Cardiology Practice Questions

Q: Strawberry tongue is a clinical sign seen in which of the following conditions?

Kawasaki disease. **Explanation:** **Strawberry tongue** is a classic clinical sign characterized by a bright red, swollen tongue with prominent, enlarged fungiform papillae. It is a hallmark feature of **Kawasaki Disease (KD)**, a medium-vessel vasculitis that primarily affects children under five years of age. In KD, the strawberry tongue is part of the "Oropharyngeal changes" diagnostic criteria, which also includes cracked, erythematous lips and diffuse pharyngeal injection. **Analysis of Options:** * **Kawasaki Disease (Correct):** It presents with the "CRASH and Burn" mnemonic (Conjunctivitis, Rash, Adenopathy, Strawberry tongue/lips, Hand/foot edema, and high-grade Fever). * **Wegener Granulomatosis (Granulomatosis with Polyangiitis):** Typically presents with a "Strawberry Gingivitis" (friable, granular gums), not a strawberry tongue. It primarily affects the upper/lower respiratory tract and kidneys. * **Phenytoin Toxicity:** Classically associated with **Gingival Hyperplasia** (overgrowth of gums), not lingual changes. * **Polyarteritis Nodosa (PAN):** A systemic vasculitis that affects medium-sized arteries but lacks the specific mucocutaneous features (like strawberry tongue) seen in KD. **Clinical Pearls for NEET-PG:** 1. **Differential Diagnosis for Strawberry Tongue:** Besides Kawasaki Disease, it is also seen in **Scarlet Fever** (caused by Group A Streptococcus) and **Toxic Shock Syndrome**. 2. **White vs. Red Strawberry Tongue:** In Scarlet Fever, it starts as a "White Strawberry Tongue" (white coat with red papillae) and progresses to "Red Strawberry Tongue" by day 4-5. 3. **KD Complication:** The most dreaded complication is **Coronary Artery Aneurysms**. Treatment involves IVIG and high-dose Aspirin.

Q: The overall heart size in tetralogy of Fallot is usually:

Normal or relatively small. **Explanation:** In **Tetralogy of Fallot (TOF)**, the overall heart size is typically **normal or relatively small**. This is a high-yield distinction from other cyanotic congenital heart diseases. **Why the correct answer is right:** The hallmark of TOF is the combination of a large ventricular septal defect (VSD) and right ventricular outflow tract obstruction (RVOTO/Pulmonary Stenosis). Because the pulmonary stenosis limits the amount of blood entering the lungs, there is no pulmonary over-circulation. Furthermore, the VSD is "non-restrictive," allowing the right ventricle (RV) to decompress into the aorta. While the RV undergoes **concentric hypertrophy** to handle the pressure, it does not typically undergo significant dilatation. This results in the classic **"Coeur-en-sabot" (boot-shaped heart)** on X-ray, where the apex is tilted upward by the hypertrophied RV, but the total cardiothoracic ratio remains within normal limits. **Why the incorrect options are wrong:** * **Options A, C, and D:** These are incorrect because TOF is a "cyanotic heart disease with **decreased** pulmonary blood flow." Marked or moderate cardiomegaly is usually seen in conditions with **increased** pulmonary blood flow (e.g., large VSD, PDA, or TGA) or valvular regurgitation, where the heart chambers must dilate to accommodate volume overload. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray Findings:** Boot-shaped heart, narrow vascular pedicle (due to pulmonary hypoplasia), and **oligemic lung fields** (decreased pulmonary markings). * **Right-sided Aortic Arch:** Seen in approximately 25% of TOF cases. * **The "Shunt" Rule:** If a cyanotic child has a **large** heart on X-ray, think of Transposition of the Great Arteries (TGA) or Ebstein’s Anomaly, not TOF. * **Murmur:** The murmur in TOF is due to **pulmonary stenosis**, not the VSD. A softer murmur during a "Tet spell" indicates worsening obstruction.

Q: A child has Transposition of the Great Arteries. What maternal condition should be investigated?

Diabetes mellitus. **Explanation:** **1. Why Diabetes Mellitus is Correct:** Maternal pregestational diabetes mellitus is a well-established and potent risk factor for congenital heart disease (CHD) in the offspring. Hyperglycemia during the period of organogenesis (the first 8 weeks of gestation) acts as a teratogen, disrupting the normal development of the heart. While diabetes is associated with various defects (most commonly Ventricular Septal Defects and Hypertrophic Cardiomyopathy), **Transposition of the Great Arteries (TGA)** is specifically and strongly associated with maternal diabetes. The metabolic derangements lead to abnormal looping and septation of the conotruncal region. **2. Why Other Options are Incorrect:** * **Maternal Pregnancy-Induced Hypertension (PIH) & Hypertension:** Chronic or gestational hypertension is more commonly associated with placental insufficiency, intrauterine growth restriction (IUGR), and prematurity, rather than specific structural cardiac malformations like TGA. * **Thyroid Disease:** Maternal thyroid dysfunction (hypo- or hyperthyroidism) is primarily linked to fetal growth issues, goiter, or neurodevelopmental delays, but it is not a recognized risk factor for TGA. **3. Clinical Pearls for NEET-PG:** * **Most Common CHD in Infants of Diabetic Mothers (IDM):** Ventricular Septal Defect (VSD). * **Most Characteristic/Specific CHD in IDM:** Transposition of the Great Arteries (TGA). * **Hypertrophic Cardiomyopathy (HCM):** IDMs often present with transient subaortic septal hypertrophy, which usually resolves spontaneously after birth. * **TGA Presentation:** Presents as "Early, Deep Cyanosis" in a newborn. On X-ray, it shows the classic **"Egg-on-a-string"** appearance. * **Management:** Prostaglandin E1 (to keep the ductus open) followed by the **Arterial Switch Operation (Jatene procedure)**, which is the treatment of choice.

Q: Which of the following statements is false regarding Atrial Septal Defect?

It typically involves a right-to-left shunt.. **Explanation:** **1. Why Option B is the correct (False) statement:** Atrial Septal Defect (ASD) is an **acyanotic** congenital heart disease. Under normal physiological conditions, the pressure in the left atrium is higher than in the right atrium. Therefore, blood flows from the left atrium to the right atrium, resulting in a **left-to-right shunt**. A right-to-left shunt only occurs if pulmonary hypertension develops (Eisenmenger syndrome), which is a late complication. **2. Analysis of other options:** * **Option A:** **Ostium secundum** is indeed the most common type of ASD (75% of cases), located in the region of the fossa ovalis. * **Option C:** ASD is frequently associated with other anomalies. Specifically, **Sinus Venosus ASD** is classically associated with partial or total anomalous pulmonary venous connection (TAPVC/PAPVC). * **Option D:** CCF is **very rare** in children with ASD because the right ventricle is highly compliant and can handle the volume overload for decades. Symptoms usually manifest in the 3rd or 4th decade of life. **Clinical Pearls for NEET-PG:** * **Auscultation:** Characterized by a **Wide, Fixed Split S2** (due to delayed closure of the pulmonary valve) and a mid-systolic flow murmur at the pulmonary area. * **ECG Findings:** Right axis deviation and **RSR' pattern** (incomplete RBBB) in lead V1 are high-yield diagnostic clues. * **Lutembacher Syndrome:** The combination of ASD and acquired Mitral Stenosis. * **Paradoxical Embolism:** A unique complication where a systemic venous embolus crosses the ASD to cause a stroke.

Q: A 8-month-old infant presents with severe dyspnea on exertion, clubbing of digits, and bluish sclera. What is the most likely diagnosis based on these findings?

Tetralogy of Fallot. **Explanation:** The clinical triad of **cyanosis** (implied by bluish sclera/clubbing), **clubbing**, and **dyspnea on exertion** in an 8-month-old infant is classic for **Tetralogy of Fallot (TOF)**. 1. **Why TOF is correct:** TOF is the most common cyanotic congenital heart disease (CCHD) beyond infancy. The "bluish sclera" is a clinical sign of chronic systemic desaturation (cyanosis), and clubbing signifies chronic hypoxia. Dyspnea on exertion in infants often manifests during feeding or crying (cyanotic spells/Tet spells). The pathophysiology involves a right-to-left shunt due to a large VSD and right ventricular outflow tract obstruction (RVOTO). 2. **Why other options are incorrect:** * **TGA:** Typically presents with severe cyanosis in the **neonatal period** (first days of life). Without a large mixing lesion, it is incompatible with life beyond the immediate newborn stage. * **Ebstein’s Anomaly:** While it causes cyanosis, it is characterized by massive cardiomegaly ("wall-to-wall heart") and arrhythmias. It is less likely to present with this specific exertional profile at 8 months compared to TOF. * **Coarctation of the Aorta:** This is an acyanotic condition. It presents with upper limb hypertension, radio-femoral delay, and heart failure, not chronic cyanosis or clubbing. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray finding:** Boot-shaped heart (Coeur en sabot) due to RVH and upturned apex. * **Murmur:** A harsh systolic ejection murmur at the left mid-to-upper sternal border (due to pulmonary stenosis, NOT the VSD). * **Management of Tet Spell:** Knee-chest position (increases systemic vascular resistance), Oxygen, Morphine, and Beta-blockers (Propranolol). * **Most common associated anomaly:** Right-sided aortic arch (seen in 25% of cases).

Q: Which one of the following is the most common cause of cyanotic heart disease?

Fallot's tetralogy. **Explanation:** **Tetralogy of Fallot (TOF)** is the most common cause of **cyanotic congenital heart disease (CCHD)** beyond the neonatal period. It consists of four classic features: pulmonary stenosis (the primary determinant of severity), right ventricular hypertrophy, overriding of the aorta, and a large ventricular septal defect (VSD). The cyanosis results from a right-to-left shunt across the VSD due to increased resistance at the pulmonary outflow tract. **Analysis of Options:** * **Dextrocardia (Option A):** This refers to the heart being positioned in the right side of the chest. While it can be associated with complex anomalies, it is a positional diagnosis, not a primary cause of cyanosis. * **Atrial Septal Defect (Option C):** This is an **acyanotic** heart disease characterized by a left-to-right shunt. Cyanosis only occurs if Eisenmenger syndrome develops (reversal of shunt), which is a late complication. * **Coarctation of Aorta (Option D):** This is an acyanotic obstructive lesion. It typically presents with upper limb hypertension and diminished lower limb pulses, rather than central cyanosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common CCHD overall:** Tetralogy of Fallot. * **Most common CCHD in the newborn period (first week):** Transposition of the Great Arteries (TGA). * **X-ray finding in TOF:** "Boot-shaped heart" (Coeur en sabot) due to an upturned apex from RVH and a concave pulmonary segment. * **Management of "Tet Spells":** Knee-chest position (increases systemic vascular resistance), oxygen, and morphine.

Q: Which type of Atrial Septal Defect (ASD) is most common?

Ostium secundum. **Explanation:** **Ostium secundum** is the most common type of Atrial Septal Defect (ASD), accounting for approximately **75% of all cases**. It results from the excessive resorption of the septum primum or the inadequate growth of the septum secundum. It is typically located in the region of the fossa ovalis (mid-septal). **Analysis of Options:** * **Ostium secundum (Correct):** The most frequent variety. It is usually a sporadic finding but can be associated with Holt-Oram syndrome (heart-hand syndrome). * **Patent Foramen Ovale (PFO):** While common in the general population (up to 25%), a PFO is technically a "flap-valve" opening rather than a true deficiency of septal tissue. Therefore, it is not classified as a true ASD. * **Ostium primum:** The second most common type (15-20%). It occurs low in the septum and is a form of Atrioventricular Septal Defect (AVSD). It is classically associated with **Down Syndrome** and often presents with a cleft mitral valve. * **Sinus venosus:** A rare type (5-10%) located near the entry of the Superior Vena Cava (most common) or Inferior Vena Cava. It is frequently associated with **Partial Anomalous Pulmonary Venous Connection (PAPVC)**. **High-Yield Clinical Pearls for NEET-PG:** * **Physical Exam:** Characterized by a **wide, fixed split S2** and a mid-systolic flow murmur at the upper left sternal border. * **ECG Findings:** Ostium secundum typically shows **Right Axis Deviation (RAD)** and RBBB, whereas Ostium primum shows **Left Axis Deviation (LAD)**. * **Complication:** Paradoxical embolism (stroke) is a known risk. Eisenmenger syndrome occurs much later in ASD compared to VSD or PDA.

Q: A 3-year-old child presented with a 15-day history of high-grade fever, polymorphous exanthem, rhinorrhea, vomiting, diarrhea, and abdominal pain. On examination, bilateral conjunctival injection with limbal sparing, erythema of oral and pharyngeal mucosa, edema of hands and feet, and mild cervical lymphadenopathy at III and IV levels were noted. Laboratory findings included leucocytosis with neutrophilia and immature forms, elevated erythrocyte sedimentation rate, elevated C-reactive protein, anemia, abnormal plasma lipids, hypoalbuminemia, and hyponatremia. Coronary angiogram findings are also available. What is the most important next step in the management of this child?

Start on both IVIg and aspirin. **Explanation:** The clinical presentation is a classic case of **Kawasaki Disease (KD)**, a medium-vessel vasculitis. The child meets the diagnostic criteria: fever >5 days plus at least four out of five clinical features (polymorphous rash, bilateral non-purulent conjunctival injection with limbal sparing, oral mucosal changes like "strawberry tongue," extremity changes like edema, and cervical lymphadenopathy). The laboratory findings (elevated ESR/CRP, anemia, hypoalbuminemia, and hyponatremia) and the mention of coronary angiogram findings further support this diagnosis. **Why Option C is correct:** The standard of care for acute Kawasaki Disease is the combination of **Intravenous Immunoglobulin (IVIg)** and **Aspirin**. * **IVIg (2 g/kg):** Reduces the incidence of coronary artery aneurysms from 25% to <5% if administered within the first 10 days of illness. * **Aspirin:** Used initially at high doses (80–100 mg/kg/day) for its anti-inflammatory effect, then switched to low doses (3–5 mg/kg/day) for its anti-platelet effect once the fever subsides. **Why other options are incorrect:** * **Options A & B:** Monotherapy is insufficient. IVIg is the primary disease-modifying agent, but Aspirin is essential to manage inflammation and prevent thrombotic complications in the coronary arteries. * **Option D:** Clopidogrel is only indicated in children with giant aneurysms or those who cannot tolerate aspirin; it is not the first-line acute management. **Clinical Pearls for NEET-PG:** * **Most common cause** of acquired heart disease in children in developed countries. * **Cardiac complication:** Coronary artery aneurysms (most common in the proximal LAD and RCA). * **Incomplete KD:** Suspect in infants or children with prolonged fever and fewer than 4 criteria but elevated inflammatory markers. * **Echo:** Should be performed at diagnosis, at 2 weeks, and at 6–8 weeks.

Q: Which congenital heart disease is associated with the defect shown in the diagram below?

Endocardial cushion defect. ***Endocardial cushion defect*** - Characterized by **primum atrial septal defect**, **inlet ventricular septal defect**, and **common atrioventricular valve**, creating the classic "gooseneck" appearance on chest X-ray. - Strongly associated with **Down syndrome** (trisomy 21) and presents with early **congestive heart failure** and **failure to thrive**. *Tricuspid atresia* - Involves **absence or imperforation of the tricuspid valve**, causing blood to bypass the right ventricle entirely. - Results in **cyanosis** from birth and requires blood flow through **atrial septal defect** and **patent ductus arteriosus** for survival. *Hypoplastic left ventricle* - Features **underdevelopment of the left ventricle**, **mitral valve**, and **ascending aorta**, not involving septal defects. - Presents with severe **cyanosis** and **cardiogenic shock** in the first days of life, requiring immediate intervention. *Aortic stenosis* - Involves **narrowing of the aortic valve** or **subvalvular/supravalvular areas**, not septal abnormalities. - Typically presents with **exercise intolerance**, **chest pain**, and **syncope** in older children, not early heart failure.

Question 1

Strawberry tongue is a clinical sign seen in which of the following conditions?

Accepted Answer

Kawasaki disease

Answer

Wegener granulomatosis

Answer

Phenytoin toxicity

Answer

Polyarteritis nodosa

Question 2

The overall heart size in tetralogy of Fallot is usually:

Accepted Answer

Normal or relatively small

Answer

Markedly enlarged

Answer

Slightly enlarged

Answer

Moderately enlarged

Question 3

A child has Transposition of the Great Arteries. What maternal condition should be investigated?

Accepted Answer

Diabetes mellitus

Answer

Maternal pregnancy-induced hypertension

Answer

Hypertension

Answer

Thyroid disease

Question 4

Which of the following statements is false regarding Atrial Septal Defect?

Accepted Answer

It typically involves a right-to-left shunt.

Answer

Ostium secundum is the most common type.

Answer

It may be associated with Total Anomalous Pulmonary Venous Connection (TAPVC).

Answer

Congestive Cardiac Failure (CCF) is very rare.

Question 5

A 8-month-old infant presents with severe dyspnea on exertion, clubbing of digits, and bluish sclera. What is the most likely diagnosis based on these findings?

Accepted Answer

Tetralogy of Fallot

Answer

Transposition of Great Arteries (TGA)

Answer

Ebstein's anomaly

Answer

Coarctation of the aorta

Question 6

Which one of the following is the most common cause of cyanotic heart disease?

Accepted Answer

Fallot's tetralogy

Answer

Dextrocardia

Answer

Atrial septal defect

Answer

Coarctation of aorta

Question 7

Which type of Atrial Septal Defect (ASD) is most common?

Accepted Answer

Ostium secundum

Answer

Patent foramen ovale

Answer

Ostium primum

Answer

Sinus venosus

Question 8

A 3-year-old child presented with a 15-day history of high-grade fever, polymorphous exanthem, rhinorrhea, vomiting, diarrhea, and abdominal pain. On examination, bilateral conjunctival injection with limbal sparing, erythema of oral and pharyngeal mucosa, edema of hands and feet, and mild cervical lymphadenopathy at III and IV levels were noted. Laboratory findings included leucocytosis with neutrophilia and immature forms, elevated erythrocyte sedimentation rate, elevated C-reactive protein, anemia, abnormal plasma lipids, hypoalbuminemia, and hyponatremia. Coronary angiogram findings are also available. What is the most important next step in the management of this child?

Accepted Answer

Start on both IVIg and aspirin

Answer

Start on IVIg only

Answer

Start on aspirin only

Answer

Start on Clopidogrel only

Question 9

Which of the following statements regarding Atrial Septal Defect (ASD) is true?

Accepted Answer

Large ASDs are typically surgically corrected between 1 to 3 years of age.

Answer

Ostium primum is the most common type of ASD.

Answer

Children with ASD always exhibit growth retardation.

Answer

ASD is commonly affected by infective endocarditis.

Question 10

Which congenital heart disease is associated with the defect shown in the diagram below?

Accepted Answer

Endocardial cushion defect

Answer

Tricuspid atresia

Answer

Hypoplastic left ventricle

Answer

Aortic stenosis

Cardiology — MCQs

Cardiology — MCQs

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