Dr K AMEL HASSAN - RAMALLAH, PALESTINE - ‫ بسم هللا الرحمن الر حيم‬- ‫ فلس طين‬- ‫ را م هللا‬- ‫ كامل حسان‬.

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MCQs PEDIATRIC CARDIOLOGY EMERGENCY

Question 1
A 2-year-old male is rushed in by his parents after being found
unconscious near open bottles of his grandfather' s medications. The
airway is secure, and successful bag-valve ventilations are started.
He is pulseless and unresponsive. Intravenous access is being
obtained. The cardiac monitor shows a wide complex tachycardia at
a rate of 260. What is the next step in management?
A.Shock the patient with 200 J.
B.Shock the patient with 0.5 J/kg.
C.Shock the patient with 2 J/kg.
D.Administer epinephrine 0.01 mg/kg IV.
Answer & Comments
C
Comments:
–Although ventricular tachycardia and ventricular fibrillation are
uncommon in children, they can occur with toxidromes or severe
metabolic derangement.
–This child has pulseless ventricular tachycardia and should be
immediately defibrillated.
–The appropriate initial energy setting for defibrillation in pediatric
patients is 2 J/kg, then doubled for subsequent attempts.
–Cardioversion of unstable tachy-arrhythmias with a pulse begins at 0.5
J/kg and if unsuccessful is doubled for subsequent attempts.
–Epinephrine is indicated for pulseless arrest with ventricular tachycardia
in children after unsuccessful defibrillation.
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----------Question 2
A baby girl is considered normal at birth but on the second day of
age cyanosis is noted. No murmur is heard and there is no respiratory
distress. On the third day, cyanosis is more obvious and
the respiratory rate is increased. Which of the following is correct
concerning this patient?
A.Cyanosis is most likely due to congenital heart defect.
B.The baby’s colour should improve rapidly after giving 100% 02.
C.Echocardiography can often tell the anatomic state of the newborn’s
circulation.
D.The baby’s chest x-ray shows a small heart. This is against the
diagnosis of congenital heart disease.
E.The lack of murmur is against the diagnosis of CHD.
Answer & Comments
A&C
Comments:
–Cyanosis is most likely due to a congenital heart defect and a right to left
shunt.
–100% Oxygen will not improve the degree of cyanosis in the presence
of a right to left shunt where deoxygenated blood is entering the systemic
circulation.
–Echocardiogram has a high diagnostic accuracy rate and increasingly
surgery is performed following echo findings without interim
catheterisation.
–Certain congenital heart defects such as tetralogy of fallot are associated
with small cardiac size.
–Cyanosis is often the only clinical sign present in patients with CHD.
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----------Question 3
A 3 month old infant presents with acute dyspnoea and cyanosis. On
examination the pulse rate is 180 per minute, he has a grade
3/6 pan systolic murmur at the left sternal edge, basal crepitations
and a liver measuring 4 cm below the right costal margin.
–A. The most likely diagnosis is a ventricular septal defect.
–B. He requires a diuretic.
–C. He should be digitalised with 50ug/kg of Digoxin given over 24 hours.
–D. He should make a spontaneous recovery.
–E. Chest x-ray would be likely to show a small cardiac shadow.
Answer & Comments
B&C
Comments:
–Ventricular septal defects cause shunting of oxygenated blood from
the left ventricle to the right.
–Cyanosis is a later occurrence-followin g the development of
Eisenmenger’s syndrome ie shunt reversal.
–Diuretics are required to offload pulmonary venous congestion.
–Digoxin has a positive inotropic effect.
–Cyanotic congenital heart disease requires surgical correction of
vascular or shunt anomalies.
–The differential diagnosis of cyanosis and congestive cardiac failure in
neonates includes transposition of great vessels, total anomalous
pulmonary venous drainage, hypoplastic left heart , single ventricle and
tricuspid valve abnormalities and each is associated with cardiomegaly.
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----------Question 4
Echocardiographic evidence of tamponade includes which of the
following?
A.Pericardial effusion >1 cm in largest diameter.
B.Pericardial effusion with left ventricular collapse.
C.Pericardial effusion with right ventricular collapse.
D.Pericardial fluid collection.
Answer & Comments
C
Comments:
–Although not always seen, right-sided collapse (decreased filling) due
to pericardial effusion is evidence of tamponade.
–Presence of pericardial fluid does not equate to tamponade, while the
absence of fluid does exclude the diagnosis.
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Question 5
The following are associated with sudden death in childhood:
A.Aortic stenosis.
B.Primary pulmonary hypertension.
C.Atrioventricular septal defect.
D.Fallot's tetralogy.
E.Cardiomyopathy.
Answer & Comments
A,B,D,E
Comments:
–Sudden death may be caused by tricyclic antidepressants,
haemosiderosis, SIDS, metabolic disorders such as MCAD, child abuse,
trauma, hyperthermia, asthma, meningitis/septicae mia, bacterial
endocarditis, pertussis, cholera, RSV, gastro-oesophageal reflux, Reye
Syndrome, unrecognised diaphragmatic hernia, upper respiratory
obstruction, pulmonary thromboembolism, prolonged QT
Syndrome, aortic stenosis, mitral valve prolapse, aspiration,
anomalous right coronary artery or left coronary artery, Tetralogy of
Fallot, pulmonary atresia intact septum, tricuspid atresia, transposition of
the great arteries, arrhythmia, coronary artery disease in Hurler's
Syndrome, calcinosis of the coronary arteries, viral myocarditis,
primary cardiomyopathy, hypertrophic cardiomyopathy, Marfan's
Syndrome, achondroplasia secondary to cervical cord compression,
and volatile substance abuse.
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Question 6
Sudden cardiac death in an adoloscent can occur in
A.Wolf-Parkinson- White Syndrome.
B.Severe Aortic Stenosis.
C.Long QT syndrome.
D.Atrial septal defect.
E.Familial hypercholestolemia.
Answer & Comments
ABC
Comments:
–In WPW fast AF may rapidly deteriorate into VF.
–In severe AS and Long QT there may be VT.
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Question 7
In a heart transplant recipient, each of the following statements is true
EXCEPT
A.Sinus tachycardia at rest can be normal
B.The effect of atropine is exaggerated in the denervated heart
C.The response to -adrenergic drugs is normal or increased
D.The ECG is often read as atrial fibrillation or flutter
E.The patient will be immuno-suppressed for life
Answer & Comments
B
Comments:
–Atropine has no effect on the denervated heart because it acts by
blocking actions of the vagus nerve.
–The response to catecholamines may be increased by upregulation of
receptors in the denervated heart.
–The resting heart rate is usually between 90 and 100 beats per minute.
–The ECG often displays multiple P waves, from both the new heart and
a residual portion of the original atria.
–Life long immuno-suppression is mandatory to prevent rejection.
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----------Question 8
In suspected acute rheumatic fever the following indicate carditis:
–A. An ESR of 120 mm in one hour.
–B. Short apical soft systolic bruit.
–C. Strong cardiac impulse at the apex, which is displaced laterally.
–D. Sinus arrhythmia.
–E. Erythema nodosum.
Answer & Comments
C
Comments:
–The confirmation of rheumatic carditis solely depends on the findings
of mitral and or aortic incompetence.
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Question 9
The following are common signs of heart failure in infancy
A. Intercostal retraction.
B. Basal crepitations.
C. Tachycardia.
D. Raised JVP.
E. Enlarged liver.
Answer & Comments
ACE
Comments:
–Intercostals induction and tachypnoea (60-100 respiration/ minute),
tachycardia >120-140 bpm, are common.
–Hepatomegaly is a reliable indicator of effectiveness of therapy and is
common.
–Frank pulmonary oedema is uncommon and raised JVP, though useful
in older children is not a reliable clinical sign in infants.
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Question 10
1)In the diagnosis of rheumatic fever, which of the following may be
helpful?
A.A generalized macular-papular rash.
B.ASO titer of less than 1:200.
C.Polyarthritis.
D.Staphylococcus aureus grown on throat culture.
E.Splinter hemorrhages.
Answer & Comments
1)C
Comments:
–A Jones criteria require two major or one major and two minor, and
evidence of recent streptococcal infection for the diagnosis of rheumatic
fever.
MAJOR:
–1) Pancarditis.
–2) Polyarthritis
–3) Erythema marginatum
–4) Chorea
–5) Subcutaneous nodules.
MINOR:
–1) Fever
–2) Polyarthralgia
–3) History of RF
–4) Raised ESR/CRP
–5) Prolonged PR interval on ECG.
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Question 11
Cyanosis in the newborn may be caused by which of the following:
A.Transposition of the great arteries.
B.VSD
C.Hyperbilirubinaemia .
D.Coarctation of the aorta.
E.Eisenmenger syndrome
Answer & Comments
A
Comments:
–VSD is a left to right shunt, coarctation is a narrowing of the aortic
arch and hyper-bilirubinaemi a is not associated with cyanosis.
–Eisenmenger’s syndrome though a cause of cyanosis develops much
later following reversal of a left to right shunt.
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Question 12
A 1-year-old infant is known to have heart disease and is noted to be
cyanosed. Which of the following is the most likely diagnosis?
A.Atrial septal defect
B.Coarctation of the aorta
C.Patent Ductus Arteriosus
D.Tricuspid atresia
E.Ventricular septal defect
Answer & Comments
D
Comments:
–The patient is cyanosed and of the diseases described only tricuspid
atresia is associated with cyanosis.
–Other causes are Fallot’s tetralogy, single ventricle and TGA.
–Eisenmenger’s syndrome develops with the switch to right to left flow
associated with deteriorating VSD etc.
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Question 13
An uncomplicated VSD in a 5-year-old boy may be associated with which
one of the following?
A.A collapsing pulse.
B.Wide and fixed splitting of the second heart sound.
C.Clubbing of the fingers.
D.A pansystolic murmur of grade 4/6 in intensity.
E.Splenomegaly.
Answer & Comments
D
Comments:
–A collapsing pulse may indicate associated aortic incompetence.
–The wide fixed splitting of 2nd Ht.sound id a feature of ASD.
–Clubbingis a feature of cyanotic congenital heart disease.
–A holosystolic murmur of variable intensity is characteristic.
–Splenomegaly is not associated.
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Question 14
A newborn baby, one of twins born at term, is noted to be centrally
cyanosed soon after birth. Which of the following is the most likely cause
?
A.Ventricular septal defect
B.Transposition of great arteries
C.Patent ductus arteriosus
D.Coarctation of the aorta
E.Tricuspid atresia.
Answer & Comments
B,E
Comments:
–VSD and PDA are left to right shunts; coarctation of the aorta is not
associated with cyanosis.
–Tricuspid atresia and transposition of the great arteries are both
cyanotic congenital heart diseases and present in the immediate newborn
period.
–Of the 2 TGA is more common and hence more likely to be the cause.
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Question 15
Plethoric lung fields are a common radiological feature of:
A.A large ventricular septal defect
B.Fallot’s tetralogy
C.Coarctation of the aorta
D.Epstein’s anomaly
E.Eisenmenger’s complex.
Answer & Comments
A
Comments:
–Coarctation is associated with normal pulmonary blood flow and other
than a large VSD the rest are associated with reduced pulmonary blood
flow.
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Question 16
A 14-year-old boy presents with hypertension. Which of the following
statements concerning hypertension in the young is true?
A.Sodium nitroprusside is useful for the long-term treatment of severe
cases.
B.Headache is the usual presenting feature.
C.It is defined as systolic blood pressure above the 99th centile for age.
D.Abnormalities are frequently seen on DMSA scan.
E.Aortic coarctation is the commonest secondary cause.
Answer & Comments
D
Comments:
–Sodium nitroprusside is useful only in the short term, as cyanide levels
accumulate with time.
–Hypertensionis usually diagnosed incidentally, and is defined as systolic
blood pressure >95th centile for age.
–Secondary causes are usually due to renal abnormalities, with reflux
associated scarring being the commonest renal disease. This will cause
abnormalities on DMSA scan.
–Coarctation of the aorta is the commonest non-renal cause,
with pheochromocytoma/ neuroblastoma, congenital adrenal hyperplasia,
–Cushing Syndrome and steroid therapy being rarer causes.
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Question 17
Which one of the following is a recognized feature of abeta-lipoproteinae
mia?
A.A high serum cholesterol
B.Palmar xanthomas
C.Advanced atherosclerotic vascular disease
D.Abnormal red blood cell morphology
E.Severe mental retardation
Answer & Comments
D
Comments:
–Acanthocytes are seen in abetalipoproteinaem ia.
•ABETALIPOPROTEINAEM IA
–Rare recessive disorder inability to produce LDL chylomicron formation
is defective
–Characteristic features to age 2
•Steatorrhoea, failure to thrive
•Low serum lipids, acanthocytosis
–Later childhood
•Ataxia, intention tremor, nystagmus
•Athetosis, muscle weakness, dec. reflexes
•IQ normal but emotionally labile
•Some develop retinitis pigmentosa
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Question 18
•A four year old child is found to have the classical murmur of a patent
ductus. He is underweight for age but otherwise well. Which of the
following would you recommend for this patient?
A.Recommend early operative closure?
B.Review the child constantly, expecting spontaneous closure within the
next five years?
C.Recommend prophylactic penicillin until operation is performed?
D.Delay operation until the child has reached its expected weight for age?
E.Explain to the parents that this is of little significance and can be
ignored?
Answer & Comments:
•A
•Comments:
–Early operative closure is recommended, in any patient in whom the
defect has persisted beyond six months of age.
–Prophylactic antibiotics are recommended for dental and other invasive
procedures.
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Question 19
•Which ONE of the following statements is true about the Austin Flint
murmur?
A.It is associated with a loud first heart sound.
B.It is an early sign of aortic regurgitation
C.It can be distinguished from the murmur of mitral stenosis by absence
of presystolic accentuation
D.It is due to partial closure of the anterior leaflet of the mitral valve
E.It does not occur in aortic incompetence secondary to an aortitis
ANSWER & COMMENTS:
•D
•Comments:
–Austin Flint murmur is a low frequency mid/late diastolic murmur which
may show pre-systolic accentuation which is virtually indistinguishable
from that of mitral stenosis.
–There is no correlation between presence of murmur and severity of AR,
or aetiology.
–The first heart sound is normal but in severe cases, it may be absent.
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Question 20
•Select which of the following is correct in relation to congenital heart
disease.
A.The murmur of a ventricular septal defect is likely to be loud in the first
day of life.
B.In Down’s syndrome with an endocardial cushion defect
irreversible pulmonary hypertension occurs earlier than in children with
normal chromosomes.
C.Atrial septal defects, in contrast with ventricular septal defects, never
close spontaneously.
D.Transposition of the great vessels is the most
common congenital cyanotic heart disease.
E.Failure to thrive is often found associated with Fallot’s tetralogy at
about 3 months of age.
ANSWER & COMMENTS:
•B
•Comments:
–The murmur of VSD is intensified after one month of life.
–ASDs often close spontaneously and the chance of spontaneous closure
is related to size ie. 5-8mm 80% closure, whereas if the defect is > 8mm
then there is little chance of closure.
–Tetralogy of Fallot is the most common cyanotic congenital heart
disease.
–Fallots tetralogy more commonly presents beyond 3 months of age.
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Question 21
•Concerning complete atrioventricular septal defects which of the
following statements is true?
A.Are seen frequently in patients with trisomy 21
B.Frequently have aortic valve insufficiency
C.Have a normal mitral valve structure
D.Include a coronary sinus atrial septal defect
E.Include a perimembranous ventricular septal defect
ANSWER & COMMENTS:
•A
•Comments:
–Partial AV canal defect (ostium primum ASD), Complete AV septal
defect (Large deficiency in the atrial and ventricular septa). Commonly
AV valve orifice and the commonest defect associated with Down's
syndrome.
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Question 22
•A 4 month old boy is brought in dead to hospital. He had had a cold for
3 days, with crusty nose and mild fever. He went to bed at 7 pm as usual.
Mother checked him at 11pm before going to bed. In the morning she
found him stiff and cold. He was brought to ER by ambulance, but
resuscitation was unsuccessful. Mother is single 19 years and smokes
20/d. He was born at 39/40 weighing 3.25 kg, and there were no neonatal
problems. He had been growing along the 50th centile for height and
weight. What is the most likely diagnosis?
A.Acute life-threatening event
B.Cardiac dysrhythmias
C.Seizures
D.Sudden infant death syndrome
E.Acute myocarditis
ANSWER & COMMENTS:
•D
•Comments:
–This is a typical history of SIDS.
–The official definition is: "The sudden death of an infant under 1 year of
age that remains unexplained after a thorough case investigation,
including performance of a complete autopsy, examination of the death
scene, and a review of the clinical history."
–Risk factors include: maternal smoking, prematurity, over-wrapping,
intercurrent infection, prone sleeping position, low social class
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Question 23
7-year-old girl with Down’s syndrome has
central cyanosis. Examination of her chest shows only a soft mid-systolic
murmur at the apex and in her abdomen there is a well healed scar in the
epigastrium dating from the newborn period. Which of the following
statements would be correct:
A.Her haematocrit is likely to be 30%
B.She has Fallot’s tetralogy
C.Arterial Blood gases show CO2 retention
D.The newborn period is likely to have been complicated by
Hirschsprung’s disease
E.Dental extraction should be covered by antibiotic prophylaxis

ANSWER & COMMENTS:

•E
•Comments:
–Most probably she will have secondary polycythaemia and a raised
haematocrit.
–She has (most likely) Eisenmonger’s syndrome secondary to a reversed
VSD shunt.
–She has cyanotic heart disease and the blood gases will
show hypoxia rather than CO2 retention .
–Hirschprung’s disease (congenital aganglionic megacolon) occurs more
frequently in patients with Down’s syndrome but it is still a relatively
uncommon development. Duodenal atresia may have occurred.
–She has a high risk for the development of SBE and therefore she should
receive antibiotic prophylaxis.
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Question 24

•A 15 year old female presents following a sore throat with chest pain,
fever, and a skin rash. Examination reveals a diastolic murmur. Her ASO
titre is elevated. Which of the following is a major criterion for the
diagnosis of Rheumatic fever?
A.Fever
B.Raised ESR
C.Migratory arthritis
D.erythema multiforme
E.Prolonged PR interval

ANSWER & COMMENTS:

•C
•Comments:
–Polyarthritis together with erythema marginatum (not
multiforme), Sydenham's chorea, carditis and subcutaneous nodules
constitute the major criteria associayed with Rheumatic fever.
–Minor criteria include raised ESR, Arthralgia, pyrexia and a prolonged
PR interval.
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Question 25

Choose the correct answer(s)

In uncomplicated PDA :
–A..CXR shows evidence of pulmonary plethora
–B. Raised audibility of murmur when standing
–C. There is evidence of LVH on ECG
–D. Decreased pulse volume
–E. Cyanosis is present

Answer & Comments

A,C
•Comments:
–The ductus arteriosus is a normal vascular channel during
intrauterine life.
–It is a large vessel with a muscular wall which courses between
the pulmonary artery and the aorta.
–The ductus arteriosus normally closes within the first 48 hours of
life.
–If it remains patent longer than this it is unlikely to close
spontaneously.
–The exception is in premature babies where closure should occur
within 3 months.
–A persistently patent ductus is a common congenital heart lesion,
occurring either singly or in combination with other defects.
–It is more common in: girls than in boys, congenital rubella
syndrome, premature babies
–Features include increased cardiac output, increased pulmonary
flow (plethora on CXR) LVH due to increased output, increased
pulse volume.
–Cyanosis is not a feature.
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Question 26

Choose the correct answer(s)

•At birth the following circulatory changes occur
–A. A rise in right atrial pressure
–B. Flap closure of the foramen ovale
–C. Anatomical closure of the ductus arteriosus
–D. Functional closure of the ductus venosus
–E. A 20-fold increase in lung blood flow

ANSWER & COMMENTS

•B,D
•Comments:
–At the first breath, air fills the lungs and pulmonary vascular
resistance falls.
–Blood flow to the lungs increases from 10 to 50% of cardiac output,
and the increased pulmonary venous return raises left atrial
pressure.
–There is functional closure of the ductus arteriosus and venosus.
–Ligation of the umbilicus increases systemic resistance.
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Question 27

Choose the correct answer(s)

•Ostium secundum ASD :
–A. often leads to atrial fibrillation during the second decade
–B. is associated with left axis deviation on the ECG
–C. is associated with mitral valve prolapse
–D. accounts for the majority of cases of ASD
–E. is generally thought to require surgical correction if the pulmonary
blood flow is greater than twice the systemic

ANSWER & COMMENTS:

•C,D,E
•Comments:
–A- Not that young.
–B- Long PR and RBBB.
•RAD with secundum,
•LAD or superior AD with primum defect.
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Question 28

Choose the correct answer(s)

•The following associations are recognised:
–A. Down's Syndrome and Septal Defect
–B. Maternal tyrosinaemia and cong.heart dis.
–C. Fragile X Syndrome and VSD
–D. Noonan's Syndrome ad cardiomyopathy
–E. Maternal phenylketonuria and cong.heart dis.

ANSWER & COMMENTS

•A,D,E
•Comments:
–Down's Syndrome is associated particularly with AV canal defects,
VSDs and ASDs.
–Fragile X Syndrome is associated with mitral valve prolapse and
aortic route dilatation.
–Noonan's Syndrome is associated with pulmonary stenosis
(dysplastic pulmonary valve), ASD and cardiomyopathy.
–Maternal phenylketonuria is associated with VSD, ASD, PDA,
and coarctation of the aorta.
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Question 29
Choose the correct Answer(S)
•The following stigmata may be associated with congenital heart
disease:
–A. Steinberg's sign.
–B. Hypotelorism.
–C. Absent radius.
–D. Distal triradius.
–E. Low hair-line.
ANSWER & COMMENTS
•A,B,C,D,E
•Comments:
–Steinberg's sign is where the thumb, when held in the clenched hand
protrudes beyond the palm. This is characteristic of Marfan's Syndrome,
and suggest arachnodactyly.
–Hypotelorism is found in Patau's Syndrome, which is associated with a
number of cardiac defects including VSD, ASD, PDA, coarctation and
bicuspid aortical pulmonary valves.
–TAR Syndrome (thrombocytopenia and absent radius) is associated
with ASD and Tetralogy of Fallot.
–A distal triradius is found in Down's Syndrome which is associated
with atrioventricular septal defects.
–Low hairline in Turner's Syndrome which is associated with
coarctation.
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Question 30
•In the fetal circulation
–A. Approximately each volumes of blood are pumped by the left
and right ventricles.
–B. The saturation of blood returning from the placenta is about 80%.
–C. Approximately 25% of cardiac output traverses the fetal lung.
–D. The ductus venosus is probe-patent in 75% of cases.
–E. Pulmonary vascular resistance is suprasystemic.
ANSWER & COMMENTS
•A,B,E
•Comments:
–In the fetal circulation, the vast majority of blood bypasses the lungs
through the ductus arteriosus, but the right and left ventricles pump
approximately equal volumes.
–The fetus is relatively hypoxaemic, with fetal haemoglobin being used
to increase oxygen carriage to the tissues.
–Only 10% of cardiac output traverses the fetal lung, and the ductus
venosus remains patent until the postnatal period.
–Approximately 50% of umbilical venous catheters can be passed
through it into the right atrium postnatally.
–The pulmonary-vascular resistance remains suprasystemic until the
time of the first breath, when the combination of lung aeration reducing
pulmonary blood pressure, and umbilical ligation increasing systemic
blood pressure reverses the situation.
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Question 31
Choose the Correct Answer(S)
•In mitral stenosis caused by rheumatic heart disease, prophylaxis
against endocarditis is unnecessary in:
–A. cystoscopy.
–B. dental scaling.
–C. caesarean section.
–D. cardiac catherization.
–E. transesophageal echocardiogram.
ANSWER & COMMENTS
•C,D,E
•Comments:
–The American College of Cardiology guidelines recommend antibiotic
prophylaxis for
•dental work including scaling,
•cystoscopy, endoscopy, bronchoscopy and biliary tract surgery.
–It is not recommended for Caesarian section, ToE (except high risk
cases) and Cardiac catheterisation.
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Question 32
Choose The Correct Answer(S)
•Which of the following are true of Wolf-Parkinson-White syndrome?
–A. there is an abberant conduction between atria and ventricles.
–B. broad complex tachycardia is more frequent than narrow-complex
tacchycardia.
–C. verapamil is the treatment of choice for an associated SVT.
–D. Amiodarone increases the refractory period in the accessory path.
–E. Atrial fibrillation is a well recognised rhythm disturbance.

ANSWER & COMMENTS

•A,B,D,E
•Comments:
–a-Bundle of Kent.
–b-Although orthodromic tachycardia is the commonest it frequently has
phasic aberrant conduction making it broad.
–Verapmil may exacerbate the rhythm disturbance associated with
WPW and AF may result in VF.

Question 33
Choose The Correct Answer(S)
•Myocarditis is a recognised association of:
A Salmonella infection.
–B. Mycoplasma infection.
–C. Lyme Disease.
–D. Measles.
–E. Hurler's Syndrome.

Answer & Comments:

•A,B,C,D
•Comments:
–Hurler's is associated with a cardiomyopathy.
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Question 34

Choose The Correct Answer(S)

•The following are features of aortic coarctation in infancy:
A. Rib-notching.
–B. Inverted T wave in V6.
–C. Ejection systolic murmur between the shoulder blades.
–D. Radio-femoral delay.
–E. Plateau pulses.

Answer & Comments

•B,C,D
•Comments:
–Rib notching is a late sign in adolescents, and is rarely seen these days.
–An inverted T wave in V6 suggests left ventricular strain.
–Plateau pulses are a feature of aortic stenosis.
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----------Question 35

Choose the correct Answer(S)

•Pulsus paradoxus is found with

A. Severe asthmatic attack.
–B. Severe left ventricular failure.
–C. Myocardial disease.
–D. Constrictive pericarditis.
–E. Cardiac amyloidosis

Answer & Comments

•A,C,D,E
•Comments:
–Pulsus paradoxus is the exaggerated fall of pressure associated with
inspiration due to disease process like asthma, constrictive pericarditis,
tamponade and left ventricular disease (cardiomyopathy) .
–It is not a feature of left ventricular failure.
Question 36
•The following findings suggest that a murmur is innocent:
–A. It is grade 3/6.
–B. It has a vibratory quality.
–C. It is loudest at the apex.
–D. It is only heard when the patient is febrile.
–E. It changes in intensity with posture.

Answer & Comments

•B,D,E
•Comments:
–About 30% of children can have innocent murmurs.
–These are usually ejection generated by the outflow tracts of the
left of right side of the heart, or venous hums due to turbulent
flow in the head and neck veins.
–The hallmarks are their localised nature; the fact they are
confined to systole; the fact they are soft; and that they are
associated with no symptoms or other signs.

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Question 37

•The following are true of cardiac transplantation:

–A. The donor heart is provided to the recipient with the best HLA
match.
–B. Long term hypotension is a problem.
–C. Recipients suffer less angina but accelerated coronary artery
disease.
–D. The histology of atheroma in the transplanted heart is the
same as that of typical atherosclerosis.
–E. 75% 5 year survival

Answer & Comments

•C,E
•Comments:
A.This is true of kidney transplants but hearts go to the most
needy.
B.Hypertension is a significant problem related to use of
cyclosporin and denervation of the heart.
C.The heart is denervated.
D.The pathology is different being more diffuse and symmetrical.
E.For most centres with conventional selection criteria.

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