Cardiology Practice Questions

Q: All of the following statements regarding total anomalous pulmonary venous connection are true EXCEPT?

It is always associated with a VSD.. In **Total Anomalous Pulmonary Venous Connection (TAPVC)**, all four pulmonary veins fail to connect to the left atrium and instead drain into the systemic venous circulation or the right atrium. ### **Explanation of Options** * **Option B (Correct Answer):** TAPVC is **not** associated with a Ventricular Septal Defect (VSD) by definition. Instead, it is **obligatorily associated with an Atrial Septal Defect (ASD)** or a patent foramen ovale. Since all pulmonary and systemic blood returns to the right heart, an interatrial communication is essential for survival to allow blood to reach the left side of the heart and the systemic circulation. * **Option A:** This is true. Whether the drainage is supracardiac (via the vertical vein), cardiac (via the coronary sinus), or infracardiac, the entire pulmonary venous return eventually reaches the **Right Atrium**. * **Option C:** This is true. In TAPVC, there is complete mixing of blood in the right atrium. However, because the pulmonary blood flow is usually much higher than systemic flow, the **oxygen saturation in the Pulmonary Artery is often higher than in the Aorta** (where saturation is limited by the mixing and the right-to-left shunt across the ASD). * **Option D:** This is true. **Infracardiac (Type III) TAPVC** is almost always obstructive because the pulmonary veins must pass through the diaphragm (esophageal hiatus) and often drain into the portal system, which offers high resistance. ### **High-Yield Clinical Pearls for NEET-PG** * **Chest X-ray:** Look for the **"Figure of 8"** or **"Snowman sign"** in Supracardiac TAPVC. * **Infracardiac TAPVC:** Presents early (first days of life) with severe respiratory distress and cyanosis; the heart size is typically normal on X-ray (unlike other types). * **Hemodynamics:** It is a **cyanotic congenital heart disease** with **increased pulmonary blood flow**.

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: Regarding Kawasaki disease, all of the following are true, EXCEPT:

Suppurative lymphadenopathy. **Explanation:** Kawasaki Disease (KD) is an acute, febrile, multi-systemic medium-vessel vasculitis that primarily affects children. The diagnosis is clinical, based on the presence of high-grade fever for at least 5 days along with specific diagnostic criteria. **Why "Suppurative lymphadenopathy" is the correct answer:** Cervical lymphadenopathy is a classic diagnostic criterion for Kawasaki disease; however, it is characteristically **non-suppurative** (dry). It is usually unilateral, involves the anterior cervical chain, and measures >1.5 cm. The presence of pus or fluctuance (suppuration) should lead a clinician to consider alternative diagnoses like bacterial lymphadenitis. **Analysis of Incorrect Options:** * **A. Mucocutaneous lesions:** These are hallmark features. They include "strawberry tongue," cracked red lips, oropharyngeal erythema, and a polymorphic skin rash. * **B. Coronary artery is involved:** KD is the leading cause of acquired heart disease in children in developed nations. Coronary artery aneurysms (CAA) occur in 20–25% of untreated cases, typically appearing in the subacute phase. * **C. Seen in children:** Approximately 80–90% of cases occur in children under the age of 5. It is rare in adults. **High-Yield NEET-PG Pearls:** * **Treatment:** The gold standard is **IVIG (2g/kg)** plus **High-dose Aspirin**. This reduces the risk of coronary aneurysms to <5%. * **Cardiac Complication:** Myocarditis is common in the acute phase; Coronary Aneurysms are the most serious long-term complication. * **Incomplete Kawasaki:** Suspect this in infants with prolonged fever who do not meet all 4/5 clinical criteria but have elevated inflammatory markers (ESR/CRP). * **BCG Site Reactivity:** Erythema or crusting at a prior BCG vaccination site is a highly specific clinical sign for KD.

Q: All of the following are characteristic of the classic tetralogy of Fallot except?

Left ventricular hypertrophy. **Explanation:** Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. It is characterized by a single developmental defect: the **anterior and cephalad deviation of the infundibular (conal) septum**. This malalignment leads to the four classic anatomical features. **Why Option D is the Correct Answer:** In TOF, the right ventricle (RV) faces high pressure because it must pump against a stenosed pulmonary valve and the systemic pressure of the aorta (via the VSD). This leads to **Right Ventricular Hypertrophy (RVH)**, not left. The left ventricle typically remains normal in size or may even be slightly smaller due to reduced pulmonary venous return. Therefore, **Left Ventricular Hypertrophy** is not a feature of TOF. **Analysis of Incorrect Options:** * **A. Large VSD:** A non-restrictive malalignment VSD is a core component, allowing equalized pressures between the two ventricles. * **B. Overriding Aorta:** Due to the displaced septum, the aortic root is shifted to the right, "straddling" the VSD and receiving blood from both ventricles. * **C. RV Outflow Obstruction (RVOTO):** This is usually infundibular (subvalvular) stenosis, though it can be valvular or supravalvular. The severity of cyanosis in TOF is directly proportional to the degree of RVOTO. **NEET-PG High-Yield Pearls:** * **X-ray Finding:** "Boot-shaped heart" (*Coeur en sabot*) due to an upturned apex (from RVH) and a concave pulmonary segment. * **Clinical Sign:** "Tet Spells" (hypoxic spells) occur due to an acute increase in right-to-left shunting. Management includes the **knee-chest position** (to increase systemic vascular resistance). * **Murmur:** The murmur in TOF is due to **pulmonary stenosis**, not the VSD. A softer murmur indicates a more severe obstruction (less flow). * **ECG:** Characteristically shows **Right Axis Deviation** and RVH.

Q: Which of the following is a true statement about Coarctation of the Aorta?

Lower limb pulses are barely palpable or absent.. **Explanation:** Coarctation of the Aorta (CoA) is a congenital narrowing of the aortic lumen, typically occurring near the insertion of the ductus arteriosus. **1. Why Option A is Correct:** The hallmark clinical finding of CoA is a **significant pressure gradient** between the upper and lower extremities. Because the narrowing obstructs blood flow to the descending aorta, the femoral, popliteal, and dorsalis pedis pulses are characteristically weak, delayed (**radio-femoral delay**), or entirely absent. **2. Analysis of Incorrect Options:** * **Option B:** While the statement about blood pressure is physiologically true, Option A is the "most" characteristic clinical sign used for bedside diagnosis. However, in many standardized exams, if multiple statements are factually correct, the most definitive clinical sign is prioritized. *Note: In some contexts, B is also true, but A is the classic physical exam finding.* * **Option C:** CoA is actually **two to five times more common in males** than in females. However, it is famously associated with **Turner Syndrome (45, XO)** in females. * **Option D:** The radiological sign is **rib notching** (Roesler’s sign), which is **erosion/atrophy** of the inferior aspect of the 3rd to 8th ribs due to pressure from dilated collateral intercostal arteries, not hypertrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Associated Conditions:** Bicuspid aortic valve (most common, ~70%), Turner Syndrome, and Berry aneurysms (Circle of Willis). * **Chest X-ray:** Look for the **"Figure of 3" sign** (pre- and post-stenotic dilatation) and rib notching (usually seen after age 5). * **Physical Exam:** Systolic murmur best heard at the **left infrascapular area**. * **Treatment:** Prostaglandin E1 in neonates to keep the ductus open; balloon angioplasty or surgical resection for definitive repair.

Q: What is a common cause of cyanosis?

Tetralogy of Fallot. **Explanation:** Cyanosis in pediatrics is primarily categorized into cyanotic and acyanotic congenital heart diseases (CHDs). **Why Tetralogy of Fallot (TOF) is the correct answer:** TOF is the **most common cyanotic heart disease** presenting after the neonatal period. It consists of four components: Pulmonary stenosis (the primary determinant of severity), Right Ventricular Hypertrophy, Overriding of the Aorta, and a large VSD. The obstruction to right ventricular outflow causes deoxygenated blood to shunt right-to-left through the VSD into the systemic circulation, leading to clinical cyanosis. **Analysis of Incorrect Options:** * **B. Patent Ductus Arteriosus (PDA):** This is an **acyanotic** CHD characterized by a left-to-right shunt. Cyanosis only occurs if reversal of the shunt (Eisenmenger syndrome) develops much later in life. * **C. Tricuspid Atresia:** While this is a cyanotic CHD, it is significantly **less common** than TOF. It presents early in the neonatal period and is characterized by a "left axis deviation" on ECG, unlike the right axis deviation seen in TOF. * **D. Eisenmenger’s Complex:** This refers to the reversal of a long-standing left-to-right shunt (like VSD) due to pulmonary hypertension. While it causes cyanosis, it is a **late complication** rather than a primary common cause in the pediatric age group. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray finding in TOF:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex (RVH) and concave pulmonary segment. * **Tet Spells:** Hypercyanotic episodes managed with knee-chest positioning, oxygen, and morphine. * **Most common cyanotic CHD at birth:** Transposition of the Great Arteries (TGA). * **Most common cyanotic CHD overall (after infancy):** Tetralogy of Fallot.

Q: A newborn presents with deepening cyanosis at birth, with congestive heart failure and a normal first heart sound. X-ray reveals cardiomegaly. What is the diagnosis?

Transposition of great vessels. **Explanation:** **Transposition of the Great Arteries (TGA)** is the most common cause of cyanotic heart disease presenting in the immediate neonatal period. In TGA, the aorta arises from the right ventricle and the pulmonary artery from the left ventricle, creating two parallel circulations. 1. **Why TGA is correct:** * **Cyanosis:** Deepening cyanosis occurs as the Ductus Arteriosus closes. * **Congestive Heart Failure (CHF):** Unlike many other cyanotic defects, TGA often presents with early CHF due to increased pulmonary blood flow and volume overload. * **X-ray:** Characteristically shows **cardiomegaly** with a narrow mediastinum (the "Egg-on-a-string" appearance). * **Heart Sounds:** S1 is usually normal; S2 is often single and loud because the aorta is anterior. 2. **Why other options are incorrect:** * **Tetralogy of Fallot (TOF):** Typically presents later (not at birth) and features a **boot-shaped heart** with *decreased* pulmonary blood flow (no cardiomegaly or CHF). * **Ebstein Anomaly:** While it causes massive cardiomegaly, it is associated with a "box-shaped" heart and multiple clicks/split sounds, not a normal S1. * **Tricuspid Atresia:** Usually presents with a **left axis deviation** on ECG and a "horizontal" or "boot-shaped" heart, but rarely presents with significant cardiomegaly and CHF simultaneously at birth. **High-Yield Clinical Pearls for NEET-PG:** * **Egg-on-a-string appearance:** Classic radiological sign for TGA. * **Medical Management:** Infusion of **PGE1 (Alprostadil)** is life-saving to keep the ductus arteriosus patent. * **Surgical Procedure:** The treatment of choice is the **Arterial Switch Operation (Jatene Procedure)**, ideally performed within the first 2 weeks of life. * **Rashkind Procedure:** Balloon atrial septostomy used as a palliative measure to improve mixing.

Q: A 5-month-old pale and lethargic male infant presents to the emergency department. On examination, heart rate is 240 bpm and does not change with crying. Lungs are clear and there is no hepatomegaly. An ECG is provided. Which of the following is the first step in the management of this patient?

Carotid sinus massage. ***Carotid sinus massage*** - **Vagal maneuvers** are the first-line treatment for stable **supraventricular tachycardia (SVT)** in infants, with carotid sinus massage being effective and safe. - The **fixed heart rate of 240 bpm** that doesn't change with crying is pathognomonic of **SVT** in infants, making vagal stimulation the appropriate initial intervention. *Rapid verapamil infusion* - **Verapamil is absolutely contraindicated** in infants under 1 year of age due to risk of severe **hypotension** and **cardiac arrest**. - Can cause **profound myocardial depression** and **cardiovascular collapse** in young infants with immature cardiac conduction systems. *Transthoracic pacing of the heart* - Pacing is used for **bradyarrhythmias** and **heart blocks**, not for treating **tachyarrhythmias** like SVT. - Would be inappropriate and potentially dangerous as it could **increase the heart rate** further in an already tachycardic patient. *Direct current cardioversion* - Reserved for **unstable SVT** with signs of **hemodynamic compromise** or when vagal maneuvers and **adenosine fail**. - This infant appears **stable** (clear lungs, no hepatomegaly), making less invasive vagal maneuvers the preferred first step.

Question 1

All of the following statements regarding total anomalous pulmonary venous connection are true EXCEPT?

Accepted Answer

It is always associated with a VSD.

Answer

The total pulmonary venous blood reaches the right atrium.

Answer

The oxygen saturation of the blood in the pulmonary artery is higher than that in the aorta.

Answer

The infracardiac type is always obstructive.

Question 2

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 3

All of the following conditions are associated with a systolic thrill in the left 2nd and 3rd intercostal space, EXCEPT:

Accepted Answer

Pink Tetralogy of Fallot

Answer

Subpulmonic Ventricular Septal Defect

Answer

Pulmonic stenosis

Answer

Ebstein's anomaly

Question 4

Regarding Kawasaki disease, all of the following are true, EXCEPT:

Accepted Answer

Suppurative lymphadenopathy

Answer

Mucocutaneous lesions

Answer

Coronary artery is involved

Answer

Seen in children

Question 5

All of the following statements about Kawasaki disease are true, EXCEPT:

Accepted Answer

Thrombocytopenia is a common finding.

Answer

Intravenous immunoglobulin is the treatment of choice.

Answer

The prognosis is generally good with appropriate treatment.

Answer

Elevated ESR is a characteristic laboratory finding.

Question 6

All of the following are characteristic of the classic tetralogy of Fallot except?

Accepted Answer

Left ventricular hypertrophy

Answer

Large ventricular septal defect (VSD)

Answer

Aorta that overrides the VSD

Answer

Severe right ventricle outflow obstruction

Question 7

Which of the following is a true statement about Coarctation of the Aorta?

Accepted Answer

Lower limb pulses are barely palpable or absent.

Answer

Blood pressure is elevated proximal to the lesion and reduced distal to it.

Answer

The condition is twice as common in males as females.

Answer

Hypertrophy of the lower ribs may be seen in older children.

Question 8

What is a common cause of cyanosis?

Accepted Answer

Tetralogy of Fallot

Answer

Patent Ductus Arteriosus

Answer

Tricuspid Atresia

Answer

Eisenmenger's Complex

Question 9

A newborn presents with deepening cyanosis at birth, with congestive heart failure and a normal first heart sound. X-ray reveals cardiomegaly. What is the diagnosis?

Accepted Answer

Transposition of great vessels

Answer

Tetralogy of Fallot

Answer

Ebstein anomaly

Answer

Tricuspid atresia

Question 10

A 5-month-old pale and lethargic male infant presents to the emergency department. On examination, heart rate is 240 bpm and does not change with crying. Lungs are clear and there is no hepatomegaly. An ECG is provided. Which of the following is the first step in the management of this patient?

Accepted Answer

Carotid sinus massage

Answer

Rapid verapamil infusion

Answer

Transthoracic pacing of the heart

Answer

Direct current cardioversion

Cardiology — MCQs

Cardiology — MCQs

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