Cardiology — MCQs

Cardiology Indian Medical PG Practice Questions and MCQs

Question 381: A 6-year-old with congenital heart disease presents with fever, new-onset murmur, and petechiae. Blood cultures are pending, but initial Gram stain shows Gram-positive cocci. What is the most appropriate initial intervention?

A. Schedule for urgent valve replacement
B. Administer high-dose steroids
C. Start broad-spectrum antibiotics (Correct Answer)
D. Wait for susceptibility testing

Explanation: ***Start broad-spectrum antibiotics*** - The presentation of **fever**, **new-onset murmur**, **petechiae**, and **Gram-positive cocci** in a patient with **congenital heart disease** is highly suggestive of **infective endocarditis**. - Prompt initiation of **broad-spectrum antibiotics** is crucial to prevent further damage to the heart valves and systemic complications while awaiting definitive culture results. *Schedule for urgent valve replacement* - **Valve replacement** is a definitive treatment for severe valvular damage but is typically considered after initial medical management has failed or in cases of severe complications like heart failure or recurrent emboli. - It is not the initial intervention for suspected infective endocarditis. *Administer high-dose steroids* - **Steroids** are anti-inflammatory but are not indicated in the treatment of active bacterial infections like endocarditis. - Administering steroids could potentially worsen the infection by suppressing the immune response. *Wait for susceptibility testing* - **Waiting for susceptibility testing** to initiate treatment would delay critical care, allowing the infection to progress and increasing morbidity and mortality. - Initial treatment should be empiric, and antibiotics can be narrowed once susceptibility results are available.

Question 382: A 2-year-old presents with fever, cervical lymphadenopathy, strawberry tongue, and desquamating rash on fingers. What is the cardiac complication?

A. Pericarditis
B. Coronary artery aneurysm (Correct Answer)
C. Endocarditis
D. Myocarditis

Explanation: ***Coronary artery aneurysm*** - The constellation of **fever**, **cervical lymphadenopathy**, **strawberry tongue**, and **desquamating rash** is highly suggestive of **Kawasaki disease**. - **Coronary artery aneurysm** is the most significant and *life-threatening cardiac complication* of untreated or severe Kawasaki disease, leading to long-term morbidity and mortality. *Pericarditis* - While pericarditis can occur in some systemic inflammatory conditions, it is **not the hallmark cardiac complication** of Kawasaki disease. - Pericarditis is characterized by **chest pain** and **pericardial friction rub**, which are not typically the primary concerns in Kawasaki disease management. *Endocarditis* - **Infective endocarditis** involves inflammation of the *inner lining of the heart and heart valves*, often caused by bacterial or fungal infections. - It is **not a typical complication of Kawasaki disease**, which is a vasculitis, not primarily an endocardial infection. *Myocarditis* - Myocarditis (inflammation of the heart muscle) can occur in various viral infections, and mild myocarditis can be present in Kawasaki disease. - However, **coronary artery aneurysms** represent the most *specific and critical cardiac complication* that requires careful monitoring and treatment to prevent rupture or thrombosis.

Question 383: A child with Tetralogy of Fallot develops worsening cyanosis and fainting spells. Which immediate intervention is recommended?

A. Morphine
B. Oxygen therapy
C. IV fluids
D. Knee-chest position (Correct Answer)

Explanation: ***Knee-chest position*** - The **knee-chest position** increases **systemic vascular resistance (SVR)**, which helps to reduce the right-to-left shunting of deoxygenated blood through the ventricular septal defect (VSD) in Tetralogy of Fallot. - This maneuver effectively alleviates **hypercyanotic spells** (tet spells) by increasing pulmonary blood flow and improving oxygenation. *Morphine* - While morphine can be used to sedate and reduce infundibular spasm during a tet spell, it is typically administered *after* initial attempts to increase SVR, such as the knee-chest position. - Its primary role is to reduce anxiety and calm the child, which can indirectly help, but it's not the immediate mechanical intervention of choice. *Oxygen therapy* - **Oxygen therapy** can be beneficial by increasing the partial pressure of oxygen in the blood, which may help to alleviate cyanosis. - However, in a severe tet spell, the primary issue is reduced pulmonary blood flow due to an outflow obstruction and right-to-left shunting, so simply providing oxygen without addressing the shunting is often insufficient as an immediate, stand-alone intervention. *IV fluids* - **IV fluids** are important for maintaining adequate **preload** and preventing dehydration, especially if the child is hyperpneic or agitated. - While supportive, IV fluids do not directly address the underlying pathophysiology of a tet spell, which involves a dynamic right ventricular outflow tract obstruction and right-to-left shunting.

Question 384: Which one of the following is a criterion of Kawasaki disease?

A. Edema
B. Rash (Correct Answer)
C. Purulent conjunctivitis
D. Strawberry tongue

Explanation: ***Rash*** - A **polymorphous rash**, which can be macular, papular, or scarlatiniform, is one of the **five principal diagnostic criteria** for **Kawasaki disease**. - This rash typically appears early in the course of the illness and can affect any part of the body, often involving the trunk and extremities. *Edema* - **Edema of the hands and feet**, especially when accompanied by **erythema** (redness), is actually one of the **principal diagnostic criteria** for Kawasaki disease under "extremity changes." - This finding typically occurs in the acute phase, followed by **desquamation** (peeling) in the convalescent phase, particularly in the periungual region. - Note: While edema is a valid criterion, **rash** is considered the most characteristic and commonly used criterion among the options listed. *Purulent conjunctivitis* - **Kawasaki disease** characteristically presents with **bilateral non-purulent (non-exudative) conjunctival injection** - red eyes without discharge or exudate. - **Purulent conjunctivitis** (conjunctivitis with pus/discharge) indicates a bacterial infection and actually argues **against** the diagnosis of Kawasaki disease. - This is the only option that is definitively **not** a criterion. *Strawberry tongue* - **Strawberry tongue** (red, swollen tongue with prominent papillae) is part of the **oral changes criterion** in Kawasaki disease, which includes red cracked lips, strawberry tongue, and erythema of the oropharyngeal mucosa. - While also seen in scarlet fever and toxic shock syndrome, strawberry tongue is a **recognized feature** of Kawasaki disease. - Note: This is technically a valid criterion, though less specific than the polymorphous rash.

Question 385: What is the pathophysiologic basis for cyanosis in congenital heart disease?

A. Increased pulmonary blood flow due to left-to-right shunt
B. Increased systemic vascular resistance
C. Right-to-left shunt
D. Decreased oxygenation from right-to-left shunt (Correct Answer)

Explanation: ***Decreased oxygenation from right-to-left shunt*** - In cyanotic congenital heart disease, a **right-to-left shunt** allows **deoxygenated blood** from the right side of the heart to bypass the lungs and enter the systemic circulation directly. - This results in **decreased systemic arterial oxygen saturation (hypoxemia)**, which causes the characteristic bluish discoloration of the skin and mucous membranes known as **cyanosis**. - Cyanosis becomes clinically visible when **deoxygenated hemoglobin exceeds 3-5 g/dL** in capillary blood, which occurs due to the mixing of deoxygenated and oxygenated blood. *Increased pulmonary blood flow due to left-to-right shunt* - A **left-to-right shunt** (seen in ASD, VSD, PDA) directs oxygenated blood from the left heart back into the pulmonary circulation. - This causes **acyanotic heart disease** with increased pulmonary blood flow, potentially leading to heart failure or pulmonary hypertension, but **not cyanosis**. *Increased systemic vascular resistance* - Increased **systemic vascular resistance (SVR)** affects cardiac afterload and blood pressure but does not directly cause cyanosis. - While elevated SVR may worsen right-to-left shunting in certain conditions (e.g., Tetralogy of Fallot), it is not the pathophysiologic basis for cyanosis. *Right-to-left shunt* - While a **right-to-left shunt** is the anatomic/structural abnormality that permits deoxygenated blood to enter systemic circulation, the question asks for the **pathophysiologic basis** (the functional consequence). - The shunt itself is the mechanism, but **decreased oxygenation resulting from the shunt** is what directly produces the clinical finding of cyanosis.

Question 386: What is the most appropriate management step for a 6-year-old child with a history of repaired tetralogy of Fallot who presents with exercise intolerance, palpitations, and cyanosis, and has an ECG showing ventricular arrhythmias?

A. Holter monitoring and beta-blocker therapy (Correct Answer)
B. Repeat surgical intervention for tetralogy of Fallot
C. Catheter ablation and ACE inhibitors
D. Electrophysiological study followed by ICD placement

Explanation: ***Holter monitoring and beta-blocker therapy*** - **Holter monitoring** is essential to fully characterize the type and frequency of **ventricular arrhythmias** in a patient with a history of repaired Tetralogy of Fallot, as late arrhythmias are a common complication. - **Beta-blockers** are the first-line pharmacologic treatment for **ventricular arrhythmias** in patients with underlying structural heart disease, helping to reduce symptoms such as palpitations and improve exercise tolerance. - The presence of **cyanosis** suggests possible hemodynamic issues (residual VSD, severe pulmonary regurgitation, or RV dysfunction), which require further evaluation with **echocardiography**, but initial stabilization with arrhythmia control is appropriate. - This approach allows for **risk stratification** before considering more invasive interventions. *Repeat surgical intervention for tetralogy of Fallot* - While patients with repaired Tetralogy of Fallot often require later interventions (e.g., **pulmonary valve replacement** for severe pulmonary regurgitation or **RVOT obstruction**), surgery should be guided by comprehensive imaging and hemodynamic assessment, not based on symptoms and ECG alone. - The **cyanosis** may indicate need for eventual surgical intervention, but this requires thorough diagnostic workup first (echocardiography, cardiac MRI, possibly cardiac catheterization). - Surgery does not directly address the acute **ventricular arrhythmias** without first optimizing medical management and identifying specific anatomical substrates. *Catheter ablation and ACE inhibitors* - **Catheter ablation** is typically reserved for **refractory arrhythmias** or specific arrhythmia substrates identified after initial medical management has failed. - **ACE inhibitors** are primarily used for **heart failure** with reduced ejection fraction and **hypertension**, not as first-line treatment for **ventricular arrhythmias** in this context. - This is too aggressive as initial management without prior medical optimization. *Electrophysiological study followed by ICD placement* - **Electrophysiological study (EPS)** and **ICD placement** are considered for patients with life-threatening **ventricular arrhythmias** (sustained ventricular tachycardia, ventricular fibrillation, aborted sudden cardiac death) or those at very high risk. - While repaired Tetralogy of Fallot patients have increased risk of sudden cardiac death (especially with **QRS duration >180 ms**, **RV dysfunction**, or **non-sustained VT**), initial management focuses on characterizing arrhythmias and medical therapy before proceeding to invasive interventions. - ICD may be indicated later based on risk stratification and response to initial therapy.

Question 387: Which symptom is not typically associated with Kawasaki disease?

A. Strawberry tongue
B. Prolonged fever
C. Coronary artery aneurysms
D. Hearing loss (Correct Answer)

Explanation: ***Hearing loss*** - While various complications can arise from Kawasaki disease, **sensorineural hearing loss** is not a typical manifestation or diagnostic criterion. - Hearing loss is more commonly associated with conditions like **bacterial meningitis** or certain genetic syndromes, which are distinct from Kawasaki disease. *Coronary artery aneurysms* - **Coronary artery aneurysms** are a very serious and common complication of **untreated** or severe Kawasaki disease, leading to potential long-term cardiac issues. - This symptom is a major concern in the management of affected children due to the risk of **myocardial infarction** and future cardiac events. *Strawberry tongue* - **Strawberry tongue** (red, swollen, and bumpy tongue) is a characteristic mucosal change seen in Kawasaki disease, often appearing during the acute phase. - This finding is one of the key diagnostic criteria, reflecting the widespread **inflammation** associated with the illness. *Prolonged fever* - **Prolonged fever** (lasting at least five days) is the hallmark diagnostic criterion for Kawasaki disease, indicating a systemic inflammatory response. - The fever is typically **high-spiking** and unresponsive to antipyretics, driving the need for prompt evaluation and treatment.

Question 388: A child with Down syndrome presents with heart failure and a systolic murmur. What is the most likely cardiac lesion?

A. Ventricular septal defect
B. Atrial septal defect
C. Patent ductus arteriosus
D. Atrioventricular septal defect (Correct Answer)

Explanation: ***Atrioventricular septal defect*** - This is the **most common cardiac lesion** in children with Down syndrome, accounting for approximately 40-50% of defects. - It involves a defect in both the **atrial and ventricular septa** and often an abnormality of the **atrioventricular valves**, leading to significant shunting and early heart failure. *Ventricular septal defect* - While a common congenital heart defect, isolated **ventricular septal defects (VSDs)** are less frequently associated with Down syndrome compared to AVSDs. - A VSD alone would typically present as a harsh **systolic murmur** but may not cause early heart failure unless very large. *Atrial septal defect* - An **atrial septal defect (ASD)** is also a common congenital heart defect, but it is typically asymptomatic in early childhood and less likely to cause heart failure immediately. - The murmur associated with an ASD is usually a **systolic ejection murmur** at the upper left sternal border due to increased pulmonary flow, not necessarily a pansystolic murmur. *Patent ductus arteriosus* - A **patent ductus arteriosus (PDA)** can cause heart failure, but it is less common as the primary lesion in children with Down syndrome compared to AVSD. - The characteristic murmur of a PDA is a continuous **"machinery-like" murmur** rather than a purely systolic murmur as described.

Question 389: A newborn exhibits cyanosis, tachypnea, and a murmur. Which diagnostic test would most accurately identify the underlying cardiac anomaly?

A. Echocardiogram (Correct Answer)
B. Chest X-ray (CXR)
C. Electrocardiogram
D. Cardiac catheterization (invasive)

Explanation: ***Echocardiogram*** - An **echocardiogram** provides a real-time, detailed view of the **heart's structure and function**, allowing for direct visualization of cardiac anomalies, blood flow patterns, and chamber sizes. - It is a **non-invasive** and highly accurate method for diagnosing congenital heart diseases, making it the most suitable initial diagnostic test for a newborn with cyanosis, tachypnea, and a murmur. *Chest X-ray (CXR)* - A CXR can show **cardiac silhouette size** and **pulmonary vascular markings**, which might suggest a cardiac anomaly but does not provide details on specific structural defects. - It is often used as an initial screening tool but lacks the resolution to accurately identify the underlying cardiac anomaly. *Electrocardiogram* - An **ECG** evaluates the **electrical activity of the heart**, detecting arrhythmias, chamber enlargement, and myocardial ischemia. - While it can provide clues about cardiac stress or hypertrophy, it cannot visualize the anatomical structure of the heart or precisely identify specific congenital anomalies. *Cardiac catheterization (invasive)* - **Cardiac catheterization** is an **invasive procedure** that provides very detailed information on blood pressures and oxygen saturation within the heart chambers, and can also be therapeutic. - However, due to its invasiveness and associated risks, it is typically reserved for cases where echocardiography is inconclusive, for pre-surgical planning, or for therapeutic interventions, not as the primary diagnostic tool in a neonate with suspected congenital heart disease.

Question 390: A 2-month-old infant presents with tachypnea and a harsh systolic murmur best heard over the left sternal border. Which congenital heart defect is most likely?

A. Tetralogy of Fallot
B. Ventricular septal defect (Correct Answer)
C. Atrial septal defect
D. Coarctation of the aorta

Explanation: ***Ventricular septal defect*** - A **harsh systolic murmur** heard best at the **left sternal border** is a classic finding in VSD due to blood shunting from the left to the right ventricle. - **Tachypnea in an infant** with VSD often indicates **pulmonary overcirculation** and developing heart failure due to the significant left-to-right shunt. *Tetralogy of Fallot* - This condition typically presents with **cyanosis** and a **crescendo-decrescendo systolic ejection murmur** heard at the upper left sternal border due to right ventricular outflow tract obstruction. - While tachypnea can occur, the characteristic **cyanotic spells** (tet spells) and absence of a harsh VSD murmur make it less likely. *Atrial septal defect* - An ASD typically causes a **systolic ejection murmur** at the **pulmonic area** (second intercostal space, left sternal border) due to increased flow across the pulmonic valve, not a harsh murmur at the left sternal border. - Significant respiratory distress like tachypnea is less common in infancy unless there are other associated defects or severe pulmonary hypertension. *Coarctation of the aorta* - This defect presents with **blood pressure differences** between the upper and lower extremities and often a **systolic murmur** heard in the back or left infraclavicular area. - While it can cause heart failure symptoms including tachypnea, the murmur description and location are not typical for coarctation.

Practice by Chapter

Congenital Heart Diseases: Cyanotic

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Congenital Heart Diseases: Acyanotic

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Rheumatic Heart Disease

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Kawasaki Disease

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Infective Endocarditis

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Myocarditis and Cardiomyopathies

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Arrhythmias in Children

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Heart Failure in Children

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Pulmonary Hypertension

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Systemic Hypertension

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Dyslipidemia in Children

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Cardiac Evaluation and Diagnostics

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Cardiology — MCQs

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