Cardiology Practice Questions

Q: Tetralogy of Fallot presents with one of the following:

Central cyanosis with clubbing. ***Central cyanosis with clubbing*** - Tetralogy of Fallot is a **cyanotic congenital heart defect**, meaning it causes inadequate oxygenation of the blood, leading to central cyanosis. - **Chronic hypoxemia** (low oxygen levels) associated with cyanotic heart disease typically results in **clubbing of the fingers and toes** over time. *Normal ECG and Chest x-ray* - An **ECG** in Tetralogy of Fallot typically shows **right ventricular hypertrophy** and an **axis deviation**, which is not normal. - A **chest X-ray** in Tetralogy of Fallot often reveals a characteristic **'boot-shaped' heart** due to right ventricular hypertrophy and decreased pulmonary artery markings. *Cardiomegaly* - While there is **right ventricular hypertrophy**, significant global cardiomegaly (enlargement of the entire heart) is **not a classic or consistent feature** of Tetralogy of Fallot. - The boot-shaped appearance on X-ray reflects the hypertrophied right ventricle, but the overall heart size may not be drastically enlarged. *Left ventricular hypertrophy* - Tetralogy of Fallot is characterized by **right ventricular outflow tract obstruction** and a **large ventricular septal defect**, leading primarily to **right ventricular hypertrophy**. - **Left ventricular hypertrophy** is not a typical finding in Tetralogy of Fallot; in fact, the left ventricle may be smaller due to decreased pulmonary venous return.

Q: A major criterion for Jones classification is

Chorea. ***Chorea*** - **Sydenham's chorea** is a neurological disorder characterized by involuntary, jerky movements, and is a **major criterion** [1] in the Jones classification for **rheumatic fever** [1]. - It is one of the five major manifestations, alongside carditis, polyarthritis, erythema marginatum, and subcutaneous nodules [1]. *TPR Interval* - The **Jones criteria** are used to diagnose **rheumatic fever** and do not directly include the TPR interval as a major or minor criterion. - While cardiac involvement is a major criterion (carditis), specific ECG findings like the TPR interval are not listed as stand-alone criteria. *Arthralgia* - **Arthralgia** (joint pain) is considered a **minor criterion** in the Jones classification. - Unlike **polyarthritis**, which is a major criterion due to objective joint inflammation, arthralgia alone lacks the definitive signs of inflammation. *Fever* - **Fever** is a **minor criterion** in the Jones classification for rheumatic fever. - It is a non-specific symptom that, while common in rheumatic fever, is not sufficiently diagnostic on its own to be considered a major criterion.

Q: The commonest cause of death in a diphtheritic child after few weeks of infection is:

Myocarditis. ***Myocarditis*** - Diphtheria toxin's cardiotoxicity can lead to **myocarditis**, characterized by diffuse **interstitial inflammation** and **myocardial fiber necrosis**. - This can result in **cardiac arrhythmias**, **heart failure**, or sudden **cardiac death** weeks after the initial infection, making it the most common cause of fatality in the later stages. *Septicemia* - While septicemia can occur, it is more often seen as a complication of **secondary bacterial infections** rather than a direct, delayed effect of diphtheria toxin. - The direct and most significant delayed organ damage from diphtheria is typically **cardiac** or **neurological**, not widespread systemic infection. *IIIrd nerve palsy* - **Cranial nerve palsies**, including those affecting the 3rd cranial nerve (oculomotor), are a known complication stemming from the **neurotoxic effects** of diphtheria toxin. - However, while significant, **neurological complications** such as palsies are generally less common as a direct cause of death compared to severe myocarditis. *Tonsillitis* - **Tonsillitis** is a symptom of acute diphtheria, presenting at the **initial stage** of the infection with a **grayish pseudomembrane** on the tonsils and pharynx. - It is not a cause of death in itself, but rather a manifestation of the primary infection and can lead to airway obstruction in severe cases, which is an early complication, not a delayed cause of death.

Q: A 12 year old girl was brought with fever, malaise, and migrating polyarthritis. She had a history of recurrent throat infections in the past. Elevated erythrocyte sedimentation rate is noted. Which among the following is NOT a major Jones criteria for diagnosis of acute rheumatic fever?

Raised ESR. ***Raised ESR*** - **Elevated erythrocyte sedimentation rate (ESR)** is a **minor criterion** in the Jones Criteria for acute rheumatic fever, indicating inflammation but not specific enough to be a major criterion. - While it supports the diagnosis, it is a non-specific inflammatory marker rather than a distinct clinical manifestation of the disease. *Chorea* - **Sydenham's chorea** (St. Vitus' dance) is a **major manifestation** of acute rheumatic fever, characterized by involuntary, purposeless movements. - It results from central nervous system involvement and is a highly diagnostic sign, often appearing late in the disease course. *Arthritis* - **Migratory polyarthritis** is a **major criterion** for acute rheumatic fever, typically affecting large joints in a sequential pattern. - This symptom is often the presenting complaint and is highly responsive to anti-inflammatory treatment. *Carditis* - **Carditis**, involving inflammation of the heart muscle, pericardium, or endocardium, is a **major criterion** and the most serious manifestation of acute rheumatic fever. - It can lead to long-term valvular damage, particularly affecting the mitral and aortic valves.

Q: Which heart disease is most commonly associated with rubella infection –

PDA. ***PDA*** - **Patent ductus arteriosus (PDA)** is a well-known cardiac malformation associated with congenital rubella syndrome, particularly if the infection occurs during the first trimester. - The rubella virus can interfere with the normal closure of the fetal ductus arteriosus, leading to its persistence after birth. *Eisenmenger's syndrome* - Eisenmenger's syndrome is a severe, late complication of large left-to-right shunts (like uncorrected PDA or VSD) that results in **pulmonary hypertension with shunt reversal** and cyanosis. - While congenital rubella can cause defects that *lead* to Eisenmenger's syndrome if left untreated, it is not the primary immediate cardiac anomaly directly caused by the infection itself. *VSD* - **Ventricular septal defect (VSD)** is a common congenital heart defect where there is an opening between the ventricles. - While VSDs can be associated with various congenital syndromes, they are not the *most commonly* or specifically linked heart defect seen in congenital rubella syndrome compared to PDA. *ASD* - **Atrial septal defect (ASD)** involves an opening between the atria. - Although ASDs are also congenital heart defects, they are not as predominantly associated with congenital rubella syndrome as PDA.

Q: A child with large perimembranous VSD has congestive heart failure. Over time, the child shows clinical improvement in heart failure symptoms despite persistence of the defect. What is the most likely explanation?

Vascular changes in pulmonary circulation. ***Vascular changes in pulmonary circulation*** - The development of severe **pulmonary hypertension** and subsequent **pulmonary vascular obstructive disease** (Eisenmenger syndrome) can lead to a decrease in the left-to-right shunt. - As pulmonary vascular resistance approaches or exceeds systemic vascular resistance, the shunt lessens or reverses, reducing pulmonary blood flow and, paradoxically, improving symptoms of **congestive heart failure** related to pulmonary overcirculation. *Infective endocarditis* - **Infective endocarditis** on a VSD can lead to valve damage, vegetations, emboli, and worsening cardiac function, not improvement of heart failure. - It would typically cause new or worsening symptoms like fever, fatigue, and signs of cardiac decompensation. *Aortic regurgitation* - **Aortic regurgitation** (AR) could occur in rare cases due to prolapse of an aortic valve leaflet into the VSD, which would increase left ventricular volume overload. - This would worsen, rather than improve, the signs and symptoms of **congestive heart failure**. *Closure of VSD spontaneously* - While spontaneous closure of a VSD would definitively improve heart failure symptoms, the question implies a long-standing large VSD where other changes are occurring. - Spontaneous closure is more common in smaller VSDs, and in large VSDs, it would resolve the underlying cause of heart failure, not lead to improvement through a pathological process.

Q: A child presented at 10 weeks with recurrent episode of pneumonia and failure to thrive. X-ray shows cardiomegaly & pulmonary plethora. What is the diagnosis?

VSD. ***VSD*** - **Ventricular septal defect (VSD)** is the most common cause of this presentation in early infancy (symptoms typically appear at **6-10 weeks** of age). - Large VSDs cause significant **left-to-right shunt** leading to pulmonary overcirculation, resulting in **recurrent pneumonia** and **failure to thrive**. - **Cardiomegaly** (due to volume overload of left atrium and ventricle) and **pulmonary plethora** (increased pulmonary vascular markings) on X-ray are classic findings. - The infant may also present with tachypnea, feeding difficulties, and poor weight gain. *TOF* - **Tetralogy of Fallot (TOF)** is a **cyanotic heart defect** with right-to-left shunt, presenting with cyanosis and hypoxic spells, not recurrent pneumonia. - X-ray shows **boot-shaped heart** and **pulmonary oligemia** (decreased pulmonary vascular markings), not pulmonary plethora. - Does not typically cause failure to thrive in the same manner as acyanotic left-to-right shunt lesions. *Patent foramen ovale* - A **patent foramen ovale (PFO)** is a normal variant in infants and typically remains **asymptomatic**. - Does not cause significant hemodynamic shunting in the absence of elevated right atrial pressure. - Does not cause **cardiomegaly**, **pulmonary plethora**, recurrent pneumonia, or failure to thrive. *ASD* - An **atrial septal defect (ASD)** also causes left-to-right shunt with pulmonary plethora, but the shunt develops **gradually** over time. - ASD typically presents **later in childhood or adulthood** with milder symptoms (fatigue, exercise intolerance) due to lower pressure gradient across atria. - **Recurrent pneumonia and failure to thrive at 10 weeks** are uncommon with isolated ASD, as the hemodynamic changes are less pronounced in early infancy compared to VSD. - When symptomatic in infancy, large ASDs present later (around 6 months to 1 year) rather than at 10 weeks.

Q: In Kawasaki disease, desquamation and denudation of skin from fingers and toes occurs in:

2nd and 3rd week. ***2nd and 3rd week*** - Desquamation and denudation of skin, particularly affecting the **fingers and toes**, is a characteristic late-subacute phase finding in **Kawasaki disease**. - This typically occurs during the **subacute stage** of the illness (around days 10-21), as the acute inflammatory symptoms begin to subside. - Periungual desquamation is one of the hallmark clinical features that helps confirm the diagnosis. *After 6 weeks* - By 6 weeks, most of the acute and subacute symptoms of Kawasaki disease would have fully resolved. - This represents the late convalescent phase where desquamation has typically already occurred and resolved. *After 1st week* - While technically desquamation begins after the first week, this option is too vague and non-specific. - The more precise timing is the **2nd and 3rd weeks**, which better characterizes the subacute phase. *3-6 weeks* - While some desquamation may persist into the early part of this period, the **onset and peak** of desquamation occurs earlier, in the **2nd and 3rd weeks**. - This time frame represents primarily the late subacute to convalescent stage, where desquamation is resolving rather than beginning.

Q: All are true regarding tricuspid atresia except –

Split S2. ***Split S2*** - This is the **EXCEPTION** – tricuspid atresia typically presents with a **SINGLE S2**, not a split S2. - The second heart sound (S2) splitting occurs when aortic (A2) and pulmonary (P2) valve closures are audibly separate. - In tricuspid atresia, the **hypoplastic or absent right ventricle** and **reduced pulmonary blood flow** result in a diminished or absent pulmonary component (P2), leading to a single S2 sound. - The lack of normal right ventricular ejection eliminates the typical splitting pattern. *Left axis deviation in ECG* - This is **TRUE** for tricuspid atresia and therefore not the exception. - Tricuspid atresia classically shows **marked left axis deviation** (typically -30° to -90° on ECG). - This occurs because the **left ventricle is dominant and hypertrophied**, as it must handle both systemic and, indirectly, pulmonary circulation. - The right ventricle is hypoplastic or absent, so left ventricular forces dominate the ECG axis. *Pulmonary oligemia in chest X-ray* - This is **TRUE** for tricuspid atresia and therefore not the exception. - **Pulmonary oligemia** (decreased pulmonary vascular markings) is characteristic on chest X-ray. - Results from **reduced pulmonary blood flow** due to the absence of direct right atrial to right ventricular flow. - Blood reaches the lungs only via a VSD or PDA, leading to diminished pulmonary vasculature appearance. *Patent foramen ovale* - This is **TRUE** for tricuspid atresia and therefore not the exception. - An **atrial septal defect (ASD) or patent foramen ovale (PFO)** is **essential for survival**. - Provides the only pathway for systemic venous return to reach the left atrium and subsequently the systemic circulation. - Without this right-to-left atrial shunt, no blood could reach the systemic circulation, resulting in immediate cardiovascular collapse.

Q: Most characteristic feature of TOF is

Cyanotic spells. ***Cyanotic spells*** - **Cyanotic spells**, also known as "tet spells," are acute episodes of profound hypoxemia that are characteristic of Tetralogy of Fallot (TOF), especially in infants. - These spells are caused by increased right-to-left shunting across the **ventricular septal defect** due to infundibular spasm that increases **pulmonary outflow obstruction**, leading to sudden severe cyanosis, dyspnea, and decreased consciousness. *Squatting* - While **squatting** is a common compensatory mechanism used by older children with TOF to improve oxygen saturation, it is a behavioral adaptation rather than a primary physiological feature. - Squatting increases **systemic vascular resistance**, which reduces right-to-left shunting and forces more blood into the pulmonary circulation. *Clubbing of feet* - **Clubbing of fingers and toes** is a common sign of chronic hypoxemia, which can be seen in various cyanotic congenital heart diseases, including TOF. - However, it is a long-term consequence of hypoxemia rather than a characteristic acute or primary feature specific to TOF. *Recurrent chest infection* - Children with TOF may have an increased risk of **recurrent chest infections** due to their underlying compromised cardiovascular status and hypoxemia. - However, recurrent chest infections are not a unique or characteristic feature of TOF, as they can occur in various pediatric conditions that affect respiratory health.

Question 1

Tetralogy of Fallot presents with one of the following:

Accepted Answer

Central cyanosis with clubbing

Answer

Normal ECG and Chest x-ray

Answer

Cardiomegaly

Answer

Left ventricular hypertrophy

Question 2

A major criterion for Jones classification is

Accepted Answer

Chorea

Answer

TPR Interval

Answer

Arthralgia

Answer

Fever

Question 3

The commonest cause of death in a diphtheritic child after few weeks of infection is:

Accepted Answer

Myocarditis

Answer

Septicemia

Answer

IIIrd nerve palsy

Answer

Tonsillitis

Question 4

A 12 year old girl was brought with fever, malaise, and migrating polyarthritis. She had a history of recurrent throat infections in the past. Elevated erythrocyte sedimentation rate is noted. Which among the following is NOT a major Jones criteria for diagnosis of acute rheumatic fever?

Accepted Answer

Raised ESR

Answer

Chorea

Answer

Arthritis

Answer

Carditis

Question 5

Which heart disease is most commonly associated with rubella infection –

Accepted Answer

PDA

Answer

Eisenmenger's syndrome

Answer

VSD

Answer

ASD

Question 6

A child with large perimembranous VSD has congestive heart failure. Over time, the child shows clinical improvement in heart failure symptoms despite persistence of the defect. What is the most likely explanation?

Accepted Answer

Vascular changes in pulmonary circulation

Answer

Infective endocarditis

Answer

Aortic regurgitation

Answer

Closure of VSD spontaneously

Question 7

A child presented at 10 weeks with recurrent episode of pneumonia and failure to thrive. X-ray shows cardiomegaly & pulmonary plethora. What is the diagnosis?

Accepted Answer

VSD

Answer

TOF

Answer

Patent foramen ovale

Answer

ASD

Question 8

In Kawasaki disease, desquamation and denudation of skin from fingers and toes occurs in:

Accepted Answer

2nd and 3rd week

Answer

After 6 weeks

Answer

After 1st week

Answer

3-6 weeks

Question 9

All are true regarding tricuspid atresia except –

Accepted Answer

Split S2

Answer

Left axis deviation in ECG.

Answer

Pulmonary oligemia in chest X–ray

Answer

Patent foramen ovale

Question 10

Most characteristic feature of TOF is

Accepted Answer

Cyanotic spells

Answer

Squatting

Answer

Clubbing of feet

Answer

Recurrent chest infection

Cardiology — MCQs

Cardiology — MCQs

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