Cardiology Practice Questions

Q: Which of the following is not typically heard in a patient with mitral stenosis?

S3. In Mitral Stenosis (MS), the mitral valve orifice is narrowed, creating a pressure gradient between the left atrium and left ventricle. [1] **Why S3 is NOT heard in Mitral Stenosis:** The **third heart sound (S3)** is a ventricular filling sound caused by a rapid rush of blood into a compliant, dilated left ventricle (LV). In significant mitral stenosis, the narrowed valve acts as a physical barrier, **preventing rapid ventricular filling**. [3, 5] Therefore, the LV remains "underfilled" and non-dilated. The presence of an S3 effectively rules out significant MS and instead suggests conditions like Mitral Regurgitation or Heart Failure. [4] **Explanation of Incorrect Options:** * **Loud S1:** In early-to-moderate MS, the mitral leaflets are wide apart at the end of diastole due to high atrial pressure. When the ventricle contracts, the leaflets slam shut over a greater distance, creating a loud S1. [1] (Note: S1 becomes soft if the valve is heavily calcified). * **Opening Snap (OS):** This high-pitched sound occurs due to the sudden tensing of the chordae tendineae and stenotic valve leaflets as they "snap" open under high atrial pressure. [1, 2] * **Mid-diastolic Murmur:** This is the hallmark of MS. It is a low-pitched "rumble" heard at the apex, caused by turbulent flow across the narrowed valve. [1, 3] **High-Yield NEET-PG Pearls:** * **Severity Marker:** The shorter the **A2-OS interval**, the more severe the MS (indicating higher left atrial pressure). [2] * **Graham Steell Murmur:** An early diastolic murmur of pulmonary regurgitation heard in MS due to secondary pulmonary hypertension. * **Ortner’s Syndrome:** Hoarseness of voice in MS due to an enlarged left atrium compressing the left recurrent laryngeal nerve.

Q: A pansystolic murmur is present in all of the following cardiac conditions, EXCEPT:

Mitral stenosis. **Explanation:** A **pansystolic (holosystolic) murmur** occurs when there is a pressure gradient between two chambers throughout the entire duration of systole (from $S_1$ to $S_2$) [1]. **Why Mitral Stenosis is the Correct Answer:** Mitral Stenosis (MS) is a **diastolic murmur**, not a systolic one [2]. It occurs when the mitral valve fails to open fully during ventricular filling. It is characterized by an opening snap followed by a **mid-diastolic rumbling murmur** with presystolic accentuation [3]. Since it occurs during diastole, it cannot be pansystolic. **Analysis of Incorrect Options:** * **Mitral Regurgitation (MR):** High pressure in the left ventricle (LV) compared to the left atrium (LA) throughout systole causes blood to leak backward, creating a high-pitched pansystolic murmur loudest at the apex [4]. * **Tricuspid Regurgitation (TR):** Similar to MR, the pressure gradient between the right ventricle and right atrium persists throughout systole. It is loudest at the left lower sternal border and typically increases with inspiration (**Carvallo’s sign**). * **Ventricular Septal Defect (VSD):** The left-to-right shunt persists as long as LV pressure exceeds RV pressure during systole, resulting in a harsh pansystolic murmur, usually loudest at Erb’s point. **High-Yield Clinical Pearls for NEET-PG:** 1. **Pansystolic Murmurs mnemonic:** "MTV" (Mitral regurgitation, Tricuspid regurgitation, VSD). 2. **Dynamic Auscultation:** MR/VSD murmurs increase with handgrip (increased afterload), while TR increases with inspiration. 3. **Exception:** A very small VSD (Maladie de Roger) produces a very loud murmur, whereas a large VSD may have a softer murmur due to equilibrated pressures. 4. **Mitral Stenosis:** Always look for "Loud $S_1$" and "Opening Snap" in the clinical stem [3].

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).

Question 1

Fixed and wide splitting of the second heart sound is characteristic of which of the following conditions?

Accepted Answer

Atrial Septal Defect (ASD)

Answer

Ventricular Septal Defect (VSD)

Answer

Patent Ductus Arteriosus (PDA)

Answer

Tetralogy of Fallot

Question 2

Which of the following is not typically heard in a patient with mitral stenosis?

Accepted Answer

S3

Answer

Loud S1

Answer

Opening snap

Answer

Mid-diastolic murmur

Question 3

Positive Hepatojugular Reflux is found in all of the following conditions, except?

Accepted Answer

Decreased Afterload

Answer

Tricuspid Regurgitation

Answer

Precapillary Pulmonary Hypertension

Answer

Right Ventricular Infarction

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

A pansystolic murmur is present in all of the following cardiac conditions, EXCEPT:

Accepted Answer

Mitral stenosis

Answer

Mitral regurgitation

Answer

Ventricular septal defect

Answer

Tricuspid regurgitation

Question 6

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 7

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 8

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 9

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 10

What is the drug of choice for Paroxysmal Supraventricular Tachycardia?

Accepted Answer

Adenosine

Answer

Digitalis

Answer

Adrenaline

Answer

Verapamil

Cardiology — MCQs

Cardiology — MCQs

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