Cardiology Practice Questions

Q: Which of the following statements regarding rheumatic nodules is false?

Tender on palpation. In Acute Rheumatic Fever (ARF), **Subcutaneous Nodules** are a major Jones criterion. The hallmark characteristic of these nodules is that they are **painless (non-tender)** and mobile. Therefore, the statement that they are "tender on palpation" is false. ### Explanation of Options: * **Option B (Correct):** Rheumatic nodules are characteristically **painless**. Tenderness is typically absent, which helps clinically distinguish them from other inflammatory nodules like Erythema Nodosum (which are very painful and usually located on the shins). * **Option A:** They are typically found over **extensor surfaces** of joints (elbows, knees, wrists), the occiput, or the spinous processes of the vertebrae. * **Option C:** There is a very strong clinical correlation between subcutaneous nodules and **severe carditis**. They rarely occur as an isolated finding and usually appear weeks after the onset of fever. * **Option D:** They are described as firm, symmetric, and small (ranging from a few millimeters to 2 cm), often likened to the size of a **pea**. ### High-Yield Clinical Pearls for NEET-PG: * **Jones Criteria:** Subcutaneous nodules are a **Major Criterion** but are the least common (occurring in <1–5% of cases). * **Histology:** They show a central zone of fibrinoid necrosis surrounded by histiocytes and fibroblasts (similar to Aschoff bodies but in extra-cardiac tissue). * **Duration:** They are transient, usually lasting 1–2 weeks, and do not leave permanent scars. * **Differential:** Unlike Rheumatoid nodules, Rheumatic nodules are smaller and shorter-lived.

Q: Of the following vasculitides, coronary artery aneurysms are most often seen in which condition?

Kawasaki disease. **Explanation:** **Kawasaki Disease (KD)** is the correct answer because it is a systemic, medium-vessel vasculitis that has a unique predilection for the coronary arteries. It is the leading cause of acquired heart disease in children in developed nations. The underlying pathophysiology involves transmural inflammation of the coronary arteries, leading to the destruction of the muscular-elastic fiber layers, which results in **coronary artery aneurysms (CAAs)** in approximately 20–25% of untreated cases. **Analysis of Incorrect Options:** * **Giant Cell Arteritis:** A large-vessel vasculitis that typically affects the branches of the external carotid artery (e.g., temporal artery) in patients over 50. It rarely involves the coronary arteries. * **Wegener’s Granulomatosis (GPA):** A small-vessel vasculitis characterized by granulomatous inflammation of the respiratory tract and glomerulonephritis. While it can cause carditis, CAAs are not a hallmark feature. * **Leukocytoclastic Vasculitis:** A small-vessel vasculitis (hypersensitivity vasculitis) that primarily affects the skin, presenting as palpable purpura. It does not involve medium-sized muscular arteries like the coronaries. **NEET-PG High-Yield Pearls:** * **Diagnostic Criteria (CRASH and Burn):** **C**onjunctivitis (non-purulent), **R**ash (polymorphous), **A**denopathy (cervical, usually unilateral), **S**trawberry tongue (and oral mucosal changes), **H**ands/feet (edema/desquamation), and **Burn** (High-grade fever for ≥5 days). * **Treatment:** High-dose IVIG (2g/kg) and Aspirin. IVIG is most effective when given within the first 10 days to prevent CAAs. * **Investigation of Choice:** Echocardiography is used to screen for and monitor coronary artery involvement.

Q: Which statement is true about Erythema Marginatum in acute rheumatic fever?

It is usually associated with carditis.. **Explanation:** **Erythema Marginatum** is one of the five **Major Jones Criteria** for the diagnosis of Acute Rheumatic Fever (ARF). 1. **Why Option D is Correct:** Erythema marginatum is highly specific for ARF and is **strongly associated with carditis**. It often appears simultaneously with or shortly after the onset of cardiac involvement. While it occurs in less than 5% of ARF patients, its presence is a significant clinical indicator of underlying rheumatic heart disease. 2. **Why Other Options are Incorrect:** * **Option A:** The rash is characteristically **non-pruritic** (not itchy) and painless. It is an evanescent, pink, ring-like eruption with clear centers and "serpiginous" (snake-like) borders. * **Option B:** It primarily involves the **trunk and proximal extremities**. Crucially, it **spares the face**, which helps differentiate it from other pediatric rashes. * **Option C:** It is actually an **uncommon** manifestation, occurring in <5% of cases. Polyarthritis and Carditis are much more frequent presentations. **High-Yield Clinical Pearls for NEET-PG:** * **Nature:** It is a "transient" or "evanescent" rash; it can appear and disappear within hours and is often brought out by heat (e.g., a warm bath). * **Jones Criteria Mnemonic (Major):** **JO**ints (Polyarthritis), **♥** (Carditis), **N**odules (Subcutaneous), **E**rythema marginatum, **S**ydenham chorea. * **Differential Diagnosis:** Do not confuse it with *Erythema Chronicum Migrans* (Lyme disease) or *Erythema Multiforme* (Target lesions).

Q: A newborn baby develops cyanosis on day three of life. On auscultation, there is a systolic murmur. Echocardiography reveals a cyanotic heart disease in the baby. Which one of the following drugs can be administered to prolong the life of the baby pending intervention?

Prostaglandin E1. **Explanation:** The clinical presentation of a newborn developing cyanosis on day three of life suggests a **Ductal-Dependent Cyanotic Heart Disease** (e.g., Transposition of the Great Arteries, Pulmonary Atresia, or Tricuspid Atresia). In these conditions, systemic or pulmonary circulation depends on the patency of the **Ductus Arteriosus**. As the ductus begins to close physiologically within 48–72 hours of birth, the baby develops sudden, severe cyanosis. **Why Prostaglandin E1 (PGE1) is correct:** PGE1 (Alprostadil) is a potent vasodilator that prevents the closure of or reopens the Ductus Arteriosus. By maintaining a **Patent Ductus Arteriosus (PDA)**, it allows for essential mixing of oxygenated and deoxygenated blood or ensures pulmonary blood flow, stabilizing the infant until surgical intervention (like a shunt or arterial switch) can be performed. **Why the other options are incorrect:** * **Indomethacin & Ibuprofen:** These are NSAIDs that act as **Cyclooxygenase (COX) inhibitors**. They inhibit prostaglandin synthesis and are used to **close** a PDA in preterm infants. Administering these would be fatal in a ductal-dependent lesion as it would accelerate ductal closure. * **Propranolol:** This is a beta-blocker used in the management of "Tet spells" in Tetralogy of Fallot to relax the infundibular spasm; it has no role in maintaining ductal patency. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice for PDA closure:** Ibuprofen (preferred over Indomethacin due to fewer renal side effects). * **Side effect of PGE1 infusion:** Apnea (most common), fever, and hypotension. Always be prepared for intubation. * **Ductal-dependent systemic flow:** Coarctation of aorta, Hypoplastic Left Heart Syndrome (HLHS). * **Ductal-dependent pulmonary flow:** Pulmonary atresia, Critical pulmonary stenosis.

Q: During a regular check-up of an 8-year-old child, you note a loud first heart sound with a fixed and widely split-second heart sound at the upper left sternal border that does not change with respirations. The patient is otherwise active and healthy. Which of the following heart lesions most likely explains these findings?

Atrial septal defect (ASD). **Explanation:** The clinical presentation of a **fixed, widely split second heart sound (S2)** in an asymptomatic child is the classic hallmark of an **Atrial Septal Defect (ASD)**, specifically the ostium secundum type. **1. Why ASD is correct:** * **Wide Splitting:** In ASD, the left-to-right shunt increases the volume of blood in the right ventricle (RV). This prolongs RV ejection time, delaying the closure of the pulmonary valve (P2) relative to the aortic valve (A2). * **Fixed Splitting:** Normally, S2 splitting increases during inspiration. In ASD, the split remains constant because the large communication between the atria equalizes the respiratory variations in venous return between the left and right sides of the heart. * **Auscultation:** The loud S1 is due to increased flow across the tricuspid valve, and a mid-systolic murmur (not mentioned but common) may be heard at the upper left sternal border due to increased flow across the pulmonary valve. **2. Why other options are incorrect:** * **VSD:** Typically presents with a harsh holosystolic murmur at the lower left sternal border. S2 splitting may be wide but is **not fixed**. * **Tricuspid Regurgitation:** Presents with a holosystolic murmur at the lower left sternal border that increases with inspiration (Carvallo’s sign). It does not cause a fixed split S2. * **Tetralogy of Fallot:** Characterized by a **single S2** (due to an anteriorly displaced aorta and a faint/absent P2) and a harsh systolic ejection murmur from pulmonary stenosis. **Clinical Pearls for NEET-PG:** * **Most common ASD:** Ostium secundum (75%). * **ECG Findings:** Right axis deviation and RSR' pattern in V1 (incomplete RBBB). * **Chest X-ray:** Cardiomegaly with increased pulmonary vascular markings. * **Paradoxical Embolism:** A significant risk where a systemic venous embolus crosses the ASD to cause a stroke.

Q: Which of the following statements about the ductus arteriosus is true?

Its patency may cause a machinery murmur.. **Explanation:** The **Ductus Arteriosus (DA)** is a vital fetal vascular connection between the pulmonary artery and the descending aorta, allowing blood to bypass the non-functional fetal lungs. **Why Option D is Correct:** When the ductus remains patent (Patent Ductus Arteriosus - PDA) after birth, blood shunts from the high-pressure aorta to the lower-pressure pulmonary artery. Because the pressure gradient between the aorta and pulmonary artery persists throughout both systole and diastole, it produces a characteristic **continuous "machinery-like" murmur**, best heard at the left infraclavicular area. **Why Other Options are Incorrect:** * **Option A:** Functional closure occurs within 10–15 hours of birth due to smooth muscle contraction. However, **anatomic closure** (fibrosis) takes much longer, usually **2–3 weeks** of life. * **Option B:** The remnant of the ductus arteriosus is the **ligamentum arteriosum**. The ligamentum venosum is the remnant of the *ductus venosus*. * **Option C:** Prostaglandins (PGE1 and PGE2) maintain patency. Closure is actually induced by the **withdrawal of prostaglandins** and the rise in arterial oxygen tension ($PaO_2$) after the first breath. **High-Yield NEET-PG Pearls:** * **Drug of Choice for Closure:** Intravenous **Indomethacin** or **Ibuprofen** (NSAIDs that inhibit prostaglandin synthesis). * **Drug to Maintain Patency:** **Alprostadil** (PGE1 infusion), used in cyanotic heart diseases (ductal-dependent circulation). * **Association:** PDA is strongly associated with **Congenital Rubella Syndrome** and **prematurity**. * **Pulse finding:** "Bounding pulses" with a wide pulse pressure are common in large PDAs.

Q: What is the commonest cause of an enlarged cardiac shadow in a chest X-ray of a child?

Rheumatic carditis. **Explanation:** The correct answer is **Rheumatic carditis**. In the pediatric population, particularly in developing countries like India, Acute Rheumatic Fever (ARF) remains a leading cause of acquired heart disease. Rheumatic carditis is a pancarditis involving the endocardium, myocardium, and pericardium. The enlargement of the cardiac shadow on a chest X-ray is primarily due to **myocarditis** (leading to cardiac chamber dilation) and/or significant **valvular regurgitation** (most commonly Mitral Regurgitation), which causes left atrial and ventricular enlargement. **Analysis of Incorrect Options:** * **Patent Ductus Arteriosus (PDA):** While a large PDA can cause left-sided heart enlargement due to volume overload, it is a congenital cause and less common than the systemic burden of rheumatic disease in older children. * **Coarctation of the Aorta:** This typically presents with left ventricular hypertrophy (LVH). On X-ray, the heart size often remains normal for a long time (concentric hypertrophy) unless heart failure develops. The classic sign is the "3" sign or rib notching, not generalized cardiomegaly. * **Pericarditis:** While pericardial effusion causes a "water-bottle" shaped enlarged shadow, isolated viral or idiopathic pericarditis is statistically less frequent than rheumatic carditis as a cause of cardiomegaly in clinical practice. **NEET-PG High-Yield Pearls:** * **Most common valve involved in ARF:** Mitral valve (followed by the Aortic valve). * **Earliest sign of ARF on X-ray:** Cardiomegaly (due to myocarditis or MR). * **Carey Coombs Murmur:** A mid-diastolic murmur heard in acute rheumatic carditis due to functional mitral stenosis (mitral valvulitis). * **Gold Standard for Diagnosis:** Jones Criteria (Revised). Cardiomegaly is a major criterion under "Carditis."

Q: The presence of left axis deviation beyond -30 degrees in an electrocardiogram suggests which of the following?

Ostium primum ASD. **Explanation:** In pediatric cardiology, the axis on an ECG is a critical diagnostic clue. A **Left Axis Deviation (LAD)** beyond -30° in a patient with an Atrial Septal Defect (ASD) is a classic hallmark of an **Ostium Primum ASD** (part of the Endocardial Cushion Defects). **1. Why Ostium Primum ASD is correct:** In Ostium Primum defects, there is a deficiency in the atrioventricular septum. This causes an anatomical displacement of the **AV node** (positioned posteriorly) and the **Bundle of His**. The left bundle branch, specifically the left superior fascicle, is activated prematurely, leading to a "superior" or leftward axis (typically between -30° and -90°). **2. Why the other options are incorrect:** * **Fossa Ovalis (Ostium Secundum) ASD:** This is the most common type of ASD. It typically presents with **Right Axis Deviation (RAD)** and Right Ventricular Hypertrophy (RVH) due to right-sided volume overload. * **Sinus Venosus ASD:** This is often associated with a **leftward shift of the P-axis** (inverted P waves in inferior leads) because the normal pacemaker site near the SVC is displaced, but the QRS axis is usually normal or shows RAD. * **Coronary Sinus ASD:** This rare defect generally presents with a normal axis or RAD, similar to secundum defects. **Clinical Pearls for NEET-PG:** * **The "Goose Neck" Deformity:** On angiography, Ostium Primum ASD shows a narrowed left ventricular outflow tract known as the "Goose Neck" appearance. * **Triad of Ostium Primum:** LAD + RBBB (Right Bundle Branch Block) + RVH. * **Association:** Ostium Primum ASDs are frequently associated with a **cleft in the anterior mitral leaflet**, leading to mitral regurgitation. * **Down Syndrome:** Strongly associated with Endocardial Cushion Defects (AVSDs), where LAD is a pathognomonic ECG finding.

Q: All the following are major criteria for the diagnosis of rheumatic fever except?

Fever. The diagnosis of Acute Rheumatic Fever (ARF) is based on the **Revised Jones Criteria**. To make a diagnosis, one requires evidence of a preceding Group A Streptococcal infection plus either two major criteria or one major and two minor criteria [1]. ### Why "Fever" is the Correct Answer **Fever** is classified as a **Minor Criterion**, not a major one. While it is a common presenting symptom of ARF, it lacks the diagnostic specificity required to be a major manifestation. ### Explanation of Major Criteria (Incorrect Options) The major criteria are represented by the mnemonic **J♥NES**: * **J (Joints): Polyarthritis.** This is typically migratory, affecting large joints (knees, ankles, elbows, wrists). It is the most common major manifestation. * **♥ (Carditis):** This is the most serious manifestation and can involve the endocardium, myocardium, or pericardium (pancarditis) [1]. It is the only manifestation that leads to chronic valvular heart disease [2]. * **N (Nodules): Subcutaneous nodules.** These are firm, painless, and usually found over bony prominences or extensor tendons. * **E (Erythema marginatum):** A characteristic non-pruritic, evanescent, pink rash with serpiginous (snake-like) borders, primarily on the trunk and limbs. * **S (Sydenham’s Chorea):** Delayed neurological manifestation characterized by involuntary, purposeless movements and emotional lability. ### NEET-PG Clinical Pearls * **Minor Criteria:** Fever, Arthralgia (joint pain without inflammation), elevated ESR/CRP, and prolonged PR interval on ECG. * **High-Yield Note:** In high-risk populations, **monoarthritis** or **polyarthralgia** can be considered major criteria (2015 AHA revision). * **Essential Requirement:** Evidence of preceding Strep infection (elevated ASO titer, positive throat culture, or Rapid Antigen Test) is mandatory for the initial diagnosis [1].

Q: Which of the following is a component of Tetralogy of Fallot?

Ventricular Septal Defect (VSD). **Explanation:** Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. It is characterized by four classic anatomical components resulting from the **anterior and cephalad deviation of the infundibular (outflow tract) septum**. 1. **Why Option A is Correct:** **Ventricular Septal Defect (VSD)** is one of the four cardinal features. It is typically a large, non-restrictive malalignment defect located in the membranous septum. The other three components are **Right Ventricular Outflow Tract Obstruction (RVOTO)** (usually infundibular stenosis), **Overriding of the Aorta**, and **Right Ventricular Hypertrophy (RVH)**. 2. **Why Other Options are Incorrect:** * **Option B (Left Ventricular Hypertrophy):** In TOF, the right ventricle faces high pressure due to pulmonary stenosis and the systemic pressure transmitted through the VSD. This leads to **Right Ventricular Hypertrophy**, not left. The left ventricle is often normal or small in size. * **Option C (Left Axis Deviation):** Due to the dominance of the right ventricle, the ECG in TOF characteristically shows **Right Axis Deviation (RAD)** and RVH. Left Axis Deviation is a classic finding in Tricuspid Atresia or AV Canal Defects, making it a high-yield "negative" finding for TOF. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray Finding:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex (RVH) and a concave pulmonary segment. * **Management:** Squatting increases systemic vascular resistance (SVR), reversing the right-to-left shunt and improving oxygenation during "Tet spells." * **Murmur:** The murmur in TOF is due to **pulmonary stenosis** (crescendo-decrescendo systolic ejection murmur), NOT the VSD. A softer murmur indicates a more severe spell.

Question 1

Which of the following statements regarding rheumatic nodules is false?

Accepted Answer

Tender on palpation

Answer

Found over extensor surfaces

Answer

Associated with carditis

Answer

Pea-sized nodules

Question 2

Of the following vasculitides, coronary artery aneurysms are most often seen in which condition?

Accepted Answer

Kawasaki disease

Answer

Giant cell arteritis

Answer

Wegener's granulomatosis

Answer

Leukocytoclastic vasculitis

Question 3

Which statement is true about Erythema Marginatum in acute rheumatic fever?

Accepted Answer

It is usually associated with carditis.

Answer

It is pruritic.

Answer

It commonly involves the face.

Answer

It is a common manifestation of acute rheumatic fever.

Question 4

A newborn baby develops cyanosis on day three of life. On auscultation, there is a systolic murmur. Echocardiography reveals a cyanotic heart disease in the baby. Which one of the following drugs can be administered to prolong the life of the baby pending intervention?

Accepted Answer

Prostaglandin E1

Answer

Indomethacin

Answer

Ibuprofen

Answer

Propranolol

Question 5

During a regular check-up of an 8-year-old child, you note a loud first heart sound with a fixed and widely split-second heart sound at the upper left sternal border that does not change with respirations. The patient is otherwise active and healthy. Which of the following heart lesions most likely explains these findings?

Accepted Answer

Atrial septal defect (ASD)

Answer

Ventricular septal defect (VSD)

Answer

Isolated tricuspid regurgitation

Answer

Tetralogy of Fallot

Question 6

Which of the following statements about the ductus arteriosus is true?

Accepted Answer

Its patency may cause a machinery murmur.

Answer

It undergoes anatomic closure within 24 hours of birth.

Answer

It forms the ligamentum venosum in later life.

Answer

It is induced to close by high levels of prostaglandins.

Question 7

What is the commonest cause of an enlarged cardiac shadow in a chest X-ray of a child?

Accepted Answer

Rheumatic carditis

Answer

Patent Ductus Arteriosus (PDA)

Answer

Coarctation of the Aorta

Answer

Pericarditis

Question 8

The presence of left axis deviation beyond -30 degrees in an electrocardiogram suggests which of the following?

Accepted Answer

Ostium primum ASD

Answer

Fossa ovalis ASD

Answer

Sinus venosus ASD

Answer

Coronary sinus ASD

Question 9

All the following are major criteria for the diagnosis of rheumatic fever except?

Accepted Answer

Fever

Answer

Carditis

Answer

Polyarthritis

Answer

Erythema marginatum

Question 10

Which of the following is a component of Tetralogy of Fallot?

Accepted Answer

Ventricular Septal Defect (VSD)

Answer

Left Ventricular Hypertrophy

Answer

Left Axis Deviation

Answer

All of the above

Cardiology — MCQs

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