Cardiology — MCQs

Cardiology Indian Medical PG Practice Questions and MCQs

Question 401: A 9-year-old child presents with shortness of breath, fatigue, and a blowing systolic murmur best heard at the right upper sternal border. What is the most likely diagnosis?

A. Aortic stenosis (Correct Answer)
B. Mitral valve prolapse
C. Tricuspid regurgitation
D. Pulmonary stenosis

Explanation: ***Aortic stenosis*** - A **blowing systolic murmur** heard best at the **right upper sternal border** is characteristic of aortic stenosis, often radiating to the neck. - In a child, symptoms like **shortness of breath** and **fatigue** suggest significant outflow obstruction, which can occur with congenital aortic valve abnormalities. *Mitral valve prolapse* - This typically presents with a **mid-systolic click** followed by a **late systolic murmur**, best heard at the apex. - While it can cause fatigue, a **blowing systolic murmur** at the right upper sternal border is not typical. *Tricuspid regurgitation* - Presents with a **holosystolic murmur** best heard at the **left lower sternal border**, which intensifies with inspiration (Carvallo's sign). - Symptoms like fatigue and shortness of breath are usually associated with right-sided heart failure. *Pulmonary stenosis* - Characterized by a **systolic ejection murmur** heard best at the **left upper sternal border**, often with a thrill and a prominent ejection click. - The murmur's location and radiation pattern differ from the right upper sternal border presentation of aortic stenosis.

Question 402: A 4-month-old infant with cyanosis and cardiomegaly: What is the most likely diagnosis?

A. Tetralogy of Fallot
B. Transposition of Great Arteries (Correct Answer)
C. VSD
D. ASD

Explanation: ***Transposition of Great Arteries*** - This condition presents with **cyanosis** and **cardiomegaly** in early infancy due to the aorta arising from the right ventricle and the pulmonary artery from the left ventricle, causing parallel circulations. - The severe cyanosis often requires immediate intervention (e.g., **PGE1 infusion** to maintain ductal patency, **balloon atrial septostomy**) and leads to rapid cardiac enlargement and failure if not addressed. *Tetralogy of Fallot* - While it causes **cyanosis**, severe **cardiomegaly** is less common in a 4-month-old as the right ventricular hypertrophy acts as a compensatory mechanism, and the heart size can appear normal or mildly enlarged initially. - The classic presentation is often with a **harsh systolic ejection murmur** and **Tet spells**, which are sudden episodes of deep cyanosis. *VSD* - An **isolated VSD** primarily causes a **left-to-right shunt**, leading to **acyanotic congenital heart disease**; cyanosis would only occur in cases of Eisenmenger syndrome, which is rare in a 4-month-old infant. - While it can cause **cardiomegaly** due to volume overload, the absence of cyanosis makes it less likely than TGA. *ASD* - An **isolated ASD** is an **acyanotic heart defect** that typically causes a **left-to-right shunt**, leading to increased pulmonary blood flow, not cyanosis. - Significant **cardiomegaly** and symptoms like heart failure often appear later in childhood or adulthood, if at all, as the shunt is usually well-tolerated in infancy.

Question 403: An infant with Down syndrome is likely to have which of the following cardiac anomalies?

A. Atrial septal defect
B. Ventricular septal defect (Correct Answer)
C. Tetralogy of Fallot
D. Pulmonary atresia

Explanation: ***Ventricular septal defect*** - **Atrioventricular septal defect (AVSD)**, also called endocardial cushion defect, is the **most common cardiac anomaly** in Down syndrome (40-45% of CHD cases), accounting for more than any other single defect. - AVSD is a **complex defect** that involves VSD, ASD, and abnormal AV valves. Since VSD is the **ventricular component of AVSD** and isolated VSDs also occur in Down syndrome, **VSD** (either as part of AVSD or isolated) is the most common ventricular pathology. - Among the options provided, **VSD is the best answer** as it represents the most frequently affected chamber septum in Down syndrome. - Clinically presents with **heart failure symptoms** and risk of **pulmonary hypertension** due to left-to-right shunting. *Atrial septal defect* - **ASDs** can occur in Down syndrome, particularly as a component of AVSD (complete or partial). - However, **isolated ASD** (especially secundum type) is less specifically associated with Down syndrome compared to the VSD component of AVSD. - While present in many Down syndrome patients with AVSD, the **ventricular component** is more hemodynamically significant. *Tetralogy of Fallot* - **Tetralogy of Fallot (TOF)** occurs in Down syndrome but with much **lower frequency** compared to AVSD. - TOF comprises: **VSD, pulmonary stenosis, right ventricular hypertrophy**, and **overriding aorta**. - Represents approximately 5-10% of CHD in Down syndrome, significantly less than AVSD. *Pulmonary atresia* - **Pulmonary atresia** is a severe cyanotic heart defect with complete obstruction of the pulmonary valve. - **Not characteristically associated** with Down syndrome; much rarer than AVSD or even TOF in this population. - Requires ductal-dependent pulmonary blood flow and urgent intervention.

Question 404: A 4-month-old infant presents with failure to thrive, a harsh systolic murmur, and signs of heart failure. What is the most likely diagnosis?

A. Atrial Septal Defect
B. Ventricular Septal Defect (Correct Answer)
C. Coarctation of the Aorta
D. Tetralogy of Fallot

Explanation: ***Ventricular Septal Defect*** - A **large ventricular septal defect** allows for significant left-to-right shunting, leading to **pulmonary overcirculation** and eventual **heart failure**, manifesting as failure to thrive and a harsh systolic murmur. - The murmur in a VSD is typically **holosystolic (pansystolic)** and loudest at the lower left sternal border. *Atrial Septal Defect* - While ASDs also cause left-to-right shunting, significant symptoms like **heart failure** and **failure to thrive** are uncommon in infancy unless the defect is very large. - The murmur associated with an ASD is typically a **systolic ejection murmur** at the upper left sternal border, often due to increased flow across the pulmonary valve, not a harsh holosystolic murmur. *Coarctation of the Aorta* - This condition presents with **differential pulses** and **blood pressure** between the upper and lower extremities, weak femoral pulses, and often a **systolic murmur** heard in the back. - While it can lead to heart failure, the primary murmur is usually not described as a generalized "harsh systolic murmur" with generalized signs of pulmonary congestion unless severe left ventricular dysfunction has occurred. *Tetralogy of Fallot* - Tetralogy of Fallot is a **cyanotic heart disease** characterized by four defects: VSD, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. - Infants typically present with **cyanosis** (blue skin) and **tet spells**, rather than predominantly heart failure symptoms and failure to thrive in the first few months of life.

Question 405: A 2-year-old child with no past medical history presents with fever, rash, and swelling of the hands and feet. The child appears irritable and has red, cracked lips. What is the most likely diagnosis?

A. Kawasaki disease (Correct Answer)
B. Scarlet fever
C. Juvenile idiopathic arthritis
D. Hand, foot, and mouth disease

Explanation: ***Kawasaki disease*** * This constellation of symptoms, including **prolonged fever (typically ≥5 days)**, rash, **swelling of hands and feet**, **red cracked lips**, and irritability, is classic for **Kawasaki disease**. * It is an acute **vasculitis** primarily affecting young children (peak age 1-5 years) and can be associated with **coronary artery aneurysms** if untreated. *Scarlet fever* * While scarlet fever presents with fever and rash, it typically causes a **sandpaper-like rash** and a **strawberry tongue**, not prominent hand/foot swelling or cracked lips. * It is caused by Group A Streptococcus and often follows a strep throat infection. *Juvenile idiopathic arthritis* * This condition primarily involves chronic joint inflammation, not acute fever and polymorphous rash. * While joint swelling can occur, the characteristic mucocutaneous findings and fever pattern are not consistent with JIA. *Hand, foot, and mouth disease* * This viral illness typically presents with fever and characteristic **vesicular lesions** on the hands, feet, and in the mouth. * The rash in the question is described as a general rash, and the prominent swelling and specific lip changes point away from Hand, Foot, and Mouth Disease.

Question 406: A 4-year-old boy presents with irritability, poor feeding, and failure to thrive. Physical examination reveals a loud systolic murmur. Echocardiography shows a ventricular septal defect. What is the most likely long-term complication if left untreated?

A. Pulmonary hypertension (Correct Answer)
B. Endocarditis
C. Heart failure
D. Arrhythmias

Explanation: ***Pulmonary hypertension*** - A large **ventricular septal defect (VSD)** causes a significant left-to-right shunt, leading to increased blood flow and pressure in the pulmonary arteries. - Over time (typically years to decades), this sustained increase in pulmonary blood flow causes irreversible remodeling of the pulmonary vasculature, leading to **pulmonary vascular obstructive disease** and **pulmonary hypertension**. - This is the **most serious long-term complication** because once established, it is **irreversible** and leads to **Eisenmenger syndrome** (shunt reversal with cyanosis), which has a very poor prognosis. - While heart failure may develop earlier, pulmonary hypertension represents the ultimate irreversible endpoint if the VSD remains uncorrected. *Heart failure* - **Congestive heart failure** is actually the **most common complication in the short-to-medium term**, and this child is already showing signs (poor feeding, failure to thrive, irritability). - However, heart failure can be managed medically and is potentially reversible with surgical correction of the VSD. - The question asks specifically about **long-term** complications, where pulmonary hypertension becomes the more critical concern due to its irreversibility. *Endocarditis* - While patients with VSD have an **increased risk of infective endocarditis** due to turbulent blood flow, this is an acute/subacute infectious complication rather than a chronic progressive process. - It occurs episodically rather than being an inevitable consequence of untreated VSD. - Risk can be mitigated with prophylactic antibiotics during high-risk procedures. *Arrhythmias* - **Arrhythmias** are not a primary complication of uncorrected VSDs in children. - They are more commonly associated with atrial septal defects, post-surgical changes, or advanced heart failure with chamber remodeling. - Not directly related to the hemodynamic consequences of left-to-right shunting.

Question 407: A 6-month-old infant with failure to thrive and a loud systolic murmur is likely to have which condition?

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

Explanation: ***Ventricular septal defect*** - A **ventricular septal defect (VSD)** causes a **loud pansystolic murmur** due to blood shunting from the left to the right ventricle, and significant shunting can lead to **heart failure** and **failure to thrive** in infants. - The combination of a loud systolic murmur and failure to thrive in an infant strongly suggests a VSD, as the increased pulmonary blood flow contributes to poor growth. *Hypertrophic cardiomyopathy* - While it can cause a systolic murmur, the murmur in **hypertrophic cardiomyopathy** is typically ejection systolic and heard best at the lower left sternal border, often increasing with Valsalva maneuver, and **failure to thrive** is not its primary presentation unless heart failure develops later. - HCM is primarily a genetic condition leading to abnormal thickening of the myocardium, which is not directly indicated by the given symptoms. *Atrial septal defect* - An **atrial septal defect (ASD)** typically produces a **soft systolic ejection murmur** over the pulmonic area due to increased blood flow across the pulmonic valve, with a **fixed split S2**. - It usually leads to **right ventricular enlargement** and is generally well-tolerated in infancy, rarely causing **failure to thrive** during the first 6 months. - ASDs are usually asymptomatic in infancy and often not detected until later childhood or adulthood unless very large. *Patent ductus arteriosus* - A **patent ductus arteriosus (PDA)** classically presents with a **continuous "machine-like" murmur**, rather than a loud systolic murmur, which is heard best below the left clavicle. - While a large PDA can cause **failure to thrive** and heart failure, the murmur quality ("loud systolic") described does not fit the typical PDA presentation.

Question 408: A 3-year-old child with a known heart murmur presents with a fever and a new heart murmur that was not previously documented. What should be the next step in management?

A. Immediate referral to a pediatric cardiologist
B. Start empirical antibiotics for bacterial endocarditis
C. Echocardiography to evaluate for structural heart changes (Correct Answer)
D. Observe and re-evaluate in 6 weeks

Explanation: ***Echocardiography to evaluate for structural heart changes*** - A **new heart murmur** in a febrile child with a pre-existing murmur raises concern for **infective endocarditis** or deterioration of underlying heart disease. - **Echocardiography** can visualize vegetations, assess valve function, and identify any new structural abnormalities, making it the most appropriate initial diagnostic step. *Immediate referral to a pediatric cardiologist* - While a **pediatric cardiologist** will be involved, performing an **echocardiogram** first provides critical diagnostic information needed for the specialist to make an informed management plan. - Referral alone without initial diagnostic imaging may delay necessary interventions. *Start empirical antibiotics for bacterial endocarditis* - Starting **empirical antibiotics** without confirmation could lead to unnecessary treatment, potential drug resistance, or mask the true underlying issue if it's not bacterial endocarditis. - **Blood cultures** and **echocardiography** are usually performed first to guide antibiotic therapy. *Observe and re-evaluate in 6 weeks* - This approach is inappropriate given the **fever** and **new murmur**, which are significant indicators of a potentially serious condition needing urgent evaluation. - Delaying diagnosis and treatment could lead to severe complications, especially in a child with a known heart murmur, who is at higher risk for conditions like **endocarditis**.

Question 409: A newborn is observed to have a loud, harsh murmur and poor feeding. Which congenital heart defect is most likely?

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

Explanation: ***Ventricular septal defect*** - A **loud, harsh murmur** is characteristic of a VSD, resulting from turbulent blood flow through the defect between the ventricles. - **Poor feeding** in a newborn often indicates **congestive heart failure** due to increased pulmonary blood flow caused by a large VSD. *Atrial septal defect* - ASDs typically produce a **soft ejection systolic murmur** and are often **asymptomatic** in infancy. - Significant symptoms like poor feeding usually appear later in childhood or adulthood, if at all, due to the low-pressure shunt. *Patent ductus arteriosus* - A PDA typically presents with a **continuous "machinery-like" murmur**, distinct from the harsh murmur described. - While it can cause poor feeding and heart failure, the murmur quality is a key differentiator. *Tetralogy of Fallot* - TOF is characterized by **cyanosis** and a **systolic ejection murmur** due to pulmonary stenosis, not typically a loud, harsh murmur from a VSD as the primary finding. - **Hypercyanotic spells** (tet spells) are common, which are not mentioned in this presentation.

Question 410: What is the most likely diagnosis for a newborn exhibiting cyanosis, tachypnea, and a systolic murmur best heard at the left sternal border?

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

Explanation: ***Tetralogy of Fallot*** - This congenital heart defect is characterized by **cyanosis** and a **systolic murmur** at the left sternal border, often due to **pulmonic stenosis** and a **ventricular septal defect**. - **Tachypnea** is a common compensatory mechanism for hypoxia in infants with significant right-to-left shunting. *Ventricular septal defect* - While a VSD can cause a systolic murmur, isolated VSDs typically present with **acyanotic heart disease** unless pulmonary hypertension is severe. - Cyanosis in the neonatal period associated with a VSD usually occurs as part of a more complex malformation like **Tetralogy of Fallot**. *Atrial septal defect* - ASDs are usually **acyanotic** and may not produce a significant murmur in the neonatal period, with sounds often being a **mid-systolic murmur** from increased flow across the pulmonic valve. - **Cyanosis** is not a primary feature of an isolated ASD unless pulmonary hypertension develops much later in life or there is a coexisting right-to-left shunt. *Patent ductus arteriosus* - A PDA typically causes a **continuous "machinery-like" murmur** rather than solely a systolic murmur. - While it can cause **tachypnea** due to pulmonary overcirculation, it does not usually cause **cyanosis** unless there is severe pulmonary hypertension with reversed shunting, which is less common in an otherwise uncomplicated PDA in a newborn.

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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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