Cardiology Practice Questions

Q: A 15-year-old patient presents with joint swelling, a pan-systolic murmur, negative rheumatoid factor (RF), and elevated ESR. The patient also reports a recent history of sore throat and exhibits subcutaneous nodules and erythema marginatum on physical examination. What is the most likely diagnosis?

Acute rheumatic fever. **Acute rheumatic fever** - The combination of **joint swelling**, a recent **sore throat**, **pan-systolic murmur** (indicating carditis), **subcutaneous nodules**, and **erythema marginatum** meets the **Jones criteria** for acute rheumatic fever [1]. - An **elevated ESR** is a common inflammatory marker, and a **negative rheumatoid factor** helps differentiate it from other rheumatic conditions. - Carditis often presents with new or changed murmurs, such as a soft systolic murmur due to mitral regurgitation [1]. Acute rheumatic carditis is also a principal cause of valve regurgitation [2]. *Seronegative rheumatoid arthritis* - This typically presents with chronic inflammatory arthritis, but lacks specific features like **carditis** or characteristic skin rashes like **erythema marginatum** and **subcutaneous nodules**. - While it has a negative RF, the acute presentation with a preceding sore throat points away from chronic arthropathy. *Juvenile idiopathic arthritis* - This is a diagnosis of exclusion for chronic arthritis in children under 16, lacking acute rheumatic fever's hallmark cardiac involvement, **subcutaneous nodules**, or **erythema marginatum**. - While it can cause joint swelling and elevated ESR, the constellation of symptoms strongly points to an acute systemic illness. *Ankylosing spondylitis* - This primarily affects the **axial skeleton** (spine and sacroiliac joints) and is characterized by back pain and stiffness, predominantly in young adults. - It does not typically present with a **pan-systolic murmur**, **subcutaneous nodules**, or **erythema marginatum**, and is rarely seen in 15-year-old patients with this acute presentation.

Q: Which of the following cyanotic heart diseases cause increased pulmonary blood flow? 1. Ebstein anomaly 2. Tetralogy of Fallot 3. Transposition of the great arteries (TGA) 4. Total anomalous pulmonary venous communication (TAPVC) Select the correct combination:

3,4. ***3,4 (TGA and TAPVC)*** - **Transposition of the great arteries (TGA)** involves two parallel circulations with the aorta arising from the right ventricle and pulmonary artery from the left ventricle. Mixing occurs through defects (ASD, VSD, or PDA), leading to **pulmonary overcirculation** as oxygenated blood recirculates through the lungs. - **Total anomalous pulmonary venous connection (TAPVC)** results in all pulmonary veins draining into the systemic venous circulation (typically right atrium). This causes **increased volume load on the right heart** and subsequently increased pulmonary blood flow, with obligatory mixing at the atrial level. *1,2 (Ebstein and ToF)* - Both conditions cause **decreased pulmonary blood flow**. - **Ebstein anomaly** involves apical displacement of the tricuspid valve with "atrialization" of the right ventricle, causing tricuspid regurgitation and right-to-left shunting through an ASD/PFO. - **Tetralogy of Fallot** features right ventricular outflow tract obstruction (pulmonary stenosis) as its defining feature, causing reduced pulmonary blood flow. *2,4* - Incorrect combination: **Tetralogy of Fallot causes decreased pulmonary blood flow** due to RVOT obstruction, not increased. *1,4* - Incorrect combination: **Ebstein anomaly causes decreased pulmonary blood flow**, not increased.

Q: Which of the following is considered a minor clinical finding suggestive of congenital heart disease?

Abnormal 2nd heart sound. ***Abnormal 2nd heart sound*** - An abnormal (loud, soft, split, or single) **second heart sound (S2)** is a minor clinical finding that can suggest congenital heart disease (CHD). - This reflects abnormalities in the **pulmonary** or **aortic valve closure**, common in various CHDs. *Low BP* - **Low blood pressure** is a general sign of circulatory compromise and is not a specific or minor clinical finding for congenital heart disease itself. - It might indicate severe heart failure or shock, which are major, late-stage complications of CHD, rather than an early suggestive sign. *Systolic murmur grade-3* - A **systolic murmur of grade 3 or higher** is generally considered a **major clinical finding** and often indicates significant structural heart disease. - Minor findings are typically less intense or specific signs that still warrant further investigation. *Diastolic murmur* - The presence of **any diastolic murmur** is considered a **major clinical finding** that is highly suggestive of significant heart disease, as it often implies structural valve abnormalities or abnormal blood flow during diastole. - This is not a "minor" finding as it virtually always indicates pathology.

Q: A child with fever for 6 days, strawberry tongue, conjunctival congestion with peeling of skin. What will be the treatment option for this child?

IVIG. ***IVIG*** - The constellation of **fever for 6 days (prolonged fever)**, **strawberry tongue**, **conjunctival congestion**, and **peeling skin** is highly indicative of **Kawasaki disease**. - **Intravenous immunoglobulin (IVIG) 2 g/kg as a single infusion** is the cornerstone of treatment for Kawasaki disease to reduce the risk of **coronary artery aneurysms** (from ~25% to <5%). - IVIG should be administered within **10 days of fever onset** for maximum efficacy. - **High-dose aspirin** (80-100 mg/kg/day) is given concurrently until the fever subsides, then switched to low-dose aspirin (3-5 mg/kg/day) for antiplatelet effect. *Antibiotics* - Kawasaki disease is a **vasculitis**, not a bacterial infection, so antibiotics are ineffective. - While other conditions like scarlet fever can present with strawberry tongue, the prolonged fever and other classic Kawasaki features differentiate it. *Steroids* - While steroids can reduce inflammation, they are **not the primary treatment** for Kawasaki disease and are typically used in conjunction with IVIG in **refractory cases** or for IVIG-resistant disease. - **Monotherapy with steroids** is not recommended for acute Kawasaki disease due to potential for increased aneurysm risk. *Antipyretics* - **Antipyretics** like acetaminophen can help manage the fever symptomatically. - However, they **do not treat the underlying vasculitis** or prevent the serious cardiac complications of Kawasaki disease. - Note: **NSAIDs like ibuprofen should be avoided** when high-dose aspirin is being used due to risk of drug interactions.

Q: Which of the following congenital heart disease has equal saturation in all heart chambers?

Total anomalous pulmonary venous circulation. ***Total anomalous pulmonary venous circulation*** - In this condition, all **pulmonary veins drain abnormally** into the systemic venous circulation, mixing oxygenated and deoxygenated blood before it reaches the left atrium. - This complete mixing results in **equal oxygen saturation** throughout all four heart chambers and the great arteries, as there is a single common mixing chamber. *Tetralogy of Fallot* - This condition involves **four defects**: pulmonary stenosis, ventricular septal defect (VSD), overriding aorta, and right ventricular hypertrophy, leading to right-to-left shunting. - Oxygen saturations would be **lower in the systemic circulation** and aorta compared to the pulmonary circulation (if measurable), but not equal across all chambers due to deoxygenated blood mixing in the systemic flow. *Transposition of great arteries* - Characterized by the **aorta arising from the right ventricle** and the pulmonary artery from the left ventricle, creating two parallel circulations. - Without mixing lesions (like a VSD or patent foramen ovale), the systemic circulation would be severely desaturated and the pulmonary circulation fully saturated, resulting in **highly disparate saturations** between chambers. *Tricuspid atresia* - Involves the **absence of a tricuspid valve**, preventing blood flow from the right atrium to the right ventricle, necessitating an atrial septal defect (ASD) or patent foramen ovale (PFO) for survival. - Blood from the right atrium goes directly to the left atrium, and then via a VSD to the pulmonary artery, leading to **different saturations** in the systemic and pulmonary circulations and not equal saturation in all chambers.

Q: Most common cardiac abnormality in Noonan syndrome is:-

Pulmonary stenosis. ***Pulmonary stenosis*** - **Valvular pulmonary stenosis**, particularly a dysplastic pulmonary valve, is the **most common cardiac defect** found in individuals with Noonan syndrome. - This condition can lead to an obstruction of blood flow from the right ventricle into the **pulmonary artery**. *Atrial septal defect* - While **atrial septal defects (ASDs)** can occur in Noonan syndrome, they are less common than pulmonary stenosis. - ASDs are characterized by a hole in the septum separating the two upper chambers of the heart. *Tetralogy of Fallot* - **Tetralogy of Fallot** is a complex congenital heart defect involving four specific abnormalities, which is not the most common cardiac finding in Noonan syndrome. - It is typically associated with a different set of genetic syndromes or occurs sporadically. *Ventricular septal defect* - **Ventricular septal defects (VSDs)** are also observed in some cases of Noonan syndrome but are less prevalent than pulmonary stenosis. - VSDs involve a hole in the wall separating the heart's lower two chambers.

Q: A 3-year-old boy is brought by his parents to the emergency department because they are concerned that he has had a high fever for several days. On examination, the boy has conjunctival and oral erythema. He has palpable cervical lymphadenopathy and erythema of his palms and soles. What is a potential life-threatening complication of this disorder?

Aneurysm of the coronary arteries. ***Aneurysm of the coronary arteries*** - The classic presentation of prolonged fever, **conjunctival and oral erythema**, cervical lymphadenopathy, and erythema of the palms and soles is highly suggestive of **Kawasaki disease**. - **Coronary artery aneurysms** are the most serious and potentially life-threatening complication of Kawasaki disease, especially if left untreated. *Dissection of the thoracic aorta* - This is a rare event in children and is not typically associated with Kawasaki disease. - Thoracic aortic dissection often presents with **sudden, severe chest pain** radiating to the back and is seen more commonly in adults with conditions like uncontrolled hypertension or connective tissue disorders. *Rupture of a berry aneurysm* - **Berry aneurysms** are typically found in the cerebral circulation and their rupture leads to subarachnoid hemorrhage. - While they can occur in children, they are not a characteristic complication of Kawasaki disease. *Aneurysm of the abdominal aorta* - Aneurysms of the abdominal aorta are rare in children and are not directly associated with Kawasaki disease. - These are typically seen in older adults due to **atherosclerosis** or in some genetic syndromes.

Q: Cyanotic heart disease with left axis deviation is:

Tricuspid atresia. ***Tricuspid atresia*** - **Tricuspid atresia** is a **cyanotic congenital heart disease** characterized by the absence of a tricuspid valve, leading to a single ventricle physiology. - The characteristic **ECG finding** in tricuspid atresia is **left axis deviation**, often with left ventricular hypertrophy, which is somewhat counterintuitive given the right-sided lesion. *TAPVC* - **Total Anomalous Pulmonary Venous Connection (TAPVC)** is a **cyanotic heart disease** where all four pulmonary veins drain into the systemic venous circulation. - While cyanotic, it typically presents with a **right axis deviation** and **right ventricular hypertrophy** on ECG, not left axis deviation. *Ebstein anomaly* - **Ebstein anomaly** involves the downward displacement of the septal and posterior leaflets of the tricuspid valve into the right ventricle, often leading to **cyanosis**. - ECG findings are usually characterized by **right atrial enlargement** and **right bundle branch block**, not left axis deviation. *TGA* - **Transposition of the Great Arteries (TGA)** is a **cyanotic heart disease** where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. - ECG typically shows **right axis deviation** and **right ventricular hypertrophy**, reflecting the increased workload of the right ventricle pumping into the high-pressure aortic circuit.

Q: All of the following are acyanotic congenital heart diseases except _________

Tetralogy of fallot. ***Tetralogy of Fallot*** - This is a **cyanotic heart disease** due to the combination of four heart defects, leading to a **right-to-left shunt** and deoxygenated blood entering the systemic circulation [1]. - The four defects include a large **ventricular septal defect (VSD)**, **pulmonary stenosis**, an **overriding aorta**, and **right ventricular hypertrophy** [1]. *PDA* - A **patent ductus arteriosus (PDA)** allows blood to flow from the aorta to the pulmonary artery, creating a **left-to-right shunt**, which typically results in an acyanotic condition [3]. - While it can lead to complications like pulmonary hypertension, it does not usually cause cyanosis unless severe pulmonary hypertension develops (Eisenmenger syndrome). *VSD* - A **ventricular septal defect (VSD)** involves an opening between the ventricles, typically causing **left-to-right shunting** [2]. - This increased blood flow to the lungs defines it as an **acyanotic** condition because oxygenated blood from the left side is rerouted to the lungs. *ASD* - An **atrial septal defect (ASD)** is a hole in the septum separating the atria, usually leading to a **left-to-right shunt** from the left atrium to the right atrium [4]. - The increased blood flow to the right side of the heart and lungs makes it an **acyanotic** condition, as oxygenated blood continues to be delivered systemically.

Q: Commonest cause of heart failure in infancy is:

Congenital heart disease. **Congenital heart disease** - **Congenital heart defects** are the leading cause of heart failure in infancy due to structural abnormalities that impair normal cardiac function and blood flow. - Conditions like **ventricular septal defects (VSDs)**, **atrial septal defects (ASDs)**, and **patent ductus arteriosus (PDA)** can lead to volume overload or pressure overload, resulting in heart failure. *Cardiomyopathy* - While a cause of heart failure, **cardiomyopathy** is less common than congenital heart disease in infancy. - It involves primary myocardial dysfunction, which can be genetic, metabolic, or idiopathic. *Rheumatic fever* - **Rheumatic fever** is a post-streptococcal inflammation that can affect the heart, but it is rare in infancy and more typically seen in older children and adolescents. - Its incidence has also significantly decreased in developed countries due to improved hygiene and antibiotic use. *Myocarditis* - **Myocarditis**, often virally induced, can cause heart failure in infants but is less frequent than congenital heart defects. - It involves inflammation of the heart muscle, leading to impaired contractility.

Question 1

A 15-year-old patient presents with joint swelling, a pan-systolic murmur, negative rheumatoid factor (RF), and elevated ESR. The patient also reports a recent history of sore throat and exhibits subcutaneous nodules and erythema marginatum on physical examination. What is the most likely diagnosis?

Accepted Answer

Acute rheumatic fever

Answer

Seronegative rheumatoid arthritis

Answer

Juvenile idiopathic arthritis

Answer

Ankylosing spondylitis

Question 2

Which of the following cyanotic heart diseases cause increased pulmonary blood flow?

1. Ebstein anomaly
2. Tetralogy of Fallot
3. Transposition of the great arteries (TGA)
4. Total anomalous pulmonary venous communication (TAPVC)

Select the correct combination:

Accepted Answer

3,4

Answer

1,2

Answer

2,4

Answer

1,4

Question 3

Which of the following is considered a minor clinical finding suggestive of congenital heart disease?

Accepted Answer

Abnormal 2nd heart sound

Answer

Low BP

Answer

Systolic murmur grade-3

Answer

Diastolic murmur

Question 4

A child with fever for 6 days, strawberry tongue, conjunctival congestion with peeling of skin. What will be the treatment option for this child?

Accepted Answer

IVIG

Answer

Antibiotics

Answer

Steroids

Answer

Antipyretics

Question 5

Which of the following congenital heart disease has equal saturation in all heart chambers?

Accepted Answer

Total anomalous pulmonary venous circulation

Answer

Tetralogy of Fallot

Answer

Transposition of great arteries

Answer

Tricuspid atresia

Question 6

Most common cardiac abnormality in Noonan syndrome is:-

Accepted Answer

Pulmonary stenosis

Answer

Atrial septal defect

Answer

Tetralogy of Fallot

Answer

Ventricular septal defect

Question 7

A 3-year-old boy is brought by his parents to the emergency department because they are concerned that he has had a high fever for several days. On examination, the boy has conjunctival and oral erythema. He has palpable cervical lymphadenopathy and erythema of his palms and soles. What is a potential life-threatening complication of this disorder?

Accepted Answer

Aneurysm of the coronary arteries

Answer

Dissection of the thoracic aorta

Answer

Rupture of a berry aneurysm

Answer

Aneurysm of the abdominal aorta

Question 8

Cyanotic heart disease with left axis deviation is:

Accepted Answer

Tricuspid atresia

Answer

TAPVC

Answer

Ebstein anomaly

Answer

TGA

Question 9

All of the following are acyanotic congenital heart diseases except _________

Accepted Answer

Tetralogy of fallot

Answer

PDA

Answer

VSD

Answer

ASD

Question 10

Commonest cause of heart failure in infancy is:

Accepted Answer

Congenital heart disease

Answer

Cardiomyopathy

Answer

Rheumatic fever

Answer

Myocarditis

Cardiology — MCQs

Cardiology — MCQs

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