Cardiology Practice Questions

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.

Q: A child after 4 weeks of birth, is acyanotic. Ejection systolic murmur detected on auscultation. Probable diagnosis is:

Coarctation of aorta. ***Coarctation of aorta*** - **Coarctation of the aorta** commonly presents with an **ejection systolic murmur** due to increased flow velocity through the narrowed segment. - Infants are often **acyanotic**, and symptoms like poor feeding or heart failure may develop as the **ductus arteriosus closes**. - The murmur is typically heard at the **left infraclavicular area and back** (interscapular region). *TOF* - **Tetralogy of Fallot** (TOF) is a **cyanotic heart defect**, which contradicts the patient's acyanotic presentation. - It typically presents with a **harsh systolic ejection murmur** at the upper left sternal border and **cyanotic spells**. *VSD* - A **ventricular septal defect** (VSD) typically produces a **holosystolic (pansystolic) murmur** best heard at the lower left sternal border, not an ejection systolic murmur. - While VSD is the most common congenital heart defect, the **murmur type** (holosystolic vs ejection systolic) is the key differentiating feature in this case. *PDA* - A **patent ductus arteriosus** (PDA) leads to a **continuous, machinery-like murmur** due to constant flow between the aorta and pulmonary artery. - It's not typically described as an ejection systolic murmur and can present with signs of **heart failure** or **pulmonary hypertension**.

Q: In the evaluation of congenital heart disease, which of the following findings is considered the LEAST specific diagnostic indicator?

Abnormal ECG findings. ***Abnormal ECG findings*** - While an electrocardiogram (ECG) is an important tool in evaluating congenital heart disease, **abnormal ECG findings** are relatively **non-specific** and can be seen in many conditions. - ECG changes may include axis deviation, chamber hypertrophy patterns, or conduction abnormalities, but these findings alone do not establish the specific diagnosis of congenital heart disease. - Some children with congenital heart disease may have **normal ECG findings**, particularly in mild cases or certain lesions like small atrial septal defects. - ECG serves as a supportive tool but requires correlation with clinical findings and echocardiography for definitive diagnosis. *Presence of a diastolic murmur* - A **diastolic murmur in a child** is highly pathological and almost always indicates significant cardiac pathology. - Diastolic murmurs suggest **aortic regurgitation**, **pulmonary regurgitation**, or **mitral stenosis**, which can be associated with congenital heart defects. - The presence of a diastolic murmur warrants immediate further investigation with echocardiography. *Congestive heart failure* - **Congestive heart failure (CHF)** in infancy or childhood is a critical clinical manifestation often indicating significant congenital heart disease. - Symptoms include tachypnea, failure to thrive, hepatomegaly, and poor feeding in infants. - CHF in children is highly specific for significant cardiac pathology, particularly left-to-right shunts (VSD, PDA) or left-sided obstructive lesions. *Cyanosis as a clinical sign* - **Cyanosis** (bluish discoloration of skin and mucous membranes) indicates arterial oxygen desaturation below 85%. - It is a cardinal sign of **cyanotic congenital heart disease** involving right-to-left shunting (Tetralogy of Fallot, Transposition of Great Arteries) or severe pulmonary obstruction. - Central cyanosis in a neonate is a medical emergency requiring urgent evaluation and management.

Q: A young boy presents to you with history of breathlessness on exertion. You being an intern proceed with auscultation of the patient's chest. Your findings are ejection systolic murmur in the left 2nd intercostal space, S1 is normal and has wide and fixed split S2. You then send the patient for an ECG, what would be the most likely finding in the ECG report?

Right axis deviation. ***Right axis deviation*** - The clinical presentation of **breathlessness on exertion**, an **ejection systolic murmur in the left 2nd intercostal space**, and a **wide and fixed split S2** are classic signs of an **atrial septal defect (ASD)** [2]. - An ASD leads to a **left-to-right shunt**, causing **volume overload** in the right atrium and right ventricle, which results in **right ventricular hypertrophy** and consequently **right axis deviation** on an ECG [1]. *Left axis deviation* - **Left axis deviation** is typically associated with conditions causing **left ventricular hypertrophy** or conduction defects involving the left bundle branch, which are not directly indicated by the described cardiac findings. - While some complex congenital heart defects can present with left axis deviation, it is not the most common finding with an isolated **atrial septal defect**. *Large p waves* - **Large P waves** (P pulmonale) indicate **right atrial enlargement**, which can occur in an ASD due to volume overload [1]. - However, while right atrial enlargement is common, **right axis deviation** due to right ventricular hypertrophy is a more specific and prominent ECG finding in symptomatic **atrial septal defects**. *Absent p waves* - **Absent P waves** are characteristic of conditions like **atrial fibrillation** or **junctional rhythms**. - These are not typical findings in an isolated **atrial septal defect** and would not explain the other clinical signs.

Q: NOT an indication for surgery in a Ventricular septal defect

Eisenmenger's Syndrome. ***Eisenmenger's Syndrome*** - This condition represents **irreversible pulmonary hypertension** due to long-standing, high-volume, high-pressure shunting, leading to a reversal of the shunt (right-to-left). - In **Eisenmenger's syndrome**, the benefits of VSD closure are outweighed by the risks, as closing the defect can acutely increase **pulmonary vascular resistance (PVR)** and right ventricular overload, leading to fatal outcomes. *Suck- Rest-Suck cycle while feeding* - This symptom indicates significant **heart failure** and **poor feeding** in an infant, often due to a large VSD causing increased pulmonary blood flow and work of breathing. - It is a clear sign of clinical compromise and is generally an **indication for surgical intervention** to improve feeding and reduce symptoms. *Pulmonary: Systemic blood flow > 2:1* - A pulmonary to systemic blood flow ratio (Qp:Qs) greater than 2:1 signifies a **large left-to-right shunt** through the VSD, leading to significant volume overload in the pulmonary circulation. - This degree of shunting is a strong **indication for surgery** to prevent the development of pulmonary hypertension and right ventricular dysfunction. *Hepatomegaly* - **Hepatomegaly** (enlarged liver) in the context of a VSD often suggests **right-sided heart failure**, a common complication of large left-to-right shunts and increased pulmonary vascular resistance. - It is a clinical sign of significant cardiac dysfunction and typically indicates the need for **surgical repair** to alleviate the underlying cardiac load.

Q: Commonest congenital heart disease is:

Ventricular septal defect. ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** is the most frequently observed type of congenital heart disease, accounting for approximately 25-30% of all congenital heart lesions. - It involves an opening in the **interventricular septum**, allowing blood to shunt between the left and right ventricles. *Persistent ductus arteriosus* - While common, **patent ductus arteriosus (PDA)** is not as prevalent as VSDs overall. - PDA is more frequently seen in **premature infants**, but VSDs are the most common in the general population of live births with congenital heart disease. *Atrial septal defect* - **Atrial septal defect (ASD)** is a common congenital heart defect, but its incidence is lower than that of VSDs. - ASDs involve a hole in the **interatrial septum**, leading to shunting of blood between the atria. *Mitral valve prolapse* - **Mitral valve prolapse (MVP)** is a relatively common valvular anomaly but is generally considered a minor congenital heart abnormality or sometimes an acquired condition, not typically classified as the most common "congenital heart disease" in the same category as septal defects. - It involves the leaflets of the **mitral valve bulging into the left atrium** during systole.

Question 1

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 2

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 3

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 4

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 5

Most characteristic feature of TOF is

Accepted Answer

Cyanotic spells

Answer

Squatting

Answer

Clubbing of feet

Answer

Recurrent chest infection

Question 6

A child after 4 weeks of birth, is acyanotic. Ejection systolic murmur detected on auscultation. Probable diagnosis is:

Accepted Answer

Coarctation of aorta

Answer

TOF

Answer

VSD

Answer

PDA

Question 7

In the evaluation of congenital heart disease, which of the following findings is considered the LEAST specific diagnostic indicator?

Accepted Answer

Abnormal ECG findings

Answer

Presence of a diastolic murmur

Answer

Congestive heart failure

Answer

Cyanosis as a clinical sign

Question 8

A young boy presents to you with history of breathlessness on exertion. You being an intern proceed with auscultation of the patient's chest. Your findings are ejection systolic murmur in the left 2nd intercostal space, S1 is normal and has wide and fixed split S2. You then send the patient for an ECG, what would be the most likely finding in the ECG report?

Accepted Answer

Right axis deviation

Answer

Left axis deviation

Answer

Large p waves

Answer

Absent p waves

Question 9

NOT an indication for surgery in a Ventricular septal defect

Accepted Answer

Eisenmenger's Syndrome

Answer

Suck- Rest-Suck cycle while feeding

Answer

Pulmonary: Systemic blood flow > 2:1

Answer

Hepatomegaly

Question 10

Commonest congenital heart disease is:

Accepted Answer

Ventricular septal defect

Answer

Patent ductus arteriosus

Answer

Atrial septal defect

Answer

Mitral valve prolapse

Cardiology — MCQs

Cardiology — MCQs

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