diastolic. *Soft systolic murmur due to mitral regurgitation* - A soft systolic murmur suggests **mitral regurgitation**, which is a backflow of blood during systole [2]. - The Carey Coombs murmur is specifically a diastolic murmur, differentiating it from systolic murmurs [3]. *Blowing late systolic murmur due to aortic stenosis* - A blowing late systolic murmur is characteristic of **aortic stenosis**, where there is narrowing of the aortic valve. - The Carey Coombs murmur is an early to mid-diastolic murmur, related to mitral valve inflammation, not aortic stenosis [1].

Q: Consider the following statements for diagnosing ventricular aneurysm in a patient with recent myocardial infarction : I. Paradoxical impulse on chest wall II. Persistent ST elevation on ECG III. Unusual bulge from cardiac silhouette on X-ray IV. Presence of pulsus paradoxsus Which of the above are correct?

I, II and III. ***I, II and III*** - A **paradoxical impulse** on the chest wall (statement I) is a classic physical finding, indicating dyskinetic movement of the aneurysm during systole [1]. - **Persistent ST segment elevation** on ECG weeks to months after a myocardial infarction (statement II) is a hallmark sign, often reflecting the fibrous scar tissue of the aneurysm [1]. - An **unusual bulge** from the cardiac silhouette on X-ray (statement III) can indicate an enlarged left ventricular contour due to the aneurysm [1]. *II, III and IV* - While statements II and III are correct for diagnosing ventricular aneurysm, **pulsus paradoxus** (statement IV) is typically associated with **cardiac tamponade** or severe asthma/COPD, not directly with ventricular aneurysms. *I and II only* - Statements I and II are indeed correct indicators, but statement III, the **cardiac silhouette bulge on X-ray**, is also a valid and often observed finding for ventricular aneurysm [1]. *I and IV* - Statement I is correct, but **pulsus paradoxus** (statement IV) is not a diagnostic feature of ventricular aneurysm; it suggests conditions like **pericardial effusion** with tamponade.

Q: Which of the following heart sounds are best heard with the bell of stethoscope? I. Opening snap II. Systolic click III. Third heart sound IV. Mid diastolic murmur Select the correct answer using the code given below :

III and IV. ***III and IV*** - The **bell of the stethoscope** is designed to auscultate **low-pitched sounds** due to its larger surface area and lighter application to the skin. - The **third heart sound (S3)** and **mid-diastolic murmurs** (e.g., from mitral stenosis) are classic examples of low-pitched sounds best heard with the bell [2]. *II and III only* - While the **third heart sound (S3)** is correctly identified as being heard with the bell, the **systolic click** is a high-pitched sound [1]. - **Systolic clicks**, often associated with mitral valve prolapse, are best heard with the **diaphragm** of the stethoscope [1]. *I, II and III* - This option incorrectly includes both the **opening snap** and **systolic click** as being best heard with the bell. - The **opening snap** (related to mitral stenosis) and **systolic click** (related to mitral valve prolapse) are typically **high-pitched sounds** and are better heard with the **diaphragm** [1], [3]. *I and IV* - This option incorrectly states that the **opening snap** is best heard with the bell. - Although the **mid-diastolic murmur** is correctly identified as a low-pitched sound [2], the **opening snap** is a high-pitched sound [1], [3], making the entire option incorrect.

Q: A 48-year-old smoker presents to the OPD with complaints of cramping pain in both the calves on walking to about 100-150 metres. The pain is relieved on taking rest for about 2-3 minutes and the patient is able to walk for some more distance again before the pain appears. This presentation is suggestive of

intermittent claudication. ***intermittent claudication*** - The classic presentation of **cramping pain in the calves** that occurs with exertion, particularly walking a specific distance, and is **relieved by rest** within a few minutes, is highly characteristic of **intermittent claudication** [1]. - This condition is a hallmark symptom of **peripheral artery disease (PAD)**, where narrowed arteries reduce blood flow to the limbs, and is exacerbated by risk factors such as **smoking** [1]. *osteoarthritis of the knee* - While osteoarthritis causes pain with activity, it typically describes a **mechanical joint pain worsened by movement** and often associated with stiffness, crepitus, and swelling [2]. - The pain from osteoarthritis is usually **localized to the joint** and less likely to be described as cramping in the calves or to have such a clear, immediate resolution with rest as seen in claudication [2]. *muscular fatigue* - Muscular fatigue can cause pain and discomfort with exertion, but it typically does not present with the **consistent, reproducible pattern** of pain onset at a specific distance and rapid relief with a short rest as described. - Fatigue-related pain is generally more diffuse and gradually improves with prolonged rest, rather than the quick resolution characteristic of claudication. *neurogenic claudication* - Neurogenic claudication also causes **leg pain with walking** but is typically associated with **spinal stenosis** and is often described as numbness, tingling, or weakness, rather than pure cramping. - Crucially, neurogenic claudication is often relieved by **bending forward or sitting**, rather than just standing still, and is less directly tied to the specific walking distance that defines intermittent claudication.

Q: Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease ?

Digital Subtraction Angiography (DSA). ***Digital Subtraction Angiography (DSA)*** - **DSA** remains the gold standard for diagnosing arterial occlusive disease as it provides **high-resolution images** of the arterial lumen, accurately depicting stenoses and occlusions [1]. - It allows for precise localization and quantification of arterial lesions, which is crucial for treatment planning, especially for **interventional procedures** [1]. *Duplex imaging* - While useful for screening and follow-up, **duplex ultrasound** is operator-dependent and may not always provide the detailed anatomical information required for definitive diagnosis or pre-procedural planning, especially in complex cases. - It assesses blood flow and vessel patency but can be limited by factors such as patient body habitus, calcification, and bowel gas. *Doppler ultrasound blood flow detection* - **Doppler ultrasound** is an excellent tool for assessing blood flow characteristics and detecting changes indicative of arterial disease, but it provides less anatomical detail compared to angiography. - It is often used for **screening** and monitoring, but it does not offer the precise visualization of the arterial lumen needed to be a gold standard for diagnosis. *Treadmill* - A **treadmill test** (exercise stress test) is used to assess the functional impact of arterial occlusive disease, particularly **intermittent claudication**, by measuring the ankle-brachial index (ABI) after exertion. - It is a physiological test that indicates the presence and severity of flow-limiting lesions, but it does not provide anatomical information about the location or nature of the arterial occlusion.

Q: Deep vein thrombosis of calf is best managed by :

anticoagulants. ***Anticoagulants*** - **Anticoagulation** therapy is the cornerstone of DVT management, preventing clot extension and reducing the risk of **pulmonary embolism** [1]. - Medications like **heparin**, **low molecular weight heparin**, or **direct oral anticoagulants (DOACs)** are commonly used [1]. *active physiotherapy* - While physical activity can prevent DVT, it is generally **contraindicated in acute DVT** due to the risk of dislodging the clot. - Mobilization is introduced gradually once anticoagulation is therapeutic and the risk of **embolization** is reduced. *thrombolysis* - **Thrombolysis** (clot dissolution) is usually reserved for **proximal, extensive DVT** [1] or DVT with **limb-threatening ischemia** [2]. - It carries a **higher risk of bleeding** compared to anticoagulation and is not typically necessary for isolated calf DVT [2]. *surgical venous thrombectomy* - **Surgical thrombectomy** is rarely performed for DVT and is generally reserved for **massive iliocaval thrombosis** with severe limb threat. - It is an **invasive procedure** with significant risks and is not indicated for typical calf DVT.

Question 1

A 30-year-old man with 6 month past history of PND and SOB. On examination, JVP is elevated with irregularly irregular pulse and tender hepatomegaly and MDM. past medical history of ARF. Which of the following is not seen in this patient?

Accepted Answer

Presystolic accentuation of mid-diastolic murmur is hallmark feature

Answer

Right heart failure

Answer

Absent a wave in JVP

Answer

Patient has increased risk of embolic stroke

Question 2

A patient presents with elevated total cholesterol, subcutaneous xanthomas, and a positive family history of similar findings. Triglyceride levels are normal (<140 mg/dL). What is the most likely type of familial dyslipidemia?

Accepted Answer

Type IIa

Answer

Type I

Answer

Type II

Answer

Type IIb

Question 3

The murmur of mitral regurgitation is best heard at

Accepted Answer

Cardiac apex

Answer

Tricuspid area

Answer

Aortic area

Answer

Pulmonary area

Question 4

Which of the following statements is correct regarding the Opening Snap (OS) in a patient of mitral stenosis?

Accepted Answer

OS moves closer to the second sound (S2) as the stenosis becomes more severe

Answer

OS is best heard at the second left intercostal space

Answer

OS is best heard with the bell of stethoscope

Answer

Intensity of OS becomes louder when the valve is calcified

Question 5

Which one of the following is correct with regard to Carey Coombs murmur?

Accepted Answer

Soft mid-diastolic murmur due to mitral valvulitis

Answer

Harsh early diastolic murmur due to aortic regurgitation

Answer

Soft systolic murmur due to mitral regurgitation

Answer

Blowing late systolic murmur due to aortic stenosis

Question 6

Consider the following statements for diagnosing ventricular aneurysm in a patient with recent myocardial infarction :
I. Paradoxical impulse on chest wall
II. Persistent ST elevation on ECG
III. Unusual bulge from cardiac silhouette on X-ray
IV. Presence of pulsus paradoxsus

Which of the above are correct?

Accepted Answer

I, II and III

Answer

II, III and IV

Answer

I and II only

Answer

I and IV

Question 7

Which of the following heart sounds are best heard with the bell of stethoscope?
I. Opening snap
II. Systolic click
III. Third heart sound
IV. Mid diastolic murmur

Select the correct answer using the code given below :

Accepted Answer

III and IV

Answer

II and III only

Answer

I, II and III

Answer

I and IV

Question 8

A 48-year-old smoker presents to the OPD with complaints of cramping pain in both the calves on walking to about 100-150 metres. The pain is relieved on taking rest for about 2-3 minutes and the patient is able to walk for some more distance again before the pain appears. This presentation is suggestive of

Accepted Answer

intermittent claudication

Answer

osteoarthritis of the knee

Answer

muscular fatigue

Answer

neurogenic claudication

Question 9

Which one of the following investigations is considered to be "Gold standard" technique for diagnosis of arterial occlusive disease ?

Accepted Answer

Digital Subtraction Angiography (DSA)

Answer

Duplex imaging

Answer

Doppler ultrasound blood flow detection

Answer

Treadmill

Question 10

Deep vein thrombosis of calf is best managed by :

Accepted Answer

anticoagulants

Answer

active physiotherapy

Answer

thrombolysis

Answer

surgical venous thrombectomy

Cardiology — MCQs

Cardiology — MCQs

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