Cardiology Practice Questions

Q: A 21-year-old male presents with exertional dyspnea, raised JVP, and loud P2. ECG shows right axis deviation. All of the following conditions are possible except?

Ostium primum. The clinical presentation of exertional dyspnea, raised JVP, loud $P_2$, and ECG evidence of **Right Axis Deviation (RAD)** points toward **Pulmonary Hypertension** and **Right Ventricular Hypertrophy (RVH)** [1], [4]. **Why Ostium Primum is the Correct Answer:** While both Ostium Secundum and Ostium Primum ASDs cause right-sided volume overload, **Ostium Primum ASD** is characteristically associated with **Left Axis Deviation (LAD)** on ECG. This occurs because the conduction system is displaced, often accompanied by a cleft mitral valve. Since the question specifies RAD, Ostium Primum is the "except" condition. **Analysis of Other Options:** * **Atrial Septal Defect (Secundum):** This is the most common type of ASD. It leads to right ventricular overload and typically presents with **Right Axis Deviation** and RSR' pattern [2]. * **Mitral Stenosis:** Chronic mitral stenosis leads to pulmonary venous hypertension, reactive pulmonary arterial hypertension, and eventually RVH, which manifests as **Right Axis Deviation**. * **Pulmonary Thromboembolism:** Acute or chronic pulmonary embolism increases right ventricular afterload, leading to right heart strain and **Right Axis Deviation** (often seen as part of the S1Q3T3 pattern or persistent RAD in chronic cases) [1]. ### High-Yield NEET-PG Pearls: * **ASD Axis Rule:** * **Ostium Secundum:** Right Axis Deviation (RAD). * **Ostium Primum:** Left Axis Deviation (LAD). * **Loud $P_2$:** A hallmark sign of Pulmonary Arterial Hypertension [3], [4]. * **ECG in RVH:** Look for R wave > S wave in V1 and Right Axis Deviation (> +90°) [4]. * **Ostium Primum Associations:** Frequently associated with Down Syndrome and Endocardial Cushion Defects.

Q: A 62-year-old male with underlying COPD develops a viral upper respiratory infection and begins taking an over-the-counter decongestant. Shortly thereafter he experiences palpitations and presents to the emergency room, where the following rhythm strip is obtained, demonstrating what rhythm?

Atrial flutter with 4:1 atrioventricular block. ***Atrial flutter with 4:1 atrioventricular block*** - Characteristic **sawtooth flutter waves (F-waves)** at approximately **300 bpm** with **4:1 AV conduction** resulting in a ventricular rate of ~75 bpm. - Clinical trigger includes **COPD exacerbation** and **sympathomimetic decongestant** use, both predisposing to atrial arrhythmias. *Normal sinus rhythm* - Would show **regular P waves** before each QRS complex with normal morphology and rate (60-100 bpm). - Patient's presentation with **palpitations** and **decongestant use** suggests an abnormal rhythm rather than normal sinus rhythm. *Junctional rhythm* - Characterized by **absent or inverted P waves** and a regular ventricular rate of 40-60 bpm originating from the AV junction. - Does not explain the **palpitations** or the typical ECG findings associated with sympathomimetic stimulation in COPD patients. *Paroxysmal atrial tachycardia with 2:1 atrioventricular block* - Would show **discrete P waves** at a faster rate (typically 150-250 bpm) with **2:1 AV conduction**. - Lacks the characteristic **sawtooth pattern** of flutter waves and typically has a different atrial rate than the ~300 bpm seen in atrial flutter.

Q: Quincke's sign in aortic regurgitation refers to which of the following?

Capillary nail bed pulsation. **Explanation:** **Aortic Regurgitation (AR)** is characterized by a high stroke volume and a rapid fall in arterial pressure during diastole, leading to a **wide pulse pressure** [1]. This "hyperdynamic circulation" results in numerous peripheral signs, of which **Quincke’s sign** is a classic manifestation. * **Correct Answer (C):** Quincke’s sign refers to **capillary pulsations** visible in the nail beds. It is elicited by applying gentle pressure to the tip of the fingernail; the nail bed alternates between flushing (systole) and blanching (diastole). This occurs due to the transmission of large pressure waves into the microvasculature. **Analysis of Incorrect Options:** * **Option A (Müller’s sign):** This refers to systolic pulsations of the **uvula**. * **Option B (Becker’s sign):** This refers to visible pulsations of the **retinal arteries** or arterioles upon ophthalmoscopic examination. * **Option D (Rosenbach’s sign):** This refers to systolic pulsations of the **liver**. (Note: A pulsating liver is also a hallmark of Tricuspid Regurgitation). **High-Yield Clinical Pearls for NEET-PG:** * **De Musset’s sign:** Rhythmic head nodding in time with the heartbeat [1]. * **Corrigan’s pulse:** "Water-hammer" pulse characterized by a rapid upstroke and collapse [1], [2]. * **Traube’s sign:** "Pistol shot" sounds heard over the femoral arteries. * **Duroziez’s sign:** A systolic and diastolic murmur heard over the femoral artery when compressed by the stethoscope. * **Hill’s sign:** Popliteal systolic BP exceeding brachial systolic BP by >20 mmHg (the most sensitive sign for AR severity).

Q: The Framingham Risk Score is used to determine which of the following?

Cardiovascular mortality risk due to atherosclerosis. **Explanation:** The **Framingham Risk Score (FRS)** is a validated clinical tool used to estimate an individual's **10-year risk of developing coronary heart disease (CHD)** or experiencing major cardiovascular events (mortality/morbidity) due to atherosclerosis [1]. It integrates multiple risk factors—age, gender, total cholesterol, HDL cholesterol, smoking status, and systolic blood pressure—to categorize patients into low, intermediate, or high-risk groups [1]. This helps clinicians decide on the intensity of primary prevention strategies, such as statin therapy [2]. **Analysis of Options:** * **Option A & B:** These are incorrect. The Framingham Risk Score is for **primary prevention of atherosclerosis**. For the **diagnosis** of Congestive Heart Failure (CHF), clinicians use the **Framingham Criteria** (Major and Minor criteria like PND, JVP elevation, and S3 gallop). For the **severity** of CHF, the **NYHA Classification** (Functional) or **ACC/AHA Stages** (Structural) are used. * **Option D:** The need for stenting in chronic stable angina is determined by symptomatic burden, response to medical therapy, and objective evidence of ischemia (e.g., Stress Test or FFR), not by a 10-year risk calculator [3]. **High-Yield Clinical Pearls for NEET-PG:** * **Framingham Criteria for CHF:** Remember that 2 major OR 1 major + 2 minor criteria are required for diagnosis. * **QRISK3 & ASCVD Risk Estimator:** These are newer alternatives to the Framingham score used in modern guidelines (NICE and AHA/ACC respectively). * **Diabetes Mellitus:** In many risk models, DM is considered a **"Coronary Artery Disease Risk Equivalent,"** automatically placing the patient in a high-risk category.

Q: A patient with mitral stenosis has developed pulmonary artery hypertension. Which of the following auscultatory findings may be heard?

Pan-systolic murmur. The correct answer is **Pan-systolic murmur**. **1. Why it is correct:** In patients with long-standing Mitral Stenosis (MS), the chronic increase in left atrial pressure leads to reactive **Pulmonary Artery Hypertension (PAH)** [1]. This increased pressure in the pulmonary circuit causes the right ventricle (RV) to enlarge and fail, leading to **Functional Tricuspid Regurgitation (TR)** due to the stretching of the tricuspid annulus. Tricuspid Regurgitation characteristically produces a **pan-systolic (holosystolic) murmur**, best heard at the left lower sternal border, which typically increases in intensity during inspiration (**Carvallo’s sign**). **2. Why the other options are incorrect:** * **Option A (Early diastolic, crescendo murmur):** This is incorrect. While PAH can cause an early diastolic murmur (Graham Steell murmur) due to functional pulmonary regurgitation, it is **decrescendo** in nature, not crescendo. * **Option B (Mid-systolic, crescendo-decrescendo murmur):** This is typical of Aortic Stenosis or Flow murmurs. While PAH may cause a brief pulmonary ejection click/murmur, the pan-systolic murmur of TR is a more definitive finding of secondary RV involvement. * **Option D (Mid-diastolic, rumbling murmur):** This is the classic murmur of **Mitral Stenosis** itself [1]. While present in this patient, the question specifically asks for findings associated with the *development of PAH*. **Clinical Pearls for NEET-PG:** * **Graham Steell Murmur:** A high-pitched, blowing, decrescendo early diastolic murmur heard in the pulmonary area due to functional PR in severe PAH. * **Signs of PAH in MS:** Loud P2 (palpable as Dressler’s sign), Right Ventricular Heave, and the murmur of TR [1]. * **Carvallo’s Sign:** Helps differentiate TR (increases with inspiration) from MR (does not increase with inspiration).

Q: Which condition is characterized by a reduced PR interval?

Wolff-Parkinson-White syndrome. ### Explanation **Correct Answer: B. Wolff-Parkinson-White (WPW) syndrome** **Why it is correct:** The PR interval represents the time taken for electrical impulses to travel from the atria to the ventricles. In a normal heart, this impulse is delayed at the AV node. In **WPW syndrome**, an accessory pathway (the **Bundle of Kent**) bypasses the AV node, conducting the impulse faster than normal [1]. This "pre-excitation" results in a **shortened PR interval (<0.12 seconds)** [1]. Other classic ECG findings in WPW include a widened QRS complex and a **Delta wave** (slurred upstroke of the QRS) [1, 3]. **Why the other options are incorrect:** * **A. Wenckebach phenomenon (Mobitz Type I):** This is characterized by progressive **prolongation** of the PR interval until a QRS complex is dropped [2]. * **C. Hypothyroidism:** This typically causes bradycardia and may lead to a **prolonged** PR interval (First-degree heart block) due to slowed conduction, along with low-voltage complexes. * **D. Complete heart block (Third-degree):** There is no relationship between P waves and QRS complexes (AV dissociation). The PR interval is **variable**, not consistently reduced. **High-Yield Clinical Pearls for NEET-PG:** * **Short PR Interval Differential:** WPW syndrome, Lown-Ganong-Levine (LGL) syndrome, and Duchenne Muscular Dystrophy [1]. * **Prolonged PR Interval (>0.20s):** Seen in First-degree AV block, Rheumatic fever (Jones criteria), Hyperkalemia, and Digoxin toxicity [2]. * **WPW Treatment:** Hemodynamically unstable patients require DC cardioversion. Definitive treatment is **Radiofrequency Ablation** of the accessory pathway. * **Contraindication:** Avoid AV nodal blockers (ABCD: **A**denosine, **B**eta-blockers, **C**alcium channel blockers, **D**igoxin) in WPW with Atrial Fibrillation, as they can promote conduction through the accessory pathway, leading to Ventricular Fibrillation [3].

Question 1

A 21-year-old male presents with exertional dyspnea, raised JVP, and loud P2. ECG shows right axis deviation. All of the following conditions are possible except?

Accepted Answer

Ostium primum

Answer

Atrial septal defect

Answer

Mitral stenosis

Answer

Pulmonary thromboembolism

Question 2

A 62-year-old male with underlying COPD develops a viral upper respiratory infection and begins taking an over-the-counter decongestant. Shortly thereafter he experiences palpitations and presents to the emergency room, where the following rhythm strip is obtained, demonstrating what rhythm?

Accepted Answer

Atrial flutter with 4:1 atrioventricular block

Answer

Normal sinus rhythm

Answer

Junctional rhythm

Answer

Paroxysmal atrial tachycardia with 2:1 atrioventricular block

Question 3

The following ECG shows:

Accepted Answer

Ventricular bigeminy

Answer

P. pulmonale

Answer

Electrical alternans

Answer

Wrong calibration

Question 4

All of the following are considered minor criteria for infective endocarditis EXCEPT?

Accepted Answer

Evidence of endocardial involvement documented by echocardiography

Answer

Janeway lesions

Answer

Embolic disease

Answer

Osler's nodes

Question 5

Quincke's sign in aortic regurgitation refers to which of the following?

Accepted Answer

Capillary nail bed pulsation

Answer

Pulsation of the uvula in time with the heartbeat

Answer

Prominent retinal artery pulsation

Answer

Pulsating liver in time with the heartbeat

Question 6

The Framingham Risk Score is used to determine which of the following?

Accepted Answer

Cardiovascular mortality risk due to atherosclerosis

Answer

Severity of Congestive Heart Failure (CHF)

Answer

Diagnosis of Congestive Heart Failure (CHF)

Answer

Need for stenting in chronic stable angina

Question 7

A patient with mitral stenosis has developed pulmonary artery hypertension. Which of the following auscultatory findings may be heard?

Accepted Answer

Pan-systolic murmur

Answer

Early diastolic, crescendo murmur

Answer

Mid-systolic, crescendo-decrescendo murmur

Answer

Mid-diastolic, rumbling murmur

Question 8

All of the following features can differentiate between ventricular tachycardia and supraventricular tachycardia EXCEPT?

Accepted Answer

Ventricular rate > 160/min

Answer

QRS duration < 0.14 seconds

Answer

Variable first heart sound

Answer

Relieved by carotid sinus massage

Question 9

What is the drug of choice for Paroxysmal Supraventricular Tachycardia?

Accepted Answer

Adenosine

Answer

Digitalis

Answer

Adrenaline

Answer

Verapamil

Question 10

Which condition is characterized by a reduced PR interval?

Accepted Answer

Wolff-Parkinson-White syndrome

Answer

Wenckebach phenomenon

Answer

Hypothyroidism

Answer

Complete heart block

Cardiology — MCQs

Cardiology — MCQs

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