Cardiology Practice Questions

Q: Which procedure is being performed in the image shown?

Percutaneous mitral balloon valvotomy. ***Percutaneous mitral balloon valvotomy*** - The image clearly depicts a **balloon catheter** being advanced through the heart chambers to the mitral valve, where it is inflated to open the valve orifice. - This procedure is specifically performed to relieve **mitral stenosis** by physically separating fused valve leaflets using the **Inoue balloon technique** or other balloon devices. - The transseptal approach shown is characteristic of mitral valve balloon procedures. *Percutaneous aortic balloon valvuloplasty* - This procedure targets the **aortic valve**, not the mitral valve, and is used primarily for aortic stenosis. - The catheter approach for aortic valvuloplasty is typically **retrograde through the femoral artery**, not transseptal as shown in this image. *Percutaneous mitral valve repair* - Mitral valve repair involves techniques like the **MitraClip procedure** where clips are used to coapt the valve leaflets, or the placement of annuloplasty devices. - These methods do not involve inflating a balloon across the valve as depicted in the image. *Percutaneous coronary intervention* - This procedure involves addressing blockages in the **coronary arteries**, which supply blood to the heart muscle. - The image shows a catheter inside the heart chambers, specifically targeting the **mitral valve**, not the coronary arteries.

Q: A 65-year-old diabetic presents with extensive sweating and dizziness. The ECG is shown below. What is the diagnosis?

Anterior wall MI. ***Anterior wall MI*** - The ECG shows significant **ST-segment elevation in leads V2, V3, and V4**, which are anterior precordial leads. This pattern is indicative of an acute **anterior wall myocardial infarction**. - The patient's symptoms of extensive sweating and dizziness, especially in a diabetic individual, are **atypical presentations of acute coronary syndrome** and can be misinterpreted, but the ECG findings are definitive for an MI. *Hypoglycemia* - While dizziness and sweating can be symptoms of **hypoglycemia**, the ECG findings are not consistent with this diagnosis. - Hypoglycemia is a metabolic condition and does not typically cause the **characteristic ST-segment changes** seen on this ECG. *Hypoglycemic unawareness* - **Hypoglycemic unawareness** refers to the absence of the typical warning symptoms of hypoglycemia, which is not directly suggested by the patient's presentation of extensive sweating and dizziness (these are warning symptoms). - Additionally, this condition is a clinical phenomenon related to altered symptom perception, not an ECG-diagnosable cardiac event. *Inferior wall MI* - An **inferior wall MI** would typically show ST-segment elevation in the **inferior leads (II, III, aVF)**. - The provided ECG does not show significant ST-segment elevation in these leads; instead, the elevations are prominent in the anterior leads.

Q: All are associated with pulse being checked in the image except:

Decreased LV end diastolic pressure. ***Decreased LV end diastolic pressure*** - Aortic regurgitation is characterized by a **volume overload of the left ventricle (LV)**, leading to increased LV end-diastolic volume and consequently **increased LV end-diastolic pressure**, not decreased. - The image shows a doctor checking the pulse, likely evaluating for a **water-hammer pulse** (Corrigan's pulse), which is highly characteristic of aortic regurgitation due to a rapid rise and fall in peripheral pulse pressure. *Durozie's sign* - This is a **diastolic murmur** heard over the femoral artery, produced by compressing the artery distally, resulting from the oscillation of blood due to the reverse flow typical of aortic regurgitation. - It is a classic physical finding associated with significant **aortic regurgitation**, which is implied by the clinical context of the image showing a pulse examination. *Early diastolic murmur* - This murmur is the hallmark auscultatory finding in **aortic regurgitation**, caused by blood flowing back into the left ventricle during diastole through an incompetent aortic valve. - Its presence is a primary diagnostic indicator of aortic regurgitation, a condition known for causing a **hyperdynamic circulation** and characteristic peripheral pulse findings. *Pulsus bisferiens* - A **pulsus bisferiens**, characterized by two palpable systolic peaks (percussion wave and tidal wave), is typically found in conditions with a **high stroke volume** and/or dynamic outflow obstruction, such as severe aortic regurgitation, with or without aortic stenosis. - This specific pulse pattern indicates a significant increase in stroke volume and rapid ejection into the aorta, a physiological consequence of the compensatory mechanisms in severe aortic regurgitation.

Q: ECG shows which electrolyte abnormality?

Hyperkalemia. ***Hyperkalemia*** - The ECG shows **peaked T waves** (especially prominent in V2-V5), **prolonged PR interval**, and a **widened QRS complex**, which are classic findings of hyperkalemia. - As hyperkalemia worsens, the T waves become taller and more symmetrical, PR interval lengthens, and the QRS complex widens, eventually leading to a **sine wave pattern** and cardiac arrest. *Hypocalcemia* - Hypocalcemia typically manifests with a **prolonged QT interval** on the ECG due to changes in ventricular repolarization. - It does not cause peaked T waves or QRS widening. *Hypercalcemia* - Hypercalcemia is associated with a **shortened QT interval** on the ECG due to accelerated repolarization. - Other common findings might include Osborn waves or J waves in severe cases, but not the changes seen here. *Hypokalemia* - Hypokalemia typically presents with **prominent U waves**, **flattened or inverted T waves**, and a prolonged QT interval. - The ECG in the image clearly shows peaked T waves, which is the opposite of the T wave changes seen in hypokalemia.

Q: Comment on the diagnosis of the patient?

Ventricular flutter. ***Ventricular flutter*** - This ECG shows a very rapid, regular ventricular rhythm with **sine-wave-like morphology** and no discernible P waves or T waves, characteristic of ventricular flutter. - The rate is typically between **250-350 bpm**, and the QRS complexes are wide and uniform but merge with the T waves to create a continuous undulating pattern. *Ventricular tachycardia* - While ventricular tachycardia (VT) is a fast ventricular rhythm, it usually presents with **discrete QRS complexes** and identifiable (although wide) QRS and ST-T segments. - The rate in VT is typically **100-250 bpm**, and the complexes often show some degree of variability in morphology or R-R interval. *Ventricular fibrillation* - Ventricular fibrillation (VF) is characterized by **chaotic, irregular electrical activity** with no identifiable QRS complexes, P waves, or T waves. - The waveforms are highly variable in shape and amplitude, representing uncoordinated ventricular muscle activity, unlike the regular, undulating pattern seen here. *Electromechanical dissociation* - **Electromechanical dissociation (EMD)**, also known as pulseless electrical activity (PEA), occurs when there is organized electrical activity on the ECG but no palpable pulse. - The ECG in EMD can show a variety of rhythms, including normal sinus rhythm or bradycardia, but it will always show **discernible electrical complexes**, unlike the continuous sinusoidal pattern of ventricular flutter.

Q: CXR was done for a 15-year-old boy with low cardiac output. Which is incorrect about the patient?

Carey Coombs murmur. ***Carey Coombs murmur*** - A **Carey Coombs murmur** is a mid-diastolic murmur typically heard in **acute rheumatic fever** due to active mitral valvulitis, which causes relative mitral stenosis. - The patient's CXR indicates **Coarctation of Aorta**, as evidenced by the **reverse 3 sign** (figure-of-3 sign) and **rib notching** from collateral circulation. - Carey Coombs murmur is **not associated with coarctation of aorta**, making this the **incorrect finding** for this patient. *Reverse split S2* - A **reverse split S2** (paradoxical splitting) occurs when the **aortic component (A2) follows the pulmonary component (P2)** due to delayed left ventricular ejection. - This can occur in conditions causing **left ventricular outflow obstruction** such as severe aortic stenosis or coarctation of aorta. - In coarctation, increased LV afterload can delay aortic valve closure, potentially causing reverse splitting of S2. *Straightening of left heart border* - **Straightening of the left heart border** on CXR is observed in conditions causing **left ventricular hypertrophy** or prominence of the pulmonary artery. - In coarctation of the aorta, the left ventricle works against increased afterload, leading to **concentric LV hypertrophy**, which can result in this CXR finding. *Ejection systolic murmur* - An **ejection systolic murmur** is commonly heard in coarctation of aorta due to turbulent flow across the narrowed segment. - The murmur is best heard over the **left infraclavicular area and back** (between the scapulae). - Associated aortic stenosis or bicuspid aortic valve (present in 50-85% of coarctation cases) can also produce an ejection systolic murmur at the aortic area.

Q: A previously healthy patient, presents with dyspnea and low grade fever since 4 months. His lungs are clear. JVP is normal. ECG showed low voltage complexes. What is the possible diagnosis?

Tuberculous pericardial effusion. ***Tuberculous pericardial effusion*** - The combination of **dyspnea**, **low-grade fever** for 4 months, and **low voltage complexes on ECG** strongly suggests a pericardial effusion, which is often tuberculous in endemic areas, especially with chronic symptoms. - While JVP is normal here, a large effusion can lead to cardiac tamponade with elevated JVP later; current findings are consistent with an evolving effusion. *Syphilitic aortic aneurysm* - This typically presents with symptoms related to **aortic insufficiency** or compression of surrounding structures, often without fever unless complicated by infection. - **ECG low voltage** is not a characteristic feature of an uncomplicated syphilitic aortic aneurysm. *Hypertrophic cardiomyopathy* - Characterized by **ventricular hypertrophy** and often presents with dyspnea, but typically without fever or low voltage ECG unless a significant comorbid condition exists. - The disease is usually asymptomatic for years and the hypertrophy is often visible on ECG by **increased voltage or S-waves**. *Rheumatic mitral stenosis* - This condition involves **valvular heart disease** leading to dyspnea due to pulmonary congestion, but usually through a history of acute rheumatic fever. - **Low-grade fever** for several months and **low voltage ECG** are not typical findings for isolated rheumatic mitral stenosis.

Q: The ECG shows a heart rate of 40 bpm, left axis deviation, and QRS duration >120 msec. There are deep monophasic S waves in V1-V3, broad monophasic R waves in lateral leads I, aVL, V5-V6, and absent Q waves in lateral leads with M shaped notch in peak of R wave in V5-V6. What is the diagnosis?

LBBB. ***LBBB*** - The ECG criteria for **LBBB** include a **QRS duration >120 msec** (broad QRS), a **broad, monophasic R wave** or "M-shaped" R wave (sometimes called rabbit ears) in **lateral leads (I, aVL, V5-V6)** signifying delayed activation of the left ventricle, and **deep S waves in V1-V3**. - The presence of **left axis deviation** can also be associated with LBBB, although not a primary diagnostic criterion. The absence of Q waves in lateral leads further supports delayed septal activation. *RBBB* - **RBBB** is characterized by a widened QRS complex (>120 msec) with an **RSR' pattern (M-shaped)** in leads **V1 and V2**, representing delayed right ventricular activation. - It typically presents with a **wide, slurred S wave in lateral leads (I, aVL, V5-V6)**, which is opposite to the findings described in the question. *Left anterior fascicular block* - **Left anterior fascicular block (LAFB)** is characterized by **left axis deviation (usually -45 to -90 degrees)** and a **normal QRS duration** (<120 msec), along with an absent Q wave and tall r wave in aVL, and a qR pattern in lead I. - It does not involve significant QRS widening or the specific morphology (broad R waves in lateral leads, deep S waves in V1-V3) seen in this ECG. *Left posterior fascicular block* - **Left posterior fascicular block (LPFB)** is rare and is characterized by **right axis deviation** and a **normal QRS duration** (<120 msec). - It does not present with the specific wide QRS and characteristic QRS morphology in precordial and lateral leads observed in this ECG tracing.

Q: A 30-year-old lady with scleroderma presents with progressive dyspnea on exertion. Which of the following is incorrect about the ECG finding?

Heart rate of 75 bpm. ***Heart rate of 75 bpm*** - This ECG shows a heart rate of approximately 100 bpm (one large box is 0.2 seconds; 300/3 = 100). Therefore, a heart rate of 75 bpm is **incorrect**. - The rhythm is generally regular, and the calculation of heart rate involves counting the number of R waves in a 6-second strip and multiplying by 10, or by dividing 300 by the number of large squares between R waves. *Right axis deviation* - The QRS complex in lead I is predominantly negative, and in aVF it is predominantly positive, which indicates **right axis deviation**. - Right axis deviation suggests possible **right ventricular hypertrophy** or strain, consistent with pulmonary hypertension which can occur in scleroderma. *T wave inversion in V1-V3* - The ECG clearly shows **T-wave inversions** in leads V1, V2, and V3. - This pattern can be suggestive of **right ventricular strain** or hypertrophy, commonly seen in pulmonary hypertension. *rSR' pattern in V1* - In lead V1, there is a small initial r wave, followed by an S wave, and then a larger R' wave, forming an **rSR' pattern**. - This morphology is characteristic of an **incomplete right bundle branch block (IRBBB)**, which is often associated with right ventricular volume or pressure overload, such as in pulmonary hypertension.

Question 1

Chest X-ray was performed on a patient with malar flush and effort intolerance. All are true about the condition shown in the figure except:

Accepted Answer

Presystolic accentuation becomes louder with atrial fibrillation

Answer

Straightening of left heart border

Answer

Pressure half-time is used to assess severity on Doppler

Answer

Pulmonary apoplexy

Question 2

Which procedure is being performed in the image shown?

Accepted Answer

Percutaneous mitral balloon valvotomy

Answer

Percutaneous aortic balloon valvuloplasty

Answer

Percutaneous mitral valve repair

Answer

Percutaneous coronary intervention

Question 3

A 65-year-old diabetic presents with extensive sweating and dizziness. The ECG is shown below. What is the diagnosis?

Accepted Answer

Anterior wall MI

Answer

Hypoglycemia

Answer

Hypoglycemic unawareness

Answer

Inferior wall MI

Question 4

All are associated with pulse being checked in the image except:

Accepted Answer

Decreased LV end diastolic pressure

Answer

Durozie's sign

Answer

Early diastolic murmur

Answer

Pulsus bisferiens

Question 5

ECG shows which electrolyte abnormality?

Accepted Answer

Hyperkalemia

Answer

Hypocalcemia

Answer

Hypercalcemia

Answer

Hypokalemia

Question 6

Comment on the diagnosis of the patient?

Accepted Answer

Ventricular flutter

Answer

Ventricular tachycardia

Answer

Ventricular fibrillation

Answer

Electromechanical dissociation

Question 7

CXR was done for a 15-year-old boy with low cardiac output. Which is incorrect about the patient?

Accepted Answer

Carey Coombs murmur

Answer

Reverse split S2

Answer

Straightening of left heart border

Answer

Ejection systolic murmur

Question 8

A previously healthy patient, presents with dyspnea and low grade fever since 4 months. His lungs are clear. JVP is normal. ECG showed low voltage complexes. What is the possible diagnosis?

Accepted Answer

Tuberculous pericardial effusion

Answer

Syphilitic aortic aneurysm

Answer

Hypertrophic cardiomyopathy

Answer

Rheumatic mitral stenosis

Question 9

The ECG shows a heart rate of 40 bpm, left axis deviation, and QRS duration >120 msec. There are deep monophasic S waves in V1-V3, broad monophasic R waves in lateral leads I, aVL, V5-V6, and absent Q waves in lateral leads with M shaped notch in peak of R wave in V5-V6. What is the diagnosis?

Accepted Answer

LBBB

Answer

RBBB

Answer

Left anterior fascicular block

Answer

Left posterior fascicular block

Question 10

A 30-year-old lady with scleroderma presents with progressive dyspnea on exertion. Which of the following is incorrect about the ECG finding?

Accepted Answer

Heart rate of 75 bpm

Answer

Right axis deviation

Answer

T wave inversion in V1-V3

Answer

rSR' pattern in V1

Cardiology — MCQs

Cardiology — MCQs

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