Pericardial Diseases — MCQs
Identify the ECG given below?
Becks triad is seen in
A previously healthy patient presents with dyspnea and low grade fever since 4 months. His lungs are clear. JVP is normal. ECG showed low voltage complexes. What is the possible diagnosis?
Kussmaul's sign is classically described in:
Which finding on echocardiography suggests 'constrictive pericarditis'?
A 50-year-old male presents with sharp, localized chest pain, worse with deep breaths and relieved by sitting up. ECG is normal. What is the most likely diagnosis?
Which of the following conditions is least likely to present with pleuritic chest pain?
Flask shaped heart is seen in –
For pericardial calcifications, which is the best investigation?
Which of the following is best assessed by FAST USG?
Pericardial Diseases Indian Medical PG Practice Questions and MCQs
Question 1: Identify the ECG given below?
- A. Viral myocarditis
- B. Torsades de pointes (Correct Answer)
- C. Cardiac tamponade
- D. Pericarditis
Explanation: ***Torsades de pointes*** - The ECG shows a polymorphic ventricular tachycardia where the **QRS complexes appear to twist around the baseline**, a classic feature of Torsades de pointes. - This condition is often associated with **QT prolongation**, which is evident in some of the strips preceding the tachyarrhythmia. *Viral myocarditis* - While viral myocarditis can lead to various ECG abnormalities, it typically doesn't present with this specific **polymorphic ventricular tachycardia** morphology. - Common ECG findings in myocarditis include non-specific ST-T wave changes, sinus tachycardia, or conduction blocks, rather than the characteristic "twisting" pattern seen here. *Cardiac tamponade* - Cardiac tamponade is characterized by **electrical alternans** (alternating QRS amplitude), low voltage, and sinus tachycardia on ECG. - It does not cause a polymorphic ventricular tachycardia with the appearance of QRS complexes twisting around the baseline. *Pericarditis* - Pericarditis typically presents with **diffuse ST-segment elevation** (often concave up) and PR-segment depression. - It does not manifest as a polymorphic ventricular tachycardia like Torsades de pointes.
Question 2: Becks triad is seen in
- A. Cardiac tamponade (Correct Answer)
- B. Restrictive cardiomyopathy
- C. Constrictive pericarditis
- D. None of the options
Explanation: ***Cardiac tamponade*** - **Beck's triad** is a set of three clinical signs associated with acute cardiac tamponade: **hypotension**, **jugular venous distension (JVD)**, and **muffled heart sounds**. [1] - These signs result from the accumulation of fluid in the pericardial sac, which compresses the heart and impairs its ability to fill. [1] *Constrictive pericarditis* - While it can manifest with JVD and signs of right heart failure, **muffled heart sounds** and acute **hypotension** as part of Beck's triad are not typical for its chronic nature. [2] - It involves a rigid, fibrotic pericardium that restricts diastolic filling, often with a **pericardial knock** rather than muffled sounds. [2] *Restrictive cardiomyopathy* - This condition involves impaired ventricular relaxation and filling, leading to signs of heart failure, including JVD. [3] - However, it does not typically present with the acute, severe **hypotension** or **muffled heart sounds** characteristic of cardiac tamponade. [3] *None of the options* - This option is incorrect as cardiac tamponade is the condition associated with Beck's triad.
Question 3: A previously healthy patient presents with dyspnea and low grade fever since 4 months. His lungs are clear. JVP is normal. ECG showed low voltage complexes. What is the possible diagnosis?
- A. Rheumatic mitral stenosis
- B. Hypertrophic cardiomyopathy
- C. Tuberculous pericardial effusion (Correct Answer)
- D. Syphilitic aortic aneurysm
Explanation: ***Tuberculous pericardial effusion*** - **Dyspnea** and a **low-grade fever** persisting for several months are suggestive of **tuberculosis** [1]. - **Low voltage complexes on ECG** are characteristic of a **pericardial effusion**, where fluid dampens electrical activity [1]. *Rheumatic mitral stenosis* - While it can cause **dyspnea**, the absence of **JVP elevation** and **clear lungs** make significant heart failure less likely [2]. - ECG in mitral stenosis would typically show **left atrial enlargement** and potentially **atrial fibrillation**, not widespread low voltage. *Hypertrophic cardiomyopathy* - This condition presents with **dyspnea** and can cause **abnormal ECG findings** (e.g., left ventricular hypertrophy, Q waves), but not typically **low voltage complexes**. - **Clear lungs** and normal JVP are inconsistent with severe heart failure from the condition [3]. *Syphilitic aortic aneurysm* - This condition affects the **aorta** and can lead to **aortic regurgitation** or **aortic dissection**, but usually presents differently. - While it can cause **dyspnea** due to heart failure or mass effect, it does not typically cause **low voltage complexes on ECG** or **low-grade fever** for months as the primary presentation.
Question 4: Kussmaul's sign is classically described in:
- A. Acute myocardial damage
- B. Acute cardiac compression
- C. Chronic ventricular stiffening
- D. Chronic inflammatory heart condition (Correct Answer)
Explanation: ***Chronic inflammatory heart condition*** - **Kussmaul's sign**, characterized by a paradoxical rise in **jugular venous pressure (JVP)** during inspiration, is classically seen in conditions like **constrictive pericarditis** [1], which is often a chronic inflammatory heart condition. - This sign reflects the heart's inability to accommodate increased venous return during inspiration due to a rigid, fibrotic pericardium [1]. *Acute cardiac compression* - **Cardiac tamponade** [3], a form of acute cardiac compression, typically presents with **pulsus paradoxus** and muffled heart sounds, not Kussmaul's sign. - While it involves elevated JVP, the paradoxical inspiratory rise is less common compared to constrictive pericarditis. *Acute myocardial damage* - **Acute myocardial infarction** [2] or myocarditis, leading to acute myocardial damage, primarily causes symptoms related to reduced cardiac output and arrhythmias, such as chest pain or dyspnea. - Kussmaul's sign is not a typical feature of acute myocardial damage because the pericardium is usually not rigid or constricting. *Chronic ventricular stiffening* - Conditions involving **chronic ventricular stiffening**, such as **restrictive cardiomyopathy**, can mimic some features of constrictive pericarditis, including elevated JVP and sometimes Kussmaul's sign. - However, the classic description and most prominent cases of Kussmaul's sign are associated with external compression from a diseased pericardium rather than intrinsic myocardial stiffness, although differentiation can be challenging.
Question 5: Which finding on echocardiography suggests 'constrictive pericarditis'?
- A. Pericardial thickening and septal bounce (Correct Answer)
- B. Increased wall thickness
- C. Global hypokinesis
- D. Pericardial effusion
Explanation: ***Pericardial thickening and septal bounce*** - **Pericardial thickening** is a direct anatomical feature of constrictive pericarditis, indicating the fibrotic and inflamed state of the pericardium. - **Septal bounce**, or interventricular septal motion variation with respiration, is a highly specific sign of constriction, due to exaggerated ventricular interdependence. *Increased wall thickness* - This finding is more characteristic of **hypertrophic cardiomyopathy** or **hypertensive heart disease**, where the myocardial muscle itself thickens. - While it can impair diastolic function, it doesn't indicate a primary pericardial issue. *Global hypokinesis* - **Global hypokinesis** refers to reduced overall contractility of the heart muscle, typically seen in conditions like **dilated cardiomyopathy** or significant **ischemic heart disease**. - This indicates systolic dysfunction, whereas constrictive pericarditis primarily affects diastolic filling. *Pericardial effusion* - A **pericardial effusion** is an accumulation of fluid around the heart, which can cause **cardiac tamponade** if severe. - While effusions can sometimes precede or coexist with constrictive pericarditis, the fluid itself is not the hallmark of constriction, which is defined by a thickened, rigid pericardium.
Question 6: A 50-year-old male presents with sharp, localized chest pain, worse with deep breaths and relieved by sitting up. ECG is normal. What is the most likely diagnosis?
- A. Pneumothorax
- B. Myocardial infarction
- C. Pleuritis
- D. Pericarditis (Correct Answer)
Explanation: ***Pericarditis*** - The classic presentation of **sharp, localized chest pain** that is **worse with deep breaths** and **relieved by sitting up and leaning forward** is highly characteristic of pericarditis [2]. - A **normal ECG** makes other cardiac causes less likely, supporting the diagnosis of pericarditis, which can have diffuse ST elevation or PR depression as ECG findings, but a normal ECG doesn't rule it out, especially early on [2]. *Pneumothorax* - While pneumothorax can cause **sharp chest pain** and be **respiratory variation**, it is typically associated with **dyspnea** and **diminished breath sounds** on examination, which are not mentioned here. - The pain relief with sitting up is not characteristic of pneumothorax. *Myocardial infarction* - **Myocardial infarction** pain is typically described as a **heavy, pressure-like sensation**, often radiating to the arm, jaw, or back, and is usually not relieved by position changes [1]. - A **normal ECG** makes acute myocardial infarction less likely, though it does not entirely rule out non-ST elevation myocardial infarction (NSTEMI). *Pleuritis* - **Pleuritis** also causes **sharp, pleuritic chest pain** that worsens with deep inspiration or coughing. - However, the classic relief with **sitting up and leaning forward** is more specific to pericarditis than pleuritis.
Question 7: Which of the following conditions is least likely to present with pleuritic chest pain?
- A. Aortic dissection (Correct Answer)
- B. Acute pericarditis
- C. Pneumothorax
- D. Pulmonary embolism
Explanation: ### Aortic dissection - While it causes severe chest pain, the pain from **aortic dissection** is typically described as **ripping or tearing** and does not usually worsen with breathing, making pleuritic pain unlikely [2]. - The pain is usually due to the dissection of the **aortic wall** itself, which is not innervated in a way that produces pleuritic pain. *Acute pericarditis* - **Acute pericarditis** frequently causes pleuritic chest pain that is often described as sharp, **stabbing**, and worse with inspiration or lying flat [1]. - This is because the inflamed pericardium can irritate the adjacent pleura, leading to pain that is exacerbated by respiratory movements. *Pneumothorax* - **Pneumothorax** (collapsed lung) classically presents with sudden onset **sharp**, pleuritic chest pain and shortness of breath [3]. - The pain is due to the stretching of the **pleura** as air accumulates in the pleural space, leading to irritation and inflammation [3]. *Pulmonary embolism* - **Pulmonary embolism (PE)** can cause pleuritic chest pain, particularly if it leads to **pulmonary infarction** affecting the pleural surface. - The pain is often sudden, sharp, and worsened by deep breathing or coughing, reflecting irritation of the parietal pleura.
Question 8: Flask shaped heart is seen in –
- A. Pericardial effusion (Correct Answer)
- B. TOF
- C. Ebstein anomaly
- D. TAPVC
Explanation: ***Pericardial effusion*** - A **"flask-shaped"** or **"water bottle-shaped" heart** on chest X-ray is a classic finding in significant pericardial effusion. - This appearance results from the accumulation of a large amount of fluid in the **pericardial sac**, which causes the cardiac silhouette to enlarge symmetrically and assume a globular shape. *TOF (Tetralogy of Fallot)* - TOF typically presents with a **"boot-shaped" heart** (coeur en sabot) on chest X-ray due to right ventricular hypertrophy and a concave pulmonary artery segment. - This morphology is distinctly different from the flask-shaped appearance of pericardial effusion. *Ebstein anomaly* - Ebstein anomaly is characterized by apical displacement of the tricuspid valve, leading to **massive right atrial enlargement**. - On chest X-ray, this often results in a **markedly enlarged oval-shaped heart**, which can be quite massive but does not typically have the distinct flask/water bottle shape. *TAPVC (Total Anomalous Pulmonary Venous Connection)* - TAPVC can present with different X-ray findings depending on the type, but a classic finding for the supracardiac type is a **"snowman" or "figure-of-8" heart** in children. - This appearance is due to the dilated superior vena cava and anomalous veins draining to it, not a flask shape.
Question 9: For pericardial calcifications, which is the best investigation?
- A. Ultrasound
- B. CT scan (Correct Answer)
- C. MRI
- D. Transesophageal echocardiography
Explanation: ***Correct: CT scan*** - **CT scans** are highly sensitive and specific for detecting **pericardial calcifications** due to their excellent spatial resolution and ability to measure calcium density (Hounsfield units). - They provide detailed anatomical information about the **pericardium** and can accurately map the extent, location, and thickness of calcified areas. - **CT is the gold standard** for detecting and quantifying pericardial calcification, particularly in constrictive pericarditis. *Incorrect: Ultrasound* - While ultrasound (echocardiography) can visualize the pericardium and may detect calcifications, its ability to definitively identify and characterize **calcifications** is limited compared to CT. - **Acoustic shadowing** from calcifications can obscure underlying structures, making a precise assessment challenging. - Useful for detecting pericardial effusion and thickening, but not optimal for calcification assessment. *Incorrect: MRI* - **MRI excels** in visualizing soft tissues, pericardial inflammation, and fluid collections, but it is **poor at detecting calcium**. - Calcifications typically appear as signal voids (black) on MRI, making it difficult to differentiate them from other structures, air, or motion artifacts. - MRI is valuable for assessing pericardial inflammation and constriction but not the preferred method for calcification. *Incorrect: Transesophageal echocardiography* - TEE offers high-resolution images of cardiac structures and is primarily used for assessing valve function, intracardiac masses, endocarditis, and aortic pathology. - Its utility in detecting and characterizing **pericardial calcifications** is limited compared to CT, especially for diffuse or subtle calcifications. - The pericardium is not optimally visualized with TEE compared to transthoracic echocardiography.
Question 10: Which of the following is best assessed by FAST USG?
- A. Liver
- B. Pericardium (Correct Answer)
- C. Spleen
- D. Pleural cavity
Explanation: ***Pericardium*** - FAST USG is **most clinically significant** for detecting **pericardial effusions** and **cardiac tamponade** in trauma patients. - The **subxiphoid view** provides **excellent direct visualization** of the heart and pericardial space with minimal interference. - **Small volumes** of pericardial fluid (as little as 50-100 mL) are **clinically significant** and potentially life-threatening, requiring immediate intervention. - Cardiac tamponade is an **immediately reversible cause of shock** that demands urgent diagnosis and pericardiocentesis. - **Sensitivity >90%** for clinically significant pericardial effusions in the trauma setting. *Liver* - FAST assesses the **hepatorenal space (Morison's pouch)** for free fluid, not the liver parenchyma itself. - Requires **larger volumes of free fluid** (>200-500 mL) to be reliably detected in the peritoneal cavity. - Detailed assessment of actual liver injury requires **contrast-enhanced CT imaging**. *Spleen* - FAST evaluates the **splenorenal recess** for free fluid surrounding the spleen, not splenic parenchymal injury. - Detection depends on adequate volume of free fluid being present. - **CT scanning** is superior for defining splenic lacerations, hematomas, and grading injury severity. *Pleural cavity* - While Extended FAST (eFAST) can assess **pleural spaces** for effusion or pneumothorax, this is an **extension** of the standard 4-view FAST protocol. - Standard FAST focuses on the **four primary windows**: pericardial, perihepatic, perisplenic, and pelvic. - **Chest X-ray** and **CT** remain primary modalities for comprehensive thoracic assessment.
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