Cardiology Practice Questions

Q: A 3-year-old child presents with the clinical features shown in the image. What is the most likely diagnosis?

Kawasaki disease. ***Kawasaki disease*** * The image displays classic signs of **Kawasaki disease**, including **bilateral conjunctivitis without exudates** (top left), **erythema of the palms and soles with desquamation** (top right), **cervical lymphadenopathy** (bottom left, indicated by swelling in the neck region), and a **strawberry tongue** (bottom right). * These clinical features, especially in a young child, are diagnostic for **Kawasaki disease**, which is a vasculitis affecting medium-sized arteries, most notably the coronary arteries. *Scarlet fever* * While **scarlet fever** can cause a **strawberry tongue** and a rash, the rash is typically a **fine, sandpaper-like rash** that blanches with pressure, not usually characterized by the distinct palm/sole erythema and desquamation seen in the image. * **Conjunctivitis** is not a prominent feature of scarlet fever, and the lymphadenopathy is typically less pronounced and may be tender. *Kikuchi disease* * **Kikuchi disease** (histiocytic necrotizing lymphadenitis) primarily presents with **cervical lymphadenopathy, fever**, and often rash, but it does **not typically involve conjunctivitis or changes in the hands, feet, or tongue** as dramatically depicted. * It is a self-limiting condition of unknown etiology, distinct from the systemic vasculitis of Kawasaki disease. *Rosai-Dorfman disease* * **Rosai-Dorfman disease** (sinus histiocytosis with massive lymphadenopathy) is characterized by **massive, painless lymphadenopathy**, particularly cervical, with fever and other systemic symptoms. * However, it does **not present with the specific mucocutaneous findings** of conjunctivitis, strawberry tongue, or characteristic hand/foot changes seen in the images indicative of Kawasaki disease.

Q: A 10-year-old child with Valvular heart disease on heart failure treatment, has the following ECG tracing. What is the diagnosis?

Non paroxysmal atrial tachycardia with regular AV block. ***Non paroxysmal atrial tachycardia with regular AV block*** - The ECG shows a sustained atrial tachycardia with a **consistent P-P interval**, indicating a non-paroxysmal origin. - There is a **fixed ratio between P waves and QRS complexes** (e.g., 2:1 or 3:1), demonstrating a regular AV block, likely due to increased vagal tone or AV nodal dysfunction, often seen in cases of **digoxin toxicity** (given the patient is on heart failure treatment for valvular heart disease). *Tall tented T-wave* - **Tall, tented T-waves** are characteristic of **hyperkalemia**, but the ECG tracing does not exhibit this morphology. - While hyperkalemia can cause rhythm disturbances, the predominant feature here is a regular atrial tachycardia with AV block, not T-wave changes typical of electrolyte imbalance. *Ventricular bigeminy* - **Ventricular bigeminy** would manifest as alternating normal QRS complexes with premature ventricular contractions (PVCs). - The ECG shows a narrow complex tachycardia with visible P waves, which are not characteristic of PVCs or ventricular bigeminy. *Non paroxysmal atrial tachycardia with irregular AV block* - Although there is non-paroxysmal atrial tachycardia, the **AV block is regular** (e.g., a consistent 2:1 or 3:1 conduction ratio), not irregular. - An irregular AV block would suggest variability in AV nodal conduction, such as in AV Wenckebach or Mobitz type II with variable conduction, which is not what is seen in this tracing.

Q: A 1-year-old child with CHD is on heart failure treatment. The ECG shows all except:

Heart rate of 60 bpm approximately. ***Heart rate of 60 bpm approximately*** - The ECG rhythm is irregular; however, the predominant rhythm shows a normal heart rate for a 1-year-old child. A heart rate of 60 bpm would be considered **bradycardia** in an infant, where the normal heart rate ranges from 100-160 bpm. - The calculated heart rate from the provided ECG strip is approximately 100-120 bpm (counting 10 small squares between R waves, which corresponds to 1500/100 = 150 bpm, or 15 small squares, hence 1500/15 = 100 bpm if the duration between two consecutive R waves is 15 small squares on the ECG graph). *Ventricular bigeminy* - The ECG shows a regular QRS complex followed by a premature ventricular contraction (PVC), which is then followed by another regular QRS complex, fitting the pattern of **ventricular bigeminy**. - This pattern can be observed as the wide, bizarre QRS complexes interspersed between normal beats. *ST depression* - The ST-segment, which is the interval between the end of the QRS complex and the beginning of the T wave, appears to be **depressed**, particularly in the leads shown (V3 and V6). - This finding can indicate **myocardial ischemia** or strain, commonly seen in heart failure. *U wave* - A **U wave** is a small deflection immediately following the T wave, typically positive and best seen in V2-V3. - These waves are visible on this ECG, often prominent when there's hypokalemia or digitalis toxicity, which is plausible in a child on heart failure treatment.

Q: Which one of the following is a cyanotic congenital heart disease?

Tetralogy of Fallot. ***Tetralogy of Fallot*** - This condition is characterized by **four distinct heart defects** that result in **right-to-left shunting** of unoxygenated blood into the systemic circulation, leading to cyanosis. - The four defects are **ventricular septal defect**, **pulmonary stenosis**, **overriding aorta**, and **right ventricular hypertrophy**. *Patent ductus arteriosus* - This is an **acyanotic heart defect** where there is a persistent opening between the aorta and pulmonary artery, leading to a **left-to-right shunt**, increasing pulmonary blood flow. - It does not typically cause cyanosis unless there is severe pulmonary hypertension leading to shunt reversal (Eisenmenger syndrome). *Ventricular septal defect* - This is also primarily an **acyanotic heart defect** where a hole exists between the ventricles, causing a **left-to-right shunt** of oxygenated blood. - Cyanosis would only occur in severe cases with significant pulmonary hypertension and shunt reversal (Eisenmenger syndrome). *Atrial septal defect* - This is an **acyanotic heart defect** involving an opening between the atria, usually resulting in a **left-to-right shunt** of oxygenated blood into the right atrium. - It rarely causes cyanosis unless there are significant complications like pulmonary hypertension with shunt reversal.

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: Ebstein anomaly is due to -

Lithium. ***Correct: Lithium*** - **Lithium** exposure during the first trimester of pregnancy is a known teratogen associated with an increased risk of **Ebstein anomaly** - **Ebstein anomaly** is a congenital heart defect affecting the **tricuspid valve**, characterized by its displacement into the right ventricle - The association with lithium is well-documented, though the absolute risk remains relatively low (approximately 1-2% compared to baseline risk of 0.01%) *Incorrect: Copper (Cu)* - **Copper (Cu)** is an essential trace element required for various enzymatic functions - While both copper deficiency and toxicity can cause health issues, there is no clear evidence linking copper exposure or deficiency directly to Ebstein anomaly - Not a recognized teratogen for this specific cardiac malformation *Incorrect: Nickel (Ni)* - **Nickel (Ni)** exposure has not been established as a significant risk factor for congenital heart defects like Ebstein anomaly - While nickel can act as an allergen and cause contact dermatitis or other toxic effects in high doses, it is not a recognized cardiac teratogen - No documented association with tricuspid valve abnormalities during fetal development *Incorrect: Cobalt (Co)* - **Cobalt (Co)** is a trace element that in excessive amounts can lead to toxicity including cardiomyopathy in adults - However, cobalt is not linked to the development of **Ebstein anomaly** during fetal development - No known direct association between cobalt exposure and congenital tricuspid valve abnormalities

Question 1

A 3-year-old child presents with the clinical features shown in the image. What is the most likely diagnosis?

Accepted Answer

Kawasaki disease

Answer

Scarlet fever

Answer

Kikuchi disease

Answer

Rosai-Dorfman disease

Question 2

A 10-year-old child with Valvular heart disease on heart failure treatment, has the following ECG tracing. What is the diagnosis?

Accepted Answer

Non paroxysmal atrial tachycardia with regular AV block

Answer

Tall tented T-wave

Answer

Ventricular bigeminy

Answer

Non paroxysmal atrial tachycardia with irregular AV block

Question 3

A 1-year-old child with CHD is on heart failure treatment. The ECG shows all except:

Accepted Answer

Heart rate of 60 bpm approximately

Answer

Ventricular bigeminy

Answer

ST depression

Answer

U wave

Question 4

Which one of the following is a cyanotic congenital heart disease?

Accepted Answer

Tetralogy of Fallot

Answer

Patent ductus arteriosus

Answer

Ventricular septal defect

Answer

Atrial septal defect

Question 5

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 6

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 7

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 8

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 9

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 10

Ebstein anomaly is due to -

Accepted Answer

Lithium

Answer

Cu

Answer

Ni

Answer

Co

Cardiology — MCQs

Cardiology — MCQs

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