Cardiology Practice Questions

Q: A 12-year-old child with a history of rheumatic heart disease presents with a one-month history of low-grade fever. She has pallor, splenomegaly, clubbing, and microscopic hematuria. What is the most important diagnostic test to perform?

Blood culture. **Explanation:** The clinical presentation of a child with pre-existing **Rheumatic Heart Disease (RHD)** presenting with prolonged low-grade fever, splenomegaly, clubbing, and microscopic hematuria is a classic textbook description of **Infective Endocarditis (IE)**. In any patient with structural heart disease and unexplained fever, IE must be ruled out first. **Why Blood Culture is the correct answer:** Blood culture is the **"Gold Standard"** and a **Major Criterion** according to the **Modified Duke Criteria** for diagnosing IE. It identifies the causative organism and determines antibiotic sensitivity, which is critical for life-saving treatment. Microscopic hematuria in this patient (focal glomerulonephritis) and clubbing are peripheral "immunological phenomena" strongly suggestive of IE. **Why other options are incorrect:** * **ASO Titer:** This is used to diagnose a recent Group A Streptococcal infection (Acute Rheumatic Fever). While the patient has a history of RHD, the current subacute presentation points toward endocarditis, not a fresh episode of rheumatic fever. * **C-reactive Protein (CRP):** This is a non-specific marker of inflammation. While it will likely be elevated, it does not provide a definitive diagnosis or guide specific therapy. * **Urine Culture:** While the patient has hematuria, this is typically due to immune-complex mediated glomerulonephritis or embolic phenomena from the heart valves, not a primary urinary tract infection. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Duke Criteria:** Diagnosis requires 2 Major, or 1 Major + 3 Minor, or 5 Minor criteria. * **Most common organism in IE (Overall):** *Staphylococcus aureus*. * **Most common organism in Subacute IE (Native valve):** *Viridans group Streptococci*. * **Echocardiography:** The other Major Criterion is the presence of vegetation, abscess, or new valvular regurgitation on Echo (TEE is more sensitive than TTE).

Q: A 2-week-old neonate presents with central cyanosis, a grade II murmur, a single S2, and plethoric lungs. What is the most likely diagnosis?

Transposition of the great arteries (TGA). ### Explanation The correct diagnosis is **Transposition of the Great Arteries (TGA)**. **1. Why TGA is the correct answer:** TGA is the most common cause of cyanotic congenital heart disease (CCHD) presenting in the first two weeks of life. * **Cyanosis:** Due to parallel circulation where deoxygenated blood returns to the body. * **Single S2:** Because the aorta is anterior and the pulmonary artery is posterior, the closure of the aortic valve (A2) masks the pulmonary valve (P2). * **Plethoric Lungs:** Unlike many other cyanotic conditions, TGA (without pulmonary stenosis) features **increased pulmonary blood flow**, leading to pulmonary plethora on X-ray. * **Murmur:** Often absent or soft (Grade II) unless there is an associated VSD. **2. Why other options are incorrect:** * **TAPVC:** While it presents with plethoric lungs and cyanosis, it typically features a "Snowman" or "Figure-of-8" appearance on X-ray (in the supracardiac type) and usually presents slightly later or with more severe respiratory distress if obstructed. * **Tetralogy of Fallot (TOF):** Characterized by **oligemic lungs** (decreased blood flow) and a loud ejection systolic murmur due to right ventricular outflow tract obstruction. It rarely presents with severe cyanosis in the first two weeks. * **Pulmonary Atresia:** Presents with severe cyanosis and **oligemic lungs** due to the lack of blood flow to the pulmonary circuit. **3. High-Yield Clinical Pearls for NEET-PG:** * **X-ray finding in TGA:** "Egg-on-a-string" appearance (narrow mediastinum due to stress-induced thymic atrophy and malposed vessels). * **Management:** Immediate administration of **Prostaglandin E1 (Alprostadil)** to keep the ductus arteriosus open; definitive treatment is the **Arterial Switch Operation (Jatene procedure)**. * **Hyperoxic Test:** Used to differentiate cardiac cyanosis (minimal rise in $PaO_2$) from respiratory causes.

Q: Coarctation of aorta is most commonly associated with which cardiac anomaly?

Bicuspid aortic valve. **Explanation:** **1. Why Bicuspid Aortic Valve (BAV) is the correct answer:** Coarctation of the aorta (CoA) is a localized narrowing of the aortic lumen, typically occurring near the insertion of the ductus arteriosus. The most common associated congenital cardiac anomaly is a **Bicuspid Aortic Valve (BAV)**, which is present in **50% to 85%** of patients with CoA. This association is so strong that any patient diagnosed with CoA must be screened for BAV via echocardiography. Both conditions are thought to arise from related developmental defects in the migration of neural crest cells or altered hemodynamics during fetal life. **2. Why the other options are incorrect:** * **Ventricular Septal Defect (VSD):** While VSD is a common association (especially in the infantile/pre-ductal type), it occurs in roughly 25-30% of cases, making it less frequent than BAV. * **Patent Ductus Arteriosus (PDA):** PDA is frequently seen in symptomatic neonates with "pre-ductal" coarctation to maintain systemic circulation, but it is considered a compensatory or associated feature rather than the most common structural anomaly. * **Atrial Septal Defect (ASD):** ASD can occur with CoA but is significantly less common than BAV or VSD. **3. High-Yield Clinical Pearls for NEET-PG:** * **Turner Syndrome:** Approximately 15-20% of females with Turner Syndrome (45,XO) have CoA. * **Clinical Sign:** "Radio-femoral delay" and blood pressure discrepancy between upper and lower limbs. * **Chest X-ray:** Look for the **"3" sign** (indentation of the aorta) and **rib notching** (due to collateral circulation through intercostal arteries; usually involves 3rd to 8th ribs). * **Non-Cardiac Association:** **Berry Aneurysms** in the Circle of Willis (risk of subarachnoid hemorrhage).

Q: A neonate born with congenital rubella syndrome is diagnosed with patent ductus arteriosus (PDA). What is the most common cause of death in this condition?

Cardiac failure. **Explanation:** **1. Why Cardiac Failure is the Correct Answer:** In Patent Ductus Arteriosus (PDA), there is a persistent communication between the aorta and the pulmonary artery. Due to higher systemic pressure, blood shunts from **left to right**, leading to significant pulmonary over-circulation and volume overload of the left atrium and left ventricle. In neonates, especially those with large defects or associated congenital rubella syndrome, the heart is unable to compensate for this increased volume, leading to **congestive cardiac failure (CCF)**. This remains the most common cause of mortality in symptomatic PDA patients. **2. Why Other Options are Incorrect:** * **B. Respiratory Failure:** While PDA can cause pulmonary congestion and tachypnea, primary respiratory failure is usually a secondary consequence of cardiac failure rather than the direct cause of death. * **C. Infective Endocarditis:** Although PDA increases the risk of endarteritis (usually at the pulmonary end of the ductus), it is a late complication and rarely the primary cause of death in the neonatal period. * **D. Embolization:** This is more commonly associated with atrial fibrillation or valvular vegetations. In PDA, the shunt is typically left-to-right, making systemic embolization unlikely unless there is a reversal of shunt (Eisenmenger syndrome). **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Murmur:** Continuous "machinery" murmur, loudest at the left infraclavicular area. * **Pulse:** "Water-hammer" or bounding pulses due to wide pulse pressure. * **Drug of Choice:** **Indomethacin** or **Ibuprofen** (NSAIDs) are used to close a PDA in preterm neonates by inhibiting prostaglandins. * **Prostaglandin E1:** Used to keep the ductus *open* in ductal-dependent cyanotic heart diseases. * **Association:** PDA is the most common cardiac defect associated with **Congenital Rubella Syndrome**.

Q: A pressure difference of 5 mm Hg between the two upper limbs occurs in which congenital heart disease?

Supravalvular aortic stenosis. **Explanation:** The correct answer is **Supravalvular aortic stenosis (SVAS)**. **Why it is correct:** In SVAS, there is a narrowing of the ascending aorta just above the coronary ostia. The pressure difference between the two upper limbs (specifically, a higher blood pressure in the right arm compared to the left) is due to the **Coanda Effect**. The high-velocity jet of blood passing through the stenotic area is directed preferentially toward the **innominate (brachiocephalic) artery**. This leads to higher systolic pressure in the right subclavian and right carotid arteries. A pressure gradient of $\geq$ 5-10 mmHg between the arms is a classic clinical sign of SVAS. **Why the other options are incorrect:** * **Tetralogy of Fallot (TOF):** Characterized by a right-to-left shunt and decreased pulmonary blood flow. It does not typically cause a blood pressure discrepancy between the upper limbs unless there has been a previous Blalock-Taussig shunt surgery. * **Transposition of the Great Arteries (TGA):** Presents with cyanosis due to parallel circulations. While differential cyanosis can occur if a PDA is present, it does not typically cause a 5 mmHg pressure gradient between the two upper limbs. * **HOCM:** This is a dynamic subvalvular obstruction. While it causes a "jerky" pulse, the obstruction occurs within the ventricle and affects systemic output uniformly, not creating a limb-to-limb gradient. **High-Yield Pearls for NEET-PG:** * **Williams Syndrome:** SVAS is frequently associated with Williams Syndrome (deletion on chromosome 7q11), characterized by "elfin facies," intellectual disability, and **idiopathic infantile hypercalcemia**. * **Coarctation of the Aorta:** This is the most common cause of BP discrepancy between **upper and lower limbs** (radio-femoral delay). * **Differential Cyanosis:** Seen in PDA with reversal of shunt (Eisenmenger syndrome)—pink upper body, cyanotic lower body.

Q: A chest X-ray showing globular cardiomegaly with oligemic lung fields in a child is suggestive of which condition?

Ebstein's anomaly. ### Explanation **Ebstein’s Anomaly (Correct Answer)** Ebstein’s anomaly is characterized by the downward displacement of the tricuspid valve leaflets into the right ventricle, leading to "atrialization" of the ventricle. This results in a massive right atrium, which produces a **globular or "box-shaped" heart** on a chest X-ray. Because the right ventricle is small and the tricuspid regurgitation is often severe, pulmonary blood flow is significantly reduced, leading to **oligemic lung fields** (decreased vascular markings). **Analysis of Incorrect Options:** * **Tetralogy of Fallot (TOF):** Classically shows a **"boot-shaped" heart** (*coeur en sabot*). While it features oligemic lung fields, the heart size is usually normal or only mildly enlarged because the right ventricle is hypertrophied but not dilated. * **TAPVC:** In the supracardiac type, the X-ray shows a **"snowman" or "figure-of-8" appearance** due to a dilated persistent left vertical vein and SVC. Lung fields in TAPVC are typically **plethoric** (increased blood flow), not oligemic. * **PDA:** This is an acyanotic heart disease with a left-to-right shunt. It presents with **cardiomegaly and pulmonary plethora** (increased vascularity) due to increased volume returning to the left heart and lungs. **NEET-PG High-Yield Pearls:** * **Ebstein’s Anomaly:** Strongly associated with maternal **Lithium** intake during pregnancy. * **ECG Findings:** Characterized by "Himalayan" P-waves (tall, peaked) and right bundle branch block (RBBB). * **Arrhythmias:** Frequently associated with **Wolff-Parkinson-White (WPW) syndrome**. * **Auscultation:** Often features a "multi-click" or quadruple rhythm due to the abnormal tricuspid valve.

Q: A 9-month-old child born to a diabetic mother presents with tachypnea and hepatomegaly. Echocardiography showed normal cardiac morphology with asymmetric septal hypertrophy. What is the recommended treatment for this child?

Propranolol. ### Explanation The clinical presentation describes **Infant of Diabetic Mother (IDM)** with **Hypertrophic Cardiomyopathy (HCM)**, specifically presenting as **Asymmetric Septal Hypertrophy (ASH)**. In IDM, hyperinsulinemia in utero acts as an anabolic hormone, causing increased deposition of glycogen and fat in the myocardial septum. This leads to left ventricular outflow tract (LVOT) obstruction. **Why Propranolol is the Correct Answer:** * **Mechanism:** Beta-blockers like Propranolol are the drugs of choice. They decrease the heart rate (increasing diastolic filling time) and reduce myocardial contractility (negative inotropy). * **Effect:** By reducing the force of contraction, Propranolol decreases the dynamic pressure gradient across the LVOT, thereby improving cardiac output and relieving symptoms of heart failure in these specific cases. **Why Other Options are Incorrect:** * **Digoxin (Option A):** Strictly contraindicated. As a positive inotrope, it increases the force of contraction, which worsens the septal obstruction and narrows the LVOT further. * **Furosemide (Option B):** Diuretics reduce preload. In obstructive HCM, decreasing the ventricular volume makes the obstruction more severe (the walls "slap" together sooner), worsening the clinical state. * **Verapamil (Option D):** While a calcium channel blocker, it is generally avoided in infants due to the risk of profound hypotension and cardiovascular collapse. **NEET-PG High-Yield Pearls:** 1. **Prognosis:** Unlike genetic HCM, HCM in IDM is **transient**. It typically resolves spontaneously within 6–12 months as insulin levels normalize post-delivery. 2. **Management:** Most cases are asymptomatic and require only observation. Treatment (Propranolol) is reserved for symptomatic infants (tachypnea, heart failure). 3. **Avoid "ABCD":** Avoid **A**mines (Inotropes), **B**-agonists, **C**alcium channel blockers (in infants), and **D**iuretics/Digoxin.

Question 1

A 12-year-old child with a history of rheumatic heart disease presents with a one-month history of low-grade fever. She has pallor, splenomegaly, clubbing, and microscopic hematuria. What is the most important diagnostic test to perform?

Accepted Answer

Blood culture

Answer

Antistreptolysin O titer

Answer

C-reactive protein

Answer

Urine culture

Question 2

A 2-week-old neonate presents with central cyanosis, a grade II murmur, a single S2, and plethoric lungs. What is the most likely diagnosis?

Accepted Answer

Transposition of the great arteries (TGA)

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Tetralogy of Fallot (TOF)

Answer

Pulmonary atresia

Question 3

Which of the following statements regarding patent ductus arteriosus (PDA) is incorrect?

Accepted Answer

Bacterial endocarditis is more frequent with small PDAs.

Answer

Spontaneous closure occurs in some term infants.

Answer

Pulmonary hypertension can develop.

Answer

Recurrent chest infections and congestive failure may develop.

Question 4

A 10-year-old girl develops subcutaneous nodules over the skin of her arms and torso 3 weeks after a bout of acute pharyngitis. She manifests choreiform movements and begins to complain of pain in her knees and hips, particularly with movement. A friction rub is heard on auscultation of her chest. An abnormality detected by which of the following serum laboratory findings is most characteristic of the disease affecting this girl?

Accepted Answer

Anti-streptolysin O antibody titer

Answer

Antinuclear antibody titer

Answer

Creatinine level

Answer

Rapid plasma reagin test

Question 5

Coarctation of aorta is most commonly associated with which cardiac anomaly?

Accepted Answer

Bicuspid aortic valve

Answer

Atrial septal defect (ASD)

Answer

Ventricular septal defect (VSD)

Answer

Patent ductus arteriosus (PDA)

Question 6

A neonate born with congenital rubella syndrome is diagnosed with patent ductus arteriosus (PDA). What is the most common cause of death in this condition?

Accepted Answer

Cardiac failure

Answer

Respiratory failure

Answer

Infective endocarditis

Answer

Embolization

Question 7

A pressure difference of 5 mm Hg between the two upper limbs occurs in which congenital heart disease?

Accepted Answer

Supravalvular aortic stenosis

Answer

Tetralogy of Fallot (TOF)

Answer

Transposition of the Great Arteries (TGA)

Answer

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Question 8

A chest X-ray showing globular cardiomegaly with oligemic lung fields in a child is suggestive of which condition?

Accepted Answer

Ebstein's anomaly

Answer

Tetralogy of Fallot

Answer

Total anomalous pulmonary venous connection (TAPVC)

Answer

Patent ductus arteriosus (PDA)

Question 9

A two-month-old infant presents with marked respiratory distress. Examination reveals cyanosis, bilateral crepitations, heart rate of 180/min, respiratory rate of 56/min, and a liver span of 7.5 cm. The child has a history of repeated episodes of fever, cough, and respiratory distress since birth. Cardiovascular examination shows a grade III ejection systolic murmur in the left parasternal area. Chest X-ray reveals cardiomegaly with a narrow base and plethoric lung fields. What is the most likely diagnosis?

Accepted Answer

Transposition of great arteries

Answer

Congenital methemoglobinemia

Answer

Cystic fibrosis

Answer

Tetralogy of Fallot

Question 10

A 9-month-old child born to a diabetic mother presents with tachypnea and hepatomegaly. Echocardiography showed normal cardiac morphology with asymmetric septal hypertrophy. What is the recommended treatment for this child?

Accepted Answer

Propranolol

Answer

Digoxin

Answer

Furosemide

Answer

Verapamil

Cardiology — MCQs

Cardiology — MCQs

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