Cardiology Practice Questions

Q: All of the following statements about Tetralogy of Fallot are true, EXCEPT?

The first heart sound is soft. In Tetralogy of Fallot (TOF), the **First Heart Sound (S1) is typically normal**, not soft. S1 is produced by the closure of the mitral and tricuspid valves; since left ventricular pressure and valvular function are generally preserved in TOF, S1 remains normal. ### Explanation of Options: * **Option D (Correct - False Statement):** S1 is normal. A soft S1 is usually associated with conditions like mitral regurgitation or a long PR interval, which are not features of TOF. * **Option A (True):** JVP is normal because there is no right heart failure in uncomplicated TOF. The Right Ventricle (RV) decompresses into the aorta via the large ventricular septal defect (VSD), preventing venous congestion. * **Option B (True):** The Second Heart Sound (S2) is **single and loud**. The pulmonary component (P2) is soft or inaudible due to the low pressure in the pulmonary artery and the stenotic valve. The audible sound is primarily the aortic component (A2), which is loud because the aorta is anteriorly displaced (overriding). * **Option C (True):** The murmur in TOF is an **ejection systolic murmur** heard at the left 3rd intercostal space. Crucially, this murmur originates from **Infundibular Pulmonary Stenosis**, not the VSD. In TOF, the VSD is large and non-restrictive (silent). ### High-Yield Clinical Pearls for NEET-PG: * **The "Tet" Spell:** Characterized by hyperpnea and cyanosis; managed by the knee-chest position (increases systemic vascular resistance). * **X-ray Finding:** "Coeur en sabot" (Boot-shaped heart) due to an upturned apex (RV hypertrophy) and a concave pulmonary segment. * **ECG:** Shows Right Axis Deviation and Right Ventricular Hypertrophy (RVH). * **Key Rule:** The severity of cyanosis is inversely proportional to the intensity of the murmur. A softer murmur indicates more severe obstruction.

Q: Which of the following is NOT a clinical feature of ostium secundum type of atrial septal defect?

Occurrence of congestive failure in childhood. **Explanation:** **Atrial Septal Defect (ASD) - Ostium Secundum** is the most common type of ASD. Understanding its hemodynamics is key to answering this question. **1. Why Option A is the correct answer (The "NOT" feature):** In ASD, the pressure gradient between the left and right atria is low. Consequently, the shunt is relatively small initially, and the right ventricle (RV) is highly compliant. This prevents a rapid volume overload. Therefore, **congestive heart failure (CHF) is extremely rare in childhood.** CHF typically only develops in the 3rd or 4th decade of life once pulmonary hypertension or reduced RV compliance sets in. If a child with an isolated pretricuspid shunt presents with CHF, one should suspect a Large VSD or PDA instead. **2. Analysis of Incorrect Options:** * **Option B (Atrial Arrhythmias):** Chronic right atrial enlargement leads to stretching of the conduction pathways. This commonly results in atrial flutter or fibrillation, usually in adulthood. * **Option C (Wide and Fixed S02):** This is the **hallmark** of ASD. The split is "wide" due to delayed closure of the pulmonary valve (RV volume overload) and "fixed" because respiratory changes in venous return are equalized across the defect, maintaining a constant stroke volume. * **Option D (Mid-diastolic rumble):** Large shunts create "relative tricuspid stenosis" as a massive amount of blood flows across the tricuspid valve during diastole, heard best at the lower left sternal border. **High-Yield Clinical Pearls for NEET-PG:** * **Murmur:** The systolic murmur in ASD is NOT due to flow across the defect (no pressure gradient) but due to increased flow across the **pulmonary valve** (Relative Pulmonary Stenosis). * **ECG:** Secundum ASD shows **Right Axis Deviation (RAD)** and RBBB; Primum ASD shows **Left Axis Deviation (LAD)**. * **Chest X-ray:** Shows "hilar dance" (increased pulmonary plethora).

Q: Which of the following is NOT a feature of Kawasaki disease?

Thrombocytopenia. **Explanation:** Kawasaki Disease (KD) is an acute, febrile, medium-vessel vasculitis primarily affecting children under 5 years of age. **Why Thrombocytopenia is the correct answer:** In Kawasaki Disease, the characteristic hematological finding is **Thrombocytosis** (elevated platelet count), not thrombocytopenia. Platelet counts typically begin to rise in the second week (subacute phase), often exceeding 1 million/mm³. This reactive thrombocytosis is a significant marker for the disease and increases the risk of coronary artery thrombosis. **Analysis of Incorrect Options:** * **Cervical Lymphadenopathy:** This is one of the five major clinical criteria. It is typically unilateral, non-fluctuant, and >1.5 cm in diameter. * **Strawberry Tongue:** This is a classic sign of oropharyngeal mucosal involvement. It occurs due to prominent papillae on an erythematous base. * **Perianal Peeling:** While periungual (fingertip) desquamation is more famous, **perianal desquamation** is a highly specific early sign occurring in the acute phase (often within the first 5 days). **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Criteria:** Fever for ≥5 days plus 4 out of 5: (1) Bilateral non-exudative conjunctivitis, (2) Oral mucosal changes, (3) Extremity changes (edema/erythema/peeling), (4) Polymorphous rash, (5) Cervical lymphadenopathy. * **Cardiac Complication:** Coronary artery aneurysms are the most dreaded complication. Echocardiography is mandatory. * **Treatment:** High-dose IVIG (2g/kg) plus Aspirin. Note: This is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye’s syndrome. * **Incomplete Kawasaki:** Suspect in infants with prolonged fever and fewer than 4 criteria; elevated ESR/CRP are key markers.

Q: Which of the following is NOT a major criterion for the clinical diagnosis of congenital heart disease?

Abnormal chest X-ray. In pediatric cardiology, the clinical diagnosis of significant congenital heart disease (CHD) is primarily based on **Major Clinical Criteria**. These criteria are highly specific indicators of structural or functional heart disease that necessitate urgent evaluation. ### **Why "Abnormal chest X-ray" is the correct answer:** While a chest X-ray (CXR) is a vital diagnostic tool to assess cardiomegaly or pulmonary vascularity, it is considered a **minor or supportive finding**, not a major clinical criterion. Many neonates have an "abnormal" looking cardiac silhouette due to a large thymus, and conversely, some significant CHDs (like TGA) may initially present with a relatively normal-sized heart. Therefore, an abnormal CXR alone is not definitive for a clinical diagnosis of CHD. ### **Analysis of Incorrect Options (Major Criteria):** * **Diastolic Murmur:** Any diastolic murmur in a child is **always pathological** and is a major criterion. Unlike systolic murmurs, which can be "innocent," diastolic murmurs indicate structural issues like valvular regurgitation or shunts. * **Cyanosis:** Central cyanosis (not peripheral acrocyanosis) in a newborn is a hallmark of right-to-left shunts (Cyanotic CHD) and is a major clinical sign. * **Congestive Cardiac Failure (CCF):** Clinical signs of heart failure (tachycardia, tachypnea, hepatomegaly) in an infant are major indicators of underlying structural defects, such as large VSDs or PDA. ### **NEET-PG High-Yield Pearls:** * **Major Criteria for CHD:** 1. Cyanosis, 2. Diastolic murmur, 3. Congestive heart failure, 4. Loud/Single S2, 5. Systolic murmur Grade ≥3/6. * **Most common CHD:** VSD (overall); Bicuspid Aortic Valve (most common congenital heart anomaly). * **Most common Cyanotic CHD:** Tetralogy of Fallot (after 1 year of age); TGA (most common in the neonatal period). * **Innocent Murmurs:** Usually mid-systolic, Grade <3/6, and change with position (e.g., Still’s murmur).

Q: Which of the following features on X-ray chest can differentiate an Atrial Septal Defect (ASD) from a Ventricular Septal Defect (VSD)?

Enlarged Left Atrium. **Explanation:** The key to differentiating **Atrial Septal Defect (ASD)** from **Ventricular Septal Defect (VSD)** on a chest X-ray lies in identifying which cardiac chambers are dilated. **1. Why "Enlarged Left Atrium" is the correct answer:** In a **VSD**, the left-to-right shunt occurs at the ventricular level. The extra blood volume returns from the lungs into the left atrium and then into the left ventricle, leading to **Left Atrial (LA) and Left Ventricular (LV) enlargement**. In an **ASD**, the shunt occurs at the atrial level. The extra blood flows from the left atrium directly into the right atrium. Consequently, the left atrium decompresses into the right side and **does not enlarge**. Therefore, the presence of LA enlargement on an X-ray (e.g., double atrial shadow, splaying of the carina) strongly suggests VSD (or PDA) rather than ASD. **2. Why other options are incorrect:** * **Pulmonary Plethora:** This refers to increased pulmonary vascular markings. It is seen in **both** ASD and VSD due to the left-to-right shunt increasing pulmonary blood flow. * **Enlarged Pulmonary Artery:** Both conditions involve increased flow to the lungs, leading to a prominent pulmonary conflux and dilated central pulmonary arteries. * **Enlarged Aorta:** In both ASD and VSD, the aorta is typically **small or normal** because blood is shunted away from the systemic circulation into the pulmonary circulation. (A large aorta is characteristic of Patent Ductus Arteriosus). **High-Yield Clinical Pearls for NEET-PG:** * **ASD:** Characterized by Right Atrial (RA) and Right Ventricular (RV) enlargement. The LA is **normal**. * **VSD:** Characterized by LA and LV enlargement. It is the most common congenital heart disease. * **PDA:** Characterized by LA and LV enlargement **plus** a prominent/enlarged aortic knuckle. * **Eisenmenger Syndrome:** Look for "pruning" of peripheral vessels (dilated central arteries with abrupt narrowing).

Q: An infant presents with cardiac failure. Examination reveals a weaker femoral pulse when compared to the radial pulse. What is the probable diagnosis?

Coarctation of the Aorta (COA). **Explanation** The clinical hallmark of **Coarctation of the Aorta (COA)** is the discrepancy between upper and lower limb pulses. In COA, there is a narrowing of the aortic lumen, typically near the insertion of the ductus arteriosus (juxtaductal). This obstruction creates high pressure proximal to the narrowing (supplying the arms via the subclavian arteries) and low pressure distal to it (supplying the lower limbs). Consequently, the radial pulse is strong, while the **femoral pulse is weak and delayed** (radio-femoral delay). In infants, this increased afterload can lead to acute left-sided heart failure. **Analysis of Incorrect Options:** * **Patent Ductus Arteriosus (PDA):** Characterized by a continuous machinery murmur and **bounding pulses** (water-hammer pulse) due to a wide pulse pressure, rather than a localized pulse deficit. * **Aorto-iliac Vasculitis (Takayasu Arteritis):** While it can cause pulse deficits ("pulseless disease"), it typically presents in older children or young women and is extremely rare in infants. * **Ventricular Septal Defect (VSD):** Presents with a pansystolic murmur and features of congestive heart failure, but pulses are generally equal in all four limbs. **NEET-PG High-Yield Pearls:** * **Classic Sign:** Radio-femoral delay or a blood pressure systolic difference >20 mmHg between upper and lower limbs. * **X-ray Findings:** "Figure of 3" sign (aorta) and "Rib notching" (due to collateral circulation; usually seen in children >5 years). * **Association:** Highly associated with **Turner Syndrome** (45,XO). * **Management:** Prostaglandin E1 (PGE1) is used in neonates to keep the ductus open and maintain distal perfusion until surgery.

Q: What is the treatment of a child with supraventricular tachycardia?

Adenosine. **Explanation:** Supraventricular Tachycardia (SVT) is the most common symptomatic tachyarrhythmia in children. The management depends on the hemodynamic stability of the patient. **1. Why Adenosine is the Correct Answer:** Adenosine is the **drug of choice** for the acute termination of SVT in both pediatric and adult populations. It works by transiently blocking conduction through the Atrioventricular (AV) node, effectively "resetting" the heart's rhythm. It has an extremely short half-life (<10 seconds), necessitating rapid IV push followed by a saline flush. **2. Why the Other Options are Incorrect:** * **Digoxin:** While used for long-term rate control or maintenance therapy, it has a slow onset of action and is never used for the acute termination of SVT. * **Sotalol:** A Class III antiarrhythmic used primarily for chronic prophylaxis of refractory SVT or ventricular arrhythmias. It is not a first-line agent for acute conversion. * **Flecainide:** A Class Ic antiarrhythmic used for long-term management of SVT (especially in Wolff-Parkinson-White syndrome). It carries a risk of proarrhythmia and is not used in the emergency setting. **Clinical Pearls for NEET-PG:** * **First Step:** If the child is hemodynamically stable, try **Vagal maneuvers** first (e.g., applying an ice bag to the face for 15–20 seconds in infants; Valsalva in older children). * **Unstable Patient:** If the child shows signs of shock or heart failure, the immediate treatment of choice is **Synchronized Cardioversion** (0.5 to 1 J/kg). * **Adenosine Dosage:** Initial dose is **0.1 mg/kg** (max 6 mg), which can be doubled to **0.2 mg/kg** (max 12 mg) if the first dose fails. * **ECG Finding:** SVT is characterized by a narrow QRS complex ( 220 bpm; in children, it is >180 bpm.

Q: Systolic murmur in Tetralogy of Fallot is primarily due to which of the following?

Pulmonary stenosis. **Explanation:** In Tetralogy of Fallot (TOF), the characteristic systolic murmur is a **Crescendo-Decrescendo Ejection Systolic Murmur (ESM)** heard best at the left upper sternal border. **1. Why Pulmonary Stenosis is correct:** The murmur in TOF originates from the **Right Ventricular Outflow Tract Obstruction (RVOTO)**, specifically infundibular or valvular pulmonary stenosis. The turbulence created as blood is forced through the narrowed pulmonary orifice during systole produces the ejection systolic murmur. A key clinical pearl: the intensity of this murmur is inversely proportional to the severity of the obstruction. In a "Tet Spell," the murmur actually softens or disappears because blood shunts right-to-left away from the lungs. **2. Why other options are incorrect:** * **Ventricular Septal Defect (VSD):** While TOF involves a large VSD, it is typically **non-restrictive** (equal pressures in both ventricles). Because there is no significant pressure gradient across the defect, the VSD in TOF is "silent" and does not produce a pansystolic murmur. * **Atrial Septal Defect (ASD):** An ASD is not a component of the classic Tetralogy (it is present in "Pentalogy of Fallot"). Even when present, simple ASDs do not produce a murmur; the associated murmur is usually due to increased flow across the pulmonary valve. **High-Yield NEET-PG Facts:** * **Boot-shaped heart (Coeur en sabot):** Seen on X-ray due to right ventricular hypertrophy and an upturned apex. * **Oligemic lung fields:** Due to decreased pulmonary blood flow. * **Squatting position:** Increases systemic vascular resistance (SVR), decreasing the right-to-left shunt and improving oxygenation. * **Most common cyanotic heart disease** after the first year of life.

Q: Two weeks after birth, a baby has persistent tachypnea, tachycardia, diaphoresis, and cyanosis. Workup reveals a patent ductus arteriosus. This can be closed with the use of?

Indomethacin. **Explanation:** The patency of the Ductus Arteriosus (DA) in utero is maintained by high levels of circulating **Prostaglandin E2 (PGE2)**, which acts as a vasodilator. After birth, oxygen levels rise and prostaglandin levels fall, leading to functional closure. If the DA remains patent (PDA), it causes a left-to-right shunt, leading to symptoms of heart failure as described in the vignette. **1. Why Indomethacin is correct:** Indomethacin is a potent, non-selective **Cyclooxygenase (COX) inhibitor**. By inhibiting the COX enzyme, it blocks the synthesis of prostaglandins. The reduction in PGE2 levels promotes the constriction and subsequent anatomical closure of the ductus arteriosus. **2. Analysis of Incorrect Options:** * **Acetaminophen:** While recent studies suggest intravenous paracetamol can be used to close a PDA with fewer gastrointestinal side effects than NSAIDs, **Indomethacin (or Ibuprofen)** remains the classic, first-line pharmacological standard taught for NEET-PG. * **Aspirin:** Although it is a COX inhibitor, it is not used in neonates due to the risk of **Reye’s Syndrome** and its less predictable efficacy in ductal closure compared to Indomethacin. * **Cyclosporine:** This is an immunosuppressant (calcineurin inhibitor) used in organ transplants and has no role in prostaglandin inhibition or ductal closure. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** IV Indomethacin or IV Ibuprofen are the drugs of choice for PDA closure in preterm infants. * **Contraindications:** Do not use NSAIDs if the infant has necrotizing enterocolitis (NEC), renal failure, or active bleeding. * **Keeping it Open:** If a "duct-dependent" cyanotic heart disease is present (e.g., Transposition of Great Arteries), **Alprostadil (PGE1 infusion)** is used to keep the ductus *open*. * **Murmur:** PDA is characterized by a "machinery-type" continuous murmur heard best at the left infraclavicular area.

Q: A child presents with failure to thrive. On examination, a fixed wide split S2 with a pulmonary flow murmur is noted. Echocardiography reveals a defect in the central portion of the atrial septum with left-to-right shunting. Despite counseling on nutritional improvement, the parents report no change. What is the likely diagnosis?

Ostium secundum, type of ASD. ***Ostium secundum, type of ASD*** - **Failure to thrive** not responding to nutritional counseling suggests an **organic cause**, with **left-to-right shunting** causing increased metabolic demands and poor weight gain. - **ECG** shows **right axis deviation** and **rSR′ pattern in V1** due to **right heart volume overload**, distinguishing it from other ASD types. *Ebstein anomaly* - Associated with **tricuspid regurgitation** and may present with failure to thrive or heart failure; cyanosis may or may not be present. - **ECG** shows **tall P waves**, **prolonged PR interval**, and **right bundle branch block**, not the typical ASD pattern. *Ostium primum, type of ASD* - Associated with **mitral valve abnormalities** and more severe symptoms including **congestive heart failure** in infancy. - **ECG** characteristically shows **left axis deviation** and **first-degree AV block**, unlike the right axis deviation seen here. *Sinus venosus, type of ASD* - Often associated with **partial anomalous pulmonary venous return** and typically **asymptomatic** in childhood. - **ECG** shows **superior P-axis** (negative P waves in leads II, III, aVF) due to abnormal atrial activation, differentiating it from secundum ASD.

Question 1

All of the following statements about Tetralogy of Fallot are true, EXCEPT?

Accepted Answer

The first heart sound is soft

Answer

Jugular venous pressure (JVP) is normal

Answer

The second heart sound is single

Answer

An ejection systolic murmur is heard in the third left intercostal space

Question 2

Which of the following is NOT a clinical feature of ostium secundum type of atrial septal defect?

Accepted Answer

Occurrence of congestive failure in childhood

Answer

Atrial arrhythmias

Answer

Wide and fixed splitting of the second heart sound

Answer

Mid-diastolic rumble along the left sternal border

Question 3

Which of the following is NOT a feature of Kawasaki disease?

Accepted Answer

Thrombocytopenia

Answer

Cervical lymphadenopathy

Answer

Strawberry tongue

Answer

Perianal peeling of skin/desquamation

Question 4

Which of the following is NOT a major criterion for the clinical diagnosis of congenital heart disease?

Accepted Answer

Abnormal chest X-ray

Answer

Diastolic murmur

Answer

Cyanosis

Answer

Congestive cardiac failure

Question 5

Which of the following features on X-ray chest can differentiate an Atrial Septal Defect (ASD) from a Ventricular Septal Defect (VSD)?

Accepted Answer

Enlarged Left Atrium

Answer

Pulmonary Plethora

Answer

Enlarged Pulmonary Artery

Answer

Enlarged Aorta

Question 6

An infant presents with cardiac failure. Examination reveals a weaker femoral pulse when compared to the radial pulse. What is the probable diagnosis?

Accepted Answer

Coarctation of the Aorta (COA)

Answer

Patent Ductus Arteriosus (PDA)

Answer

Aorto-illiac vasculitis

Answer

Ventricular Septal Defect (VSD)

Question 7

What is the treatment of a child with supraventricular tachycardia?

Accepted Answer

Adenosine

Answer

Digoxin

Answer

Sotalol

Answer

Flecainide

Question 8

Systolic murmur in Tetralogy of Fallot is primarily due to which of the following?

Accepted Answer

Pulmonary stenosis

Answer

Ventricular Septal Defect (VSD)

Answer

Atrial Septal Defect (ASD)

Answer

None of the above

Question 9

Two weeks after birth, a baby has persistent tachypnea, tachycardia, diaphoresis, and cyanosis. Workup reveals a patent ductus arteriosus. This can be closed with the use of?

Accepted Answer

Indomethacin

Answer

Acetaminophen

Answer

Aspirin

Answer

Cyclosporine

Question 10

A child presents with failure to thrive. On examination, a fixed wide split S2 with a pulmonary flow murmur is noted. Echocardiography reveals a defect in the central portion of the atrial septum with left-to-right shunting. Despite counseling on nutritional improvement, the parents report no change. What is the likely diagnosis?

Accepted Answer

Ostium secundum, type of ASD

Answer

Sinus venosus, type of ASD

Answer

Ostium primum, type of ASD

Answer

Ebstein anomaly

Cardiology — MCQs

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