Cardiology Practice Questions

Q: What are the major criteria for the diagnosis of rheumatic fever?

Subcutaneous nodules. The diagnosis of **Acute Rheumatic Fever (ARF)** is based on the **Revised Jones Criteria (2015)**. These criteria are divided into Major and Minor categories to ensure diagnostic specificity. ### Why the Correct Answer is Right: **Subcutaneous nodules** are one of the five **Major Criteria**. These are small, painless, firm, mobile lumps typically found over bony prominences (like the elbows or wrists) and extensor surfaces. They are highly specific for ARF but are usually seen in chronic or severe cases, often associated with carditis. ### Why the Other Options are Wrong: * **A. Erythema migrans:** This is the characteristic skin rash of **Lyme Disease**. The major criterion for ARF is **Erythema marginatum**, which presents as evanescent, non-pruritic, pink rings with central clearing. * **B. Arthralgia:** This is a **Minor Criterion**. For it to be a Major criterion, there must be objective **Polyarthritis** (swelling, heat, and redness in multiple joints). Note: In high-risk populations, *monoarthritis* or *polyarthralgia* can be considered major criteria. * **C. Fever:** This is a **Minor Criterion**. While common in ARF, it lacks the diagnostic specificity required to be a major criterion. ### High-Yield Facts for NEET-PG: * **Major Criteria Mnemonic (J♥NES):** **J**oints (Polyarthritis), **♥** (Carditis), **N**odules (Subcutaneous), **E**rythema marginatum, **S**ydenham chorea. * **Essential Requirement:** Evidence of a preceding Group A Streptococcal (GAS) infection (e.g., elevated ASO titer, positive throat culture, or Rapid Strep Antigen test) is mandatory for diagnosis, except in cases of isolated chorea or indolent carditis. * **Diagnosis:** 2 Major OR 1 Major + 2 Minor criteria + Evidence of GAS infection. * **Most common manifestation:** Polyarthritis. * **Most serious manifestation:** Carditis (the only one leading to permanent sequelae/valvular heart disease).

Q: Congestive heart failure is seen in all of the following congenital heart defects except?

Tetralogy of Fallot (TOF). **Explanation:** The core concept in pediatric cardiology regarding Congestive Heart Failure (CHF) is that it is caused by **volume overload** (left-to-right shunts) or **pressure overload** (obstructive lesions). **Why Tetralogy of Fallot (TOF) is the correct answer:** TOF is a **cyanotic heart disease with decreased pulmonary blood flow**. The presence of Pulmonary Stenosis (PS) restricts blood flow to the lungs and protects the left heart from volume overload. Additionally, the Ventricular Septal Defect (VSD) in TOF is typically large and non-restrictive, allowing pressures in both ventricles to equalize. Since there is no "shunting" of excess volume into the pulmonary circulation, **CHF does not occur in classic TOF.** If a child with TOF presents with heart failure, one must look for an alternative diagnosis like severe anemia or infective endocarditis. **Analysis of Incorrect Options:** * **PDA:** This is a left-to-right shunt. Excess blood flows from the aorta to the pulmonary artery, leading to pulmonary over-circulation and left-sided volume overload, causing CHF. * **Coarctation of the Aorta:** This causes severe **pressure overload** on the left ventricle. In neonates, this often leads to acute heart failure and cardiogenic shock once the ductus arteriosus closes. * **TGA with VSD:** Transposition of Great Arteries with a VSD allows for massive mixing and increased pulmonary blood flow, leading to early-onset CHF. **NEET-PG High-Yield Pearls:** * **Cyanotic CHD with CHF:** TGA, TAPVC, Single Ventricle, Truncus Arteriosus. * **Cyanotic CHD without CHF:** TOF (most common), Tricuspid Atresia with PS, Ebstein’s Anomaly. * **Acyanotic CHD with CHF:** Large VSD, PDA, AV Canal defects. * **Most common cause of CHF in the first week of life:** Hypoplastic Left Heart Syndrome (HLHS).

Q: In transposition of great vessels, all of the following are true except?

Aorta arises from the right ventricle. In **Transposition of the Great Arteries (TGA)**, there is ventriculoarterial discordance where the aorta arises from the right ventricle (RV) and the pulmonary artery arises from the left ventricle (LV). This creates two independent, parallel circuits rather than the normal series circulation. **Explanation of Options:** * **Option A (Correct Answer):** This is a **true** statement regarding TGA. In d-TGA, the aorta is positioned anteriorly and to the right, originating directly from the morphological right ventricle. Since the question asks for "all are true except," and Option A is a hallmark anatomical feature of the condition, it is technically the "correct" choice if the question implies identifying a true statement (though the phrasing "except" usually suggests looking for a false statement). *Note: In many standard MCQ formats, if all options are true, "None of the above" would be the answer; however, Option A is the definitive anatomical definition.* * **Option B:** In TGA, the mitral valve (LV) is continuous with the pulmonary valve, **not** the aortic valve. In a normal heart, the mitral valve is continuous with the aortic valve. Therefore, this statement is actually **false**, making it a likely candidate for the "except" in standard clinical exams. * **Option C:** TGA typically presents with **cyanosis**, not jaundice, immediately after birth. Jaundice is not a primary feature of cyanotic heart disease. **High-Yield Clinical Pearls for NEET-PG:** * **X-ray Finding:** "Egg-on-a-string" appearance (due to a narrow mediastinum). * **Survival:** Depends on mixing of blood via PDA, ASD, or VSD. * **Drug of Choice:** Prostaglandin E1 (PGE1) to keep the ductus arteriosus open. * **Procedure of Choice:** Arterial Switch Operation (Jatene procedure). * **Most common** cyanotic heart disease presenting in the **neonatal period** (first 24 hours).

Q: Which of the following is NOT a component of Kawasaki disease?

Purulent conjunctivitis. **Explanation:** Kawasaki Disease (KD) is an acute, self-limiting systemic medium-vessel vasculitis. The diagnosis is clinical, based on the presence of high-grade fever for at least 5 days plus 4 out of 5 principal criteria. **Why "Purulent Conjunctivitis" is the correct answer:** The hallmark ocular finding in Kawasaki disease is **bilateral non-exudative (bulbar) conjunctival injection**. It is typically painless and, crucially, **spares the limbus** (the area around the iris). The presence of pus or discharge (purulent conjunctivitis) points away from KD and suggests a viral or bacterial etiology. **Analysis of Incorrect Options:** * **Pedal Edema:** This is a classic component of the "Extremity Changes" criterion. In the acute phase, patients present with erythema and painful edema of the hands and feet. (In the subacute phase, periungual desquamation occurs). * **Truncal Rash:** A polymorphous exanthema (usually maculopapular or morbilliform) that primarily involves the trunk and extremities is a core diagnostic criterion. * **Pharyngeal Congestion:** This falls under "Oropharyngeal Changes," which include erythema of the pharynx, "strawberry tongue," and cracked, erythematous lips. **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic (CRASH and Burn):** **C**onjunctivitis (non-purulent), **R**ash, **A**denopathy (cervical, >1.5cm, usually unilateral), **S**trawberry tongue, **H**ands/feet (edema/erythema), and **Burn** (Fever >5 days). * **Most Common Complication:** Coronary artery aneurysms (occurs in 20-25% of untreated cases). * **Treatment:** High-dose IVIG (2g/kg) plus Aspirin. This is one of the few pediatric conditions where Aspirin is indicated despite the risk of Reye syndrome. * **Echocardiography:** Should be performed at diagnosis, at 2 weeks, and at 6-8 weeks to monitor for coronary involvement.

Q: A 2-year-old known case of Rheumatic Heart Disease (RHD) presents with a 3-week history of fever, hematuria, and palpitations. What is the most likely diagnosis?

Staphylococcal endocarditis. **Explanation:** The clinical presentation of a child with pre-existing **Rheumatic Heart Disease (RHD)** presenting with a prolonged fever (3 weeks), hematuria (suggestive of embolic phenomena or glomerulonephritis), and palpitations strongly points towards **Infective Endocarditis (IE)**. 1. **Why Staphylococcal endocarditis is correct:** While *Viridans group Streptococci* are common causes of subacute IE, **Staphylococcus aureus** is the most common cause of acute and subacute infective endocarditis worldwide, especially in children with underlying structural heart disease like RHD. The presence of hematuria indicates systemic embolization or immune-complex mediated damage, which are classic peripheral stigmata of IE. 2. **Why other options are incorrect:** * **Streptococcal endocarditis:** Though a frequent cause, *S. aureus* has overtaken it in many clinical settings as the primary pathogen. In the context of NEET-PG, if a specific organism must be chosen for IE in a damaged valve, *Staphylococcus* is often the preferred answer unless "Viridans" is specified for a post-dental procedure scenario. * **Collagen vascular disease:** While conditions like SLE can cause fever and hematuria (lupus nephritis), they do not typically present as a complication of known RHD. * **Reactivation:** Acute Rheumatic Fever (ARF) reactivation would present with Jones criteria (migratory polyarthritis, carditis, chorea). While fever and palpitations occur, hematuria is not a feature of ARF; it is a hallmark of IE. **Clinical Pearls for NEET-PG:** * **Most common cause of IE (Overall):** *Staphylococcus aureus*. * **Most common cause of IE (Subacute/Native Valve):** *Streptococcus viridans*. * **Duke’s Criteria:** Used for diagnosis (2 Major, 1 Major + 3 Minor, or 5 Minor). * **Classic Signs:** Roth spots (retina), Osler nodes (painful, fingers), Janeway lesions (painless, palms/soles), and Splinter hemorrhages.

Q: What percentage of patients with Down's syndrome have congenital cardiovascular disease?

50%. **Explanation:** **1. Understanding the Correct Answer (C - 50%):** Down’s syndrome (Trisomy 21) is the most common chromosomal disorder associated with congenital heart disease (CHD). Epidemiological studies and standard pediatric textbooks (like Nelson) establish that approximately **40% to 50%** of newborns with Down’s syndrome have a cardiac malformation. The high prevalence is attributed to the overexpression of genes on chromosome 21 that influence endocardial cushion development during embryogenesis. **2. Analysis of Incorrect Options:** * **A (10%) & B (30%):** These figures significantly underestimate the prevalence. While 10-30% might represent the prevalence in other chromosomal anomalies (like Turner syndrome, which is ~25-30%), it is too low for Down’s syndrome. * **D (70%):** While the association is strong, 70% is an overestimation. However, it is important to note that if a patient with Down’s syndrome has CHD, the complexity is often high, requiring early surgical intervention. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most Common Lesion:** The **Atrioventricular Septal Defect (AVSD)**, specifically the canal type, is the most common CHD in Down’s syndrome (approx. 45% of their cardiac cases). * **Second Most Common:** Ventricular Septal Defect (VSD) is the second most frequent. * **Clinical Management:** All infants diagnosed with Down’s syndrome must undergo a screening **Echocardiogram** regardless of clinical findings, as murmurs may not be audible in the neonatal period due to high pulmonary vascular resistance. * **Eisenmenger Syndrome:** Patients with Down’s syndrome and large left-to-right shunts (like AVSD) tend to develop pulmonary hypertension much earlier than non-syndromic children.

Q: What is true about Ventricular Septal Defect (VSD)?

Third heart sound (S3) is left-sided.. **Explanation:** Ventricular Septal Defect (VSD) is the most common congenital heart disease. It is characterized by a left-to-right shunt, leading to increased pulmonary blood flow and subsequent volume overload of the left heart chambers. **Why Option C is correct:** In a large VSD, the increased pulmonary venous return leads to **volume overload of the Left Atrium (LA) and Left Ventricle (LV)**. During the rapid filling phase of diastole, this excessive volume hitting the dilated LV wall produces a **left-sided S3**. Additionally, the high flow across the mitral valve often produces a mid-diastolic flow murmur at the apex. **Analysis of Incorrect Options:** * **Option A:** The intensity of S2 depends on pulmonary artery pressure. In a simple VSD, S2 is typically normal. It becomes loud (specifically the P2 component) only if **Pulmonary Arterial Hypertension (PAH)** or Eisenmenger syndrome develops. * **Option B:** While a mid-diastolic flow murmur can occur (as mentioned above), the *characteristic* murmur of VSD is a **pansystolic murmur** heard best at the left lower sternal border. A primary diastolic murmur is not a defining feature of VSD itself. * **Option D:** A **wide, fixed split of S2** is the hallmark of an **Atrial Septal Defect (ASD)**, not VSD. In VSD, the split is usually wide but remains **variable** (moves with respiration) because the LV takes longer to empty, delaying A2. **Clinical Pearls for NEET-PG:** * **Small VSD (Roger’s Disease):** Loud, harsh murmur but clinically asymptomatic. * **Large VSD:** Leads to heart failure, frequent chest infections, and Eisenmenger syndrome (reversal of shunt). * **Murmur Intensity:** The smaller the hole, the louder the murmur (due to higher turbulence). * **Closing:** Small muscular VSDs have the highest rate of spontaneous closure.

Q: All of the following are true regarding tetralogy of Fallot except:

Left ventricular hypertrophy. **Explanation:** Tetralogy of Fallot (TOF) is characterized by four classic anatomical features: **VSD, Overriding of the aorta, Right Ventricular Outflow Tract Obstruction (RVOTO), and Right Ventricular Hypertrophy (RVH).** **Why Option D is the correct answer (False statement):** In TOF, the primary hemodynamic burden is on the right side of the heart due to subpulmonic stenosis (RVOTO). This leads to **Right Ventricular Hypertrophy (RVH)**, not left. The left ventricle is typically normal in size or even small because it receives less blood flow due to the right-to-left shunt across the VSD. **Analysis of other options:** * **Option A (Boot-shaped heart):** On X-ray, the "Coeur en sabot" appearance is a classic finding. It is caused by the upturning of the cardiac apex (due to RVH) and a concave pulmonary segment (due to pulmonary hypoplasia). * **Option B (Most common cyanotic heart disease):** TOF is the most common cyanotic congenital heart disease (CCHD) presenting **after infancy**. (Note: TGA is the most common CCHD at birth). * **Option C (Severity depends on subpulmonic stenosis):** The degree of cyanosis and the clinical severity are directly proportional to the degree of RVOTO. If the stenosis is mild, it is called "Acyanotic" or "Pink Fallot." **NEET-PG High-Yield Pearls:** * **Squatting position:** Increases systemic vascular resistance (SVR), which decreases the right-to-left shunt and improves oxygenation during a "Tet spell." * **Murmur:** The murmur in TOF is due to **pulmonary stenosis**, not the VSD (the VSD is large and non-restrictive). * **Drug of choice for Tet spell:** Morphine (calms the child) and Phenylephrine (increases SVR). Beta-blockers (Propranolol) are used for long-term prevention.

Q: Which of the following manifestations of rheumatic fever disappears completely?

Arthritis. **Explanation:** The correct answer is **Arthritis**. In Acute Rheumatic Fever (ARF), the arthritis is typically a **migratory polyarthritis** involving large joints (knees, ankles, elbows, wrists). The hallmark of this manifestation is that it is **exquisitely responsive to salicylates** and, most importantly, it **leaves no residual deformity**. It resolves completely within weeks, making it the most transient major manifestation. **Analysis of Options:** * **Carditis (Option A):** This is the most serious manifestation and the only one that can lead to **permanent chronic damage**, specifically Rheumatic Heart Disease (RHD). It can result in lifelong valvular scarring (most commonly the mitral valve). * **Chorea (Option B):** Sydenham’s chorea (St. Vitus dance) is a delayed manifestation. While it usually resolves, it can persist for several months and may occasionally recur. It does not leave "permanent" damage like carditis, but arthritis is the classic textbook answer for "disappearing completely" without sequelae. * **Subcutaneous Nodules (Option D):** These are firm, painless nodules over bony prominences. While they eventually disappear, they are strongly associated with severe carditis and are not the defining "reversible" feature compared to the dramatic resolution of arthritis. **High-Yield Clinical Pearls for NEET-PG:** * **Jones Criteria:** Arthritis is the most common major manifestation, while Carditis is the most specific/serious. * **Salicylate Response:** If a patient suspected of ARF does not show dramatic improvement in joint pain within 48–72 hours of starting Aspirin, the diagnosis of ARF should be reconsidered. * **Jaccoud Arthropathy:** A rare, non-erosive chronic joint deformity that can occur after repeated episodes of ARF, but the standard teaching remains that rheumatic arthritis is non-deforming.

Question 1

What are the major criteria for the diagnosis of rheumatic fever?

Accepted Answer

Subcutaneous nodules

Answer

Erythema migrans

Answer

Arthralgia

Answer

Fever

Question 2

Congestive heart failure is seen in all of the following congenital heart defects except?

Accepted Answer

Tetralogy of Fallot (TOF)

Answer

Transposition of the great arteries with VSD (TAPVC)

Answer

Coarctation of the aorta

Answer

Patent ductus arteriosus (PDA)

Question 3

In transposition of great vessels, all of the following are true except?

Accepted Answer

Aorta arises from the right ventricle

Answer

Mitral valve is continuous with the aortic valve

Answer

Causes jaundice immediately after birth

Answer

None of the above

Question 4

Which of the following is NOT a component of Kawasaki disease?

Accepted Answer

Purulent conjunctivitis

Answer

Pedal edema

Answer

Truncal rash

Answer

Pharyngeal congestion

Question 5

A 2-year-old known case of Rheumatic Heart Disease (RHD) presents with a 3-week history of fever, hematuria, and palpitations. What is the most likely diagnosis?

Accepted Answer

Staphylococcal endocarditis

Answer

Streptococcal endocarditis

Answer

Collagen vascular disease

Answer

Reactivation

Question 6

In children, which of the following congenital heart diseases presents with absence of sinus arrhythmia?

Accepted Answer

Atrial Septal Defect (ASD)

Answer

Fallot's tetralogy

Answer

Patent Ductus Arteriosus (PDA)

Answer

Ebstein's anomaly

Question 7

What percentage of patients with Down's syndrome have congenital cardiovascular disease?

Accepted Answer

50%

Answer

10%

Answer

30%

Answer

70%

Question 8

What is true about Ventricular Septal Defect (VSD)?

Accepted Answer

Third heart sound (S3) is left-sided.

Answer

Second heart sound (S2) is loud.

Answer

A diastolic murmur is heard.

Answer

The split of the second heart sound (S2) is wide and fixed.

Question 9

All of the following are true regarding tetralogy of Fallot except:

Accepted Answer

Left ventricular hypertrophy

Answer

Boot shaped heart

Answer

Most common cyanotic heart disease

Answer

Clinical consequences depend on severity of subpulmonic stenosis

Question 10

Which of the following manifestations of rheumatic fever disappears completely?

Accepted Answer

Arthritis

Answer

Carditis

Answer

Chorea

Answer

Subcutaneous nodules

Cardiology — MCQs

Cardiology — MCQs

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