MCQS COLLECTION

PEDIATRIC CARDIOLOGY

PEDIATRIC PROGRAM RESIDENTs

KSMC 2017
 1. A previously healthy 8 years old boy has a 3-week history of low grade fever of
unknown source, fatigue, weight loss, myalgia, and headaches. On repeated exam
during this time, he was found to have a heart murmur, petechiae and mild
splenomegaly. The most likely diagnosis is:
a. Rheumatic fever
b. Kawasaki disease
c. Scarlet fever
d. Endocarditis
e. Tuberculosis
The answer is d, Endocarditis
The presentation of infective endocarditis can be quite variable, ranging from prolonged fever
with few other symptoms to an acute and severe course with early toxicity. A high index of
suspicion is necessary to make the diagnosis quickly. Identification of the causative organism
(frequently Streptococcus sp. or Staphylococcus sp.) through multiple blood cultures is
imperative for appropriate treatment. Echocardiography may identify valvular vegetations and
can be predictive of impending embolic events. Treatment usually consists of 4 to 6 weeks of
appropriate antimicrobial therapy. Bed rest should be instituted only for heart failure.
Antimicrobial prophylaxis prior to and after dental cleaning is indicated. The child is older than
typical for Kawasaki disease (80% will present under the age of 5 years), and the history is not
consistent with the diagnosis. Scarlet fever is typically self-limited and would not be consistent
with the 3-week time course. Tuberculosis can certainly cause prolonged low-grade fever, but
cardiac involvement is unusual, consisting of pericarditis; thus a friction rub would be the typical
exam finding.
2. A previously healthy 4-month-old boy has been irritable and has had a decreased
appetite for 2 days. Findings include: heart rate, 240 beats/min; respiratory rate, 60
breaths/min; rectal temperature, 37.4°C (99.3°F); diminished radial and posterior
tibial pulses; and good brachial and femoral pulses. Electrocardiography shows
tachycardia; QRS complexes are narrow without preceding P waves. Of the
following, the most appropriate INITIAL management is to
a. administer adenosine intravenously
b. administer verapamil intravenously
c. apply an ice-filled plastic bag to the entire face for 5 to 10 seconds
d. apply an ice-filled plastic bag to the upper face for 60 seconds
e. perform synchronized direct current cardioversion
The answer is c, apply an ice-filled plastic bag to the entire face for 5 to 10 seconds
This is a case of SVT, and according to the new guidelines applying an ice-filled plastic bag to
the entire face for 5 to 10 seconds with no pressure over the eyeballs is the best initial
management.
 3. In which of the following congenital heart disease PGE-1 infusion is
contraindicated:
a. Tricuspid atresia
b. Total anomalous of pulmonary venous return
c. Transposition of great arteries
d. Pulmonary atresia
e. Interrupted aortic arch
The answer is b, Total anomalous of pulmonary venous return
Chief Indications of PGE1: 1. Maintains patency of ductus arteriosus in neonates with ductal –
dependant congenital heart lesions until surgery can be done. 2. Improve shunting after balloon
septostomy has failed to improve oxygenation in certain cases of complete transposition of the
great arteries.
Possible Adverse Reactions: 1. Apnea (in up to 15% of patients) 6. Thrombocytopenia 2. Fever
7. Hypoglycemia, hypocalcaemia 3. Seizure 8. Diarrhea 4. Hypotension & Bradycardia 9.
lethargy 5. Cortical hyperostosis with prolonged use
Contraindications & Precautions: 1. Hypersensitivity to prostaglandin E 2. PPHN 3. Total
anomalous pulmonary venous return with obstruction 4. Caution use in presence of bleeding
tendencies or seizure disorders.

4. A 1 day old term 3 kg has 3/6 ejection murmur on the third day after birth,
hepatosplenomegaly developed, heart rate is 160/min and RR 60 bpm. Blood
pressure is 100/60 mmHg in upper extremities and 60/40 mmHg in the lower
extremities. Which of the following therapy would be most effective?
a. Balloon atrial septostomy
b. IV administration of PGE-1
c. Restriction of fluid intake
d. Systemic to pulmonary artery shunt
e. IV administration of indomethacin
The answer is b, IV administration of PGE-1
 5. Most common cardiac lesion in William syndrome is:
a. Aortic regurgitation
b. Supravalvular aortic stenosis
c. Coarctation of aorta
d. Valvular aortic stenosis
e. Subvalvular aortic stenosis
The answer is b, Supravalvular aortic stenosis
Williams syndrome (WS) is a rare genetic condition. The clinical manifestations include a
distinct facial appearance, cardiovascular anomalies that may be present at birth or may develop
later in life, idiopathic hypercalcemia, and a characteristic neurodevelopmental and behavioral
profile.
Pathophysiology: autosomal Dominant, haploinsufficiency (loss of 1 of 2 copies) due to a
deletion at chromosome band 7q11.23 that involves the elastin gene (ELN) is implicated. other
genes within the region of the deletion are under investigation for their role in the cognitive
profile of Williams syndrome, such as LIMK1, GTF1IRD1, GTF2IRD2, GTF2I, NCF1, STX1A,
BAZ1B, CLIP2, and TFII-1.
WS is Developmental Disorder: Facial features frequently include a broad forehead, short nose,
and full cheeks, an appearance that has been described as "elfin". Mild to moderate intellectual
disability with particular problems with visual spatial tasks such as drawing and fewer problems
with language are typical. Those affected often have an outgoing personality and interact readily
with strangers. Problems with teeth, heart problems, especially supravalvular aortic stenosis,
and periods of high blood calcium are common.
Treatment includes special education programs and various types of therapy. Surgery may be
done to correct heart problems. Dietary changes or medications may be required for high blood
calcium.
 6. 4 year old child presented to ER two years status post Tetralogy of Fallot (TOF)
repair. He was found to be short of breath with HR of 180 bpm and cyanosis. His
ECG showed bizarre and wide QRS with AV dissociation, immediate treatment is:
a. IV adenosine
b. IV digoxin
c. IV Lidocine
d. IV MgS04
e. Synchronized cardioversion
The Answer is e, Synchronized cardioversion
Wide and bizarre QRS complexes, AV dissociation, and the presence of fusion beats and capture
beats support the diagnosis of ventricular tachycardia.
Ventricular complexes with bizarre or prolonged configuration indicate only that conduction
through the ventricle is abnormal, and such complexes can occur in supraventricular tachycardias
because of preexisting bundle branch, aberrant conduction, or conduction over accessory
pathways.
AV dissociation has long been considered a hallmark of ventricular tachycardia, but at times it is
difficult to determine whether the P wave is conducted anterogradely (supraventricular
tachycardia) or retrogradely (ventricular tachycardia). As a general rule, the presence of AV
dissociation during a wide QRS tachycardia is strong presumptive evidence that it is of
ventricular origin.

7. Pre-excitation syndrome is associated with:

a. SVT
b. Premature ventricular contraction
c. Premature atrial contraction
The Answer is a, SVT
Pre-excitation syndrome is a cardiac arrhythmia in which the ventricles of the heart
become depolarized too early, which leads to their partial premature contraction ((atria to
contract before the ventricles).

Several different types have been described.

Type Conduction pathway PR QRS Delta
interval interval wave?
Wolff-Parkinson-White Bundle of Kent (atria to Short long yes
syndrome ventricles)
Lown-Ganong-Levine "James bundle" (atria to bundle Short normal no
syndrome of His)
Mahaim-type Mahaim fibers Normal long no
 8. Newborn diagnosed to have severe tricuspid atresia. You decided to start him on
PGE-1. When it was started, he went apneic and hypotensive with skin rash, best
approach is to:
a. Hold PGE-1
b. Secure airway and continue PGE-1
c. Start indomethacin
d. Septic workup and antibiotic
e. Discontinue PGE-1 because this is severe allergic reaction
The answer is ?b
During infusion of PGE1, arterial blood pressure and respiratory activity should be monitored
carefully and appropriate supportive steps taken if hypotension or respiratory depression occurs.
“It has been recommended that, when possible, the PGE1 dose be reduced to the lowest effective
rate prior to transport to avoid having to initiate artificial ventilation during transport. Even with
the increased safety associated with lower doses, all hospitals considering the use of
PGE1 should be capable of providing adequate ventilatory support in the event that severe apnea
does occur, including possible emergency intubation. In cases where a reduction in dose is not
tolerated, elective intubation prior to transport should be considered.”
The development of fever or jitteriness may require reduction of the infusion rate and, in view of
the possible increased incidence of infections, the prophylactic use of antibiotics is
recommended.

9. 11 years old with Down syndrome presented to ER with respiratory distress and
cyanosis. On exam: he had loud cardiac murmur, previous surgical scar, most likely
cause of this condition is:
a. AVSD with Eisenmenger syndrome
b. Atrial septal defect (ASD)
c. Ventricular septal defect (VSD)
d. Patent ductus arteriosus (PDA)
e. Cardiomyopathy
The answer is ?a
Eisenmenger syndrome refers to any untreated congenital cardiac defect with intracardiac
communication that leads to pulmonary hypertension, reversal of flow, and cyanosis. The
previous left-to-right shunt is converted into a right-to-left shunt secondary to elevated
pulmonary artery pressures and associated pulmonary vascular disease.
10. 2 of 3 weeks infant presented to ER with respiratory distress and cyanosis,
tachycardic, poorly perfuse, 02 sat was 84% in RA and on 100% 02 only came up to
94%. On exam: RR, HR, hepatomegaly, no murmur. Your next step to diagnose
him:
a. Echo
b. ECG
c. CXR
d. Methemoglobin level
The answer is ?
 11. Which is true regarding innocent murmur?
a. It is usually diastolic
b. Venous hum murmur more when supine
c. Grade I-II intensity
d. More at apex
e. Not change with position or fever
The answer is c, Grade I-II intensity
Innocent murmurs more common than pathologic 10:1.
Causes: Innocent Murmurs
Still's Murmur (Aortic Vibratory Systolic): Most common innocent murmur
Venous Hum of late infancy and early childhood: Second most common innocent murmur
Septal hypertrophy due to myocardial fat deposition: Resolves over six months
Pulmonary Flow Murmur
Neonatal Pulmonary branch murmur
Physiologic Peripheral Pulmonary Stenosis
Supraclavicular Murmur (Brachiocephalic Systolic Murmur)
Aortic Systolic Murmur
Mammary artery soufflé
Signs: Innocent Murmurs
Precaution: These signs are unreliable in under age 1 year due to higher Incidence of Congenital Heart
Disease
Auscultation (Seven S's - key reassuring findings in innocent murmurs)
Sensitive Murmur accentuates with position changes, activity - see below
Short duration Not holosystolic
Single Isolated murmur without click, gallup or other extra heart sounds
Small Murmur limited to small, focal distribution without radiation
Soft Low amplitude (e.g. II/VI murmur)
Sweet Non-harsh quality
Systolic  Limited to systole (Diastolic Murmurs are typically pathologic)
Accentuation maneuvers (innocent murmurs become louder in this position)
Sitting forward
Exercise or increased Heart Rate
Fever
Anxiety, Restlessness, or crying
Diagnosis: Innocent Murmur (all 4 criteria required)
No abnormal physical findings
No symptoms suggestive of Congenital Heart Disease
No increased risk of Congenital Heart Disease by history
Auscultation findings consistent with innocent murmur and no red flags suggesting pathologic murmur
 12. Among the following ECG, which more comes with hyperkalemia?
a. Inverted T wave
b. Prominent U wave
c. Wide QRS complex
d. Short PR interval
The answer is c, Wide QRS complex
Typical ECG findings in hyperkalemia progress from tall, “peaked” T waves and a shortened QT
interval to lengthening PR interval and loss of P waves, and then to widening of the QRS
complex culminating in a “sine wave” morphology and death if not treated.

13. Child known to have Ventricular septal defect (VSD) and pulmonary hypertension
came with severe metabolic acidosis and hypotension. Among the following
inotrope, what is the best choice?
a. Dopamine
b. Dobutamine
c. Epinephrine
d. Isoproterenol
e. Milrinone
The answer is d, Isoproterenol
Milrinon: Preferred in patient with pulmonary hypertension
Dobutamin: Poor perfusion, BP normal. It decreases systemic and increase pulmonary resistance
so it is contraindicated here

14. The most common cause of syncope in children?

a. Arrhythmia
b. Hyperventilation
c. Vasovagal attack
d. Seizure
e. Structural cardiac defect
The answer is c, Vasovagal attack

15. Patient known to have tricuspid atresia presents with vomiting and headache in the
morning, what will you do?
a. CSF study
b. CT scan brain
c. Skull x-ray
d. CT scan brain with technetium
The answer is d, CT scan brain with technetium (with contrast)
Cyan optic heart disease:
>2 yr. Stroke.
<2 yr.  Abscess.
 16. 3 y.o girl prefers squatting position after exercise looks mildly cyanosed :
a. TOF
b. PS
c. TGA
d. congenital heart disease in a baby , risk of recurrence ??
The answer is a, tetralogy of Fallot,
This child has tetralogy of Fallot, which consists of right ventricular outflow obstruction (pulmonary
stenosis), VSD, dextroposition of the aorta, and right ventricular hypertrophy. The radiograph shows the
typical “boot-shaped” heart, while the ECG demonstrates the increased right ventricular forces. Children
with tetralogy of Fallot may have cyanotic episodes (“tet spells”) associated with acute reduction in
pulmonary blood flow. Typically, these spells are self-limited, lasting no more than 30 minutes. Assuming
the knee-chest position is thought to increase peripheral resistance, decreasing the amount of right-to-left
shunting and thus increasing pulmonary blood flow. Alternative therapies include morphine sulfate and
propranolol. Prolonged hypoxia can lead to acidosis; correction may require infusion of sodium
bicarbonate.

17. 2 y.o referred to you because of suspected cardiomegally by CXR , you reviewed the
CXR an exp. Film with cardiac size 50% of thoracic size what you do:
a. Repeat CXR insp. Film
b. ECHO
c. ECG
d. Chest CT

18. You were at a nursery and after 6 h a baby was cyanosed and tachypneic CXR
showed no increase in pulmonary blood flow ECG: LAD.
a. TA. ( √ )
b. TGA.
c. TOF.
d. TAPvR.
e. Truncus arterosus.

19. PGE is contraindicated in which condition?:

a. TGA.
b. TOF.
c. TA with intact VSD.
d. TAPVR. ( √ )

20. A newborn was delivered in the nursery and was discharged in stable condition 4
week later the patient developed cyanosis decrease activity and perfusion (was in
shock) O2 sat was equal in both UL – LC. What's your diagnosis?
a. COA. ( √ )
b. TAVR.
c. Pulmonary atresia with. Intact VSD.
d. TOF
e. TA with VSD
f. Tricuspid atresia with VSD.
 21. In which condition is TOF prophylaxis against infective endocadits: required?
a. Cystoscopy.
b. Endoscopy.
c. Bronchial biopsy.
d. U. Catheterization.
e. Insertion of ear tube.

22. Rx of cyanotic spell all are true except:

a. Morphine.
b. Epinephrine. ( √ )
c. Propranolol.
d. Phenyleprine.
e. Na HCO3.

23. Still’s murmur is:

a. Diastolic murmur heard at LLSB.
b. An early systolic murmur which increase with jugular pressure.
c. A mid systolic murmur heard well in the recombinant position. ( √ )
d. A systolic murmur which increase with expiration.
e. A mid diastolic murmur.

24. 3 y.o with incidental finding pansystolic murmur :

a. ASD
b. VSD
c. PDA
d.

25. The sign that is occur in both IE, R fever: ?

Gallop rhythm

26. Management of cyanotic spells except:

a. Knee chest position
b. O2
c. NaHCO3
d. Digoxin
e. B-blockers

The answer is d, Digoxin

Children with tetralogy of Fallot may have cyanotic episodes (“tet spells”) associated with acute reduction
in pulmonary blood flow. Typically, these spells are self-limited, lasting no more than 30 minutes.
Assuming the knee-chest position is thought to increase peripheral resistance, decreasing the amount of
right-to-left shunting and thus increasing pulmonary blood flow. Alternative therapies include morphine
sulfate and propranolol. Prolonged hypoxia can lead to acidosis; correction may require infusion of
sodium bicarbonate.
 27. 4 years old he had hx of vomiting & fever, 1 week later, he developed tachycardia,
muttled H. sound Dx.
Another format of the question: A 4 year old child child presents with fever,
vomiting, and shortness of breath on exertion. Physical exam shows muffled heart
sounds, fever, a gallop rhythm, and tachycardia. The best diagnosis for this child is:
a. Pericanditis
b. Myocarditis

The answer is b, Myocarditis

Myocarditis presents as mild pain present for several days. After a few days of fever, vomiting, and
lightheadedness, the patient may develop pain or shortness of breath on exertion. Examination may reveal
muffled heart sounds, fever, a gallop rhyth, or tachycardia. The patient also may have orthostatic changes
in pulse or blood pressure.
28. Iron def anemia increase risk of which of the following in cynotic CHD:
a. Stroke
b. CHF
c. Infective end.
29. Kawasaki disease –
↑↑↑plt
30. Scenario of acute rheumatic fever
Example Question from Pretest:
A child has a 2-week history of spiking fevers, which have been as high as 40Æ C
(104Æ F). She has spindle-shaped swelling of finger joints and complains of upper
sternal pain. When she has fever, the parents note a faint salmon-colored rash that
resolves with the resolution of the fever. She has had no conjunctivitis or mucositis, but
her heart sounds are muffled and she has increased pulsus paradoxus. Which of the
following is the most likely diagnosis?
a. Rheumatic fever
b. Juvenile rheumatoid arthritis
c. Toxic synovitis
d. Septic arthritis
e. Osteoarthritis
The answer is a, Rheumatic Fever
The diagnosis of rheumatic fever can be difficult because no single clinical manifestation or laboratory
test is confirmatory. However, an accurate diagnosis must be made since treatment of the acute problems
promptly and effectively is required and long-term antibiotic prophylaxis to prevent recurrences must be
instituted.
To assist in diagnosis, the American Heart Association identified a set of major and minor standards
relating to the manifestations of the disease, called the Jones criteria (modified), and recommends these
criteria be applied in the diagnosis of every patient with possible rheumatic fever. The major criteria are
carditis, arthritis, erythema marginatum, chorea, and subcutaneous nodules. The minor criteria are
arthralgia (joint pain with no objective findings), fever or history of rheumatic fever, increased
erythrocyte sedimentation rate (ESR), positive C-reactive protein, increased WBC and anemia, and
prolonged PR and QT intervals on ECG. To make the diagnosis of rheumatic fever, the following criteria
should be met: two major manifestations, one major and two minor manifestations plus strong evidence
of a preceding group A β -hemolytic streptococcal infection (culture, rapid antigen-antibody rise, or
elevation), or scarlet fever.
 31. Normal ECG finding in Neonates:
a. RVH, RAD

32. Girl with L.O.C when she will present sing solo, No family hx of cardiac disease Dx:
a. vasovagal
b. panic attach
c. long QT syndrome

33. Neonate with cyanosis, oligemic lung, ECG LAD Dx:

a. tricuspid atresia
Patients with tricuspid atresia typically have a hypoplastic right ventricle, and therefore the ECG shows
left axis deviation and left ventricular hypertrophy; this translates to a left ventricular impulse on physical
examination. Almost all other forms of cyanotic congenital heart disease are associated with elevated
pressures in the right ventricle and increased right ventricular impulse. In those conditions, therefore, the
ECG will show right axis deviation and right ventricular hypertrophy.

34. a baby presented with difficulty of feeding and sweating. HR 186. RR 70 , and
bilateral crackles. What is your first action
a. anti failure treatment
b. call the cardiology
c. catheterize the patient
This is heart failure case, ?not complete q

35. patient discovered accidently to have a pansystolic murmur on LSB

a. VSD
b. ASD
The answer is a, VSD
 36. Down syndrome, previous echo showed large ASD, Now his ECG is showing RVH,
right axis deviation, Right atrial dilatation. What t will you do:
a. catheter lab
b. CXR
c.
d.
Not complete
37. a patient with cyanotic CHD has a Hct of 57 %...He is a t risk for developing
a. Stroke
b. PDA
c. PS
d. foramen ovale

38. A patient with cyanotic CHD suddenly develops hematuria and a palpable
abdominal mass. His platelets are 140,000. What is the most likely diagnosis?
a. Renal vein thrombosis (not sure)
b. Wilm’s tumour
c. Perinephric abscess
d. Dysplastic or multicyctis dysplastic kidneys

39. Turner syndrome with cyanosis, ejection systolic murmur in second intercostal
space with an ejection click. What is the most likely diagnosis?
a. Coarctation of aorta
b. Aortic subvalvular stenosis
c. Pulmonary stenosis
d. ASD ll
e. TOF
f. VSD

40. 2 weeks old baby presented in a shock like state. O2% in upper and lower limbs are
equal
a. TGA
b. Hypoplastic left heart
c. Coarctation of aorta
d. Tricuspid atresia with VSD

41. 4 years old presented with vomitting and SOB. O/E tachycardic, has muffled heart
sounds, and gallop rythm. What is the most likely diagnosis?
a. Pericarditis
b. Myocarditis
c. c.Endocarditis
42. Patient has cyanosis. His ECG shows superior axis deviation and LVH. Most likely
diagnosis is
a. TGA
b. Tricuspid atresia
c.
d.

43. Treatment of long QT syndrome

a. B-blocker
b. ACE inhibitors
c. Ca Channel blockers
d. Diuretics

44. 2 years old with pansystolic murmur, hepatomegally and lethargy

a. VSD with heart failure
b. TGA
c. TOF
d. TA

45. 10 y old girl previously healthy came with , fever, cardiac murmur and skin rash:
a) Rheumatic fever
b) Endocarditis

46. ECG picture:

a) Pre mature atrial contraction

b) Premature ventrivular contraction
c) Atrial
d) Heart block
e) AV Block
47. Patient has fever and fatigue. After 2 weeks he presented with spleenomegally,
murmur, and petechae. What is the most likely diagnosis?
a. Rheumatic fever
b. Infective endocarditis
c. Kawasaki disease
d.
????
48. Pt. with pericarditis came in shock most likely:
a. cardiac tamponad
b.
c.
d.

49. How can you differentiate B/W respiratory and cardiac cyanosis?
a) Hyper-oxia test.
50. Regarding still's murmur , which of the following is true
a. Diastolic Murmur
b. Grade IV
c. Fixed splitting of second heart sound
d. Better hear at sitting and leaning forward compared to standing or lying supine

51. most common cause of arrest in pediatrics is:

a. bradycardia – PEA – arrest
b. SVT – VF – arrest
c. AF - ?VF – arrest
d. A flutter

52. ? 7 yr old boy with cafue lait spots …..scenario of NF, with high BP , in examination,
has abdominal bruit. What is the cause of HTN?
a. Renovascular disease
b. Renal artery thrombosis
c. coarctation of Aorta
d. ? idiopathic
53. scenario of Renal failure patient with hyperkalemia , what ECG finding will support
it:
 a. short PR
b. prolonged QRS
c. Normal T wave
d. prolonged QT interval

60. Girl With Turner Features On Examination Found To Have Left 2nd Intercostal Space
Ejection Systolic Murmur ? Click
f. Pulmonary Stenosis
Any click will be
g. Supravalvular Aortic Stenosis valvular not
supravalvular
h. VSD

i.

Ddx Of LUSB :

(-PS -ASD -AS -COA -PDA )P135 HARRIT LANE

Conginital Cardiac Anomaly Associated With Turner Syndrome :

- Bicuspid Aortic Valve Most Common - Coarctation (Narrowing) Of The Aorta. 5% And
10%, Just Distal To The Of The Left Subclavian Artery
#A Coarctation Of The Aorta In A Female Is Suggestive Of Turner Syndrome And Suggests
The Need For Further Tests, S‫ش‬uch As A Karyotype.
#Prophylactic Antibiotics Should Be Considered When Procedures With A High Risk Of
Endocarditis Are Performed, Such As Dental Cleaning.[
https://en.wikipedia.org/wiki/Turner_syndrome

61. Constellation Of Coarctation Of Aorta And Hypertension In Pediatric Found In:

a. CHARGE Association
 b. Klippel-Feil Sequence
c. Noonan Syndrome
d. Trisomy 13
e. Turner Syndrome
62. Contraindication Of Use Of PGE:
a. Interrupted Aortic Arch

b. Total Anomalies Of Pulmonary Venous Drainage

c. D-TGA

d. Ta With Intact Vsd

Prostaglandin E2 (PGE2), Known As Dinoprostone

It Is Used In:
- Newborn Babies To Keep The Ductus Arteriosus Open. Until Surgery Can Be Carried Out
(Duct Dependant):

1- SYSTEMIC CIRCULATION : 1- PULMONARY CIRCULATION :

 Co-Arctation Of The Aorta  Pulmonary Atresia

 Critical Aortic Stenosis  Critical Pulmonary Stenosis

 Hypoplastic Left Heart Syndrome  TOF

INTERUPTED Arch NEONATAL ENESTIAN

 Tricuspid Atresia

 Transposition Of The Great Vessels

Http://Www.Sort.Nhs.Uk/Media/Sonet/Guidelines/Cardiac/Cardiac/Duct%20dependent%20cong
enital%20heart%20disease.Pdf

Https://Www.Slideshare.Net/Dpark419/The-Crashing-Cardiac-Baby?Next_Slideshow=1

Common Side Effects Include: -Decreased Breathing - Low Blood Pressure

- Care Should Be Taken In People With Asthma Or Glaucoma

https://en.wikipedia.org/wiki/Prostaglandin_E2#Side_effects
 Tga : The Aorta Is Connected To The Right Ventricle, And The Pulmonary Artery Is Connected
To The Left Ventricle
Two Separate Circuits Are Formed — One That Circulates Oxygen-Poor (Blue) Blood From
The Body Back To The Body, And Another That Recirculates Oxygen-Rich (Red) Blood From
The Lungs Back To The Lungs.
Http://Www.Stanfordchildrens.Org/En/Topic/Default?Id=Transposition-Of-The-Great-Arteries-
Tga-90-P01823
Initial Treatment Of Transposition Of The Great Arteries Consists Of Maintaining Ductal
Patency With Continuous Intravenous (IV) Prostaglandin E1 (Pge1) Infusion Within The
First 48 Hours After Birth Is Crucial To Reduce Early Mortality In Newborns With
Transposition Of The Great Arteries, Especially In The Simple Form. [10]
Cardiac Catheterization And Balloon Atrial Septostomy Is Indicated In Severely Hypoxemic
Patients With An Inadequate Atrial Level Communication And Insufficient Mixing
Http://Emedicine.Medscape.Com/Article/900574-Treatment
Tof : Newborns With Tetralogy Of Fallot With Pulmonary Atresia (TOF-PA) May Require The
Ductus Arteriosus (DA) As The Main Source Of Pulmonary Blood Flow. A Prostaglandin E1
(PGE1) (Alprostadil) Infusion Maintains Patency Of The Ductus.
Infants With Multiple Systemic Pulmonary Collaterals May Develop Symptomatic Heart
Failure Requiring Medical Therapy.
Http://Emedicine.Medscape.Com/Article/899368-Medication
Ta With Intact Vsd :The Right Ventricle Is Often Underdeveloped.
 An Opening Is Present Between The Two Atria (Atria Septal Defect) And The Ventricular Walls
(Ventricular Septal Defect), Allowing Oxygen-Poor (Blue) Blood And Oxygen-Rich (Red)
Blood To Mix With Each Other.Patent Ductus Arteriosus Allows Blood To Pass Through
From The Aorta To The Pulmonary Artery And Receive Oxygen In The Lungs.Treatment
For Tricuspid IV Medications, Such As Prostaglandin E1, Are Given To Help Blood
Circulate To The Heart And Lungs. Other Medications May Be Used To Help The Heart And
Lungs Function More Efficiently.
Http://Www.Stanfordchildrens.Org/En/Topic/Default?Id=Tricuspid-Atresia-Ta-90-P01819
Tapvr:pulmonary vein drain abnormally to the right atrium (right upper chamber) As A Result,
The Right Side Of The Heart Is Overworked From Pumping The Extra Blood, Children
Without At Least An Atrial Septal Defect Will Not Survive.
Open Heart Surgery In All Cases. Critically Ill Newborns Will Have Surgery Immediately. If
The Child Is Not Critically Ill, Doctors May Wait Up To Two Months To Perform Surgery,
Depending On The Strength Of The Child And The Heart Anatomy.

Http://Www.Chop.Edu/Conditions-Diseases/Total-Anomalous-Pulmonary-Venous-Return-Tapvr

Administration Of Prostaglandin E1 For Patency Of Patent Ductus Arteriosus And, In Patients

With Total Anomalous Pulmonary Venous Connection Type III, For Patency Of The Ductus
Venous.

Http://Emedicine.Medscape.Com/Article/899491-Treatmen

63. Case Scenario Of Infective Endocarditis, What Antibiotics To Start:

 a. Vancomycin And Ceftriaxone
b. Amikacin And Ciprofloxacin
c. Clindamycin And ?
d. Ampicillin And Gentamycin
therapy of native or prosthetic
valve endocarditis due to
enterococcal strains susceptible to
penicillin and gentamicin*
Treatment regimens for native
valve endocarditis due
to Staphylococcus
Treatment regimens for native
valve endocarditis due to
penicillin-susceptible viridans
streptococci and Streptococcus
bovis
Suggested regimens for therapy of
native or prosthetic valve
endocarditis due to HACEK*
64. A12-Year-Old Child With A Surgically Corrected Pulmonary Shunt Is To Undergo An
Invasive Dental Procedure. Which Of The Following Antibiotics Would Be Most
Appropriate For Prophylaxis Against Bacterial Endocarditis?
a) Amoxicillin
b) Clindamycin
c) Erythromycin
d) Oxacillin
e) Vancomycin

65. A 2 Years Old Child Was Found To Have A Systolic Murmur Grade 4/6 With A Thrill
& A Click In The Left Upper Sternal Border. ECG Showed Right Ventricular
Hypertrophy & Right Atrial Enlargement. What Is The Proper Management?

a. Glenn Operation
b. Balloon Septastomy
c. Balloon Valvoplasty
Pulmonary Stenosi
Ddx Of LUSB : - PS - ASD - AS - COA - PDA :

d. ECG abnormalities that may be seen in pulmonary stenosis :

Right axis devition: sometimes this may be the only ECG
abnormality in mild pulmonary stenosis.
If pulmonary stenosis is severe, the R wave amplitude in C1
may be >20 mm (>2mV).
Right atrial abnormality: Pulmonary stenosis is one of the
few diseases that increase P wave amplitude
Right ventricular hypertrophy pattern in adults.
http://www.metealpaslan.com/ecg/pulmdaren.htm
# A Glenn Shunt : Is The Second Of Three Surgeries (Following The Norwood Procedure And
Preceding The Fontan Procedure) Used To Treat Hypoplastic Left Heart Syndrome,
Http://Heart.Phoenixchildrens.Org/Glenn-Shunt
#Balloon Septostomy Is The Widening Of A Foramen Ovale, Patent Foramen Ovale (PFO),
Or Atrial Septal Defect (ASD) ,Allows A Greater Amount Of Oxygenated Blood To Enter
The Systemic Circulation
# Pulmonary Stenosis (PS): The Treatment Of Choice Is Percutaneous Balloon
Valvuloplasty And Is Done When APeak Gradient >60mm Hg Or A Mean >40mm Hg
https://en.wikipedia.org/wiki/Pulmonic_stenosis#Treatment

66. A Girl With Syncope Attacks. ECG Showed Prolonged QT. What Is The Treatment?
a. ACE Inhibitor
b. Beta Blocker
c. Ca Channel Blocker
 #All Patients With Long QT Syndrome (LQTS) Should Avoid Drugs That Prolong The QT
Interval Or That Reduce Their Serum Potassium Or Magnesium Level. #Although
Treating Asymptomatic Patients Is Somewhat Controversial, A Safe Approach Is To Treat
All Patients With Congenital LQTS Because Sudden Cardiac Death Can Be The First
Manifestation Of LQTS.
#Beta-Blockers Are Drugs Of Choice For Patients With LQTS. The Protective Effect Of
Beta-Blockers Is Related To Their Adrenergic Blockade, Which Diminishes The Risk Of
Cardiac Arrhythmias.
http://emedicine.medscape.com/article/157826-treatment

67. The Mother Of A 2 Year Old Boy Expresses Concern During A Health Supervision
That Her Child Has Had Increased Problems With Snoring & Periods Of Breathing
Difficulties During His Sleep. You Suspect The Boy To Have Obstructive Sleep Apnea
Due To Adenotonsillar Hypertrophy, Of The Following The Most Serious Complication
If This Condition Is Not Recognized & Treated Is:
a. FTT
b. Cor Pulmonele
c. Daytime Narcolepsy
d. Craniofascial Abnormalities
Complication Of OSA:
-Hypercapnic Respiratory Failure Present With Early Morning Headaches and Excessive
Daytime Sleepiness
=Myocardial Infarction
- Stroke
-Hypertension: Due To Sustained Increased Sympathetic Activity.
-Pulmonary Hypertension Due To The Changes In Pulmonary Artery Pressure During Each
Apnea Episode.
# Hypercapnia And Hypoxia, Pulmonary Hypertension Can Lead To Right Heart Failure.
http://www.sleep-apnea-guide.com/sleep-apnea-complications.html

68. A Newborn Discharged On The Second Day Of Life In Normal Condition, After One
Week The Patient Presented With Shock, Pulse Oximetry Is Normal In Both Upper &
Lower Limbs. What Is The Most Probable Diagnosis?
a. Coarcotation Of Aorta
b. Tricuspid Atresia With VSD
c. Total Anomalous Pulmonary Venous
d.

69. A Newborn Was Delivered In The Nursery And Was Discharged In Stable Condition 4
Week Later The Patient Developed Cyanosis Decrease Activity And Perfusion (Was In
Shock) O2 Sat Was Equal In Both UL – LC. What's Your Diagnosis?
a. COA
b. TAVR.
c. Pulmonary Atresia With. Intact VSD.
 d. TOF
e. TA With VSD
f. Tricuspid Atresia With VSD.
DUCTAL DEPANDANT
CoA: Abnormal differences in upper- and lower-extremity arterial pulses and blood
pressures; diminished and delayed pulses distal to obstruction
http://emedicine.medscape.com/article/150369-overview

2- SYSTEMIC CIRCULATION : 2- PULMONARY CIRCULATION :

 Co-Arctation Of The Aorta  Pulmonary Atresia

 Critical Pulmonary Stenosis
 Critical Aortic Stenosis
 TOF
 Hypoplastic Left Heart Syndrome  NEONATAL ENESTIAN
 Tricuspid Atresia
INTERUPTED Arch  Transposition Of The Great Vessels

Http://Www.Sort.Nhs.Uk/Media/Sonet/Guidelines/Cardiac/Cardiac/Duct%20dependent%20cong
enital%20heart%20disease.Pdf

Https://Www.Slideshare.Net/Dpark419/The-Crashing-Cardiac-Baby?Next_Slideshow=1
70. A 2 Years Old Has Minimal Cyanosis Quadruble Rythm, O/E You Heard A Systolic
Murmur On Pulmonic Area And Mid Daistolic On LLSB The ECG Showed Rt Atrial
Hypertrophy And Ventricular Block. The Most Probable Diagnosis?
a. A Pulmonary Stenosis And Tricuspid Regurge
b. Ps And Vsd
c. Ebstein Anomaly
d. Av Canal
Same In Pre Test P 122 Q 187
71. A 3 Years Old Boy Was Brought To The ER With Acute State Of Agitation, Crying
And Irritability, Suddenly Unresponsive. ECG Showed Prolonged QT And Absent P
Wave, The Most Appropriate Next Step:
A)Defebrilation Wide Complex Because pt is uresponsive need
Apply Ice Over Eyes defebrilation but she said I cant say v
Cardioversion tach of v fib without ecg
#Torsade De Pointes (Tdp) Is A Form Of Polymorphic Ventricular Tachycardia Associated With
A Long QT Interval ,It Is Characterized By Rapid, Irregular QRS Complexes,May Degenerate
Into Ventricular Fibrillation. It Causes Significant Hemodynamic Compromise And Often Death.
Diagnosis Is By ECG. Treatment Is With IV Magnesium, Measures To Shorten The QT Interval,
And Direct-Current Defibrillation When Ventricular Fibrillation Is Precipitated.
Http://Www.Msdmanuals.Com/Professional/Cardiovascular-Disorders/Arrhythmias-And-
Conduction-Disorders/Long-Qt-Syndrome-And-Torsades-De-Pointes-Ventricular-Tachycardia
#Unstable Patients With Monomorphic VT Should Be Immediately Treated With 
Synchronized Direct Current (DC) Cardioversion,
#Unstable Polymorphic VT Is Treated With Immediate Defibrillation.
#Stable Patients Monomorphic VT And Normal Left Ventricular Function (IV) Procainamide
Or Sotalol. Lidocaine May Also Be Used
If Left Ventricular Function Is Impaired, Amiodarone (Or Lidocaine) Is Preferred To
Procainamide
Http://Emedicine.Medscape.Com/Article/159075-Treatment
72. Regarding Still's Murmur , Which Of The Following Is True
A-Diastolic Murmur
B-Grade IV
C-Fixed Splitting Of Second Heart Sound
D-Better Hear At Sitting And Leaning Forward Compared To Standing Or Lying
Supine
Common In Children Ages 2 To 8 Years Old,. Signs:
#Low To Medium Frequency, Mid-Systolic Murmur,Intensity: Grade II-III Of VI
(Variable)Location
# Near Apex To Lower Left Sternal Border
#,Character,Low To Medium Pitch,Vibratory, Musical
#Positions (Increased Murmur)Supine Position (Decreased With
Standing),Fever,Anemia
Http://Www.Fpnotebook.Com/CV/Exam/Stlsmrmr.Htm
73. Still’s Murmur Is:
a. Diastolic Murmur Heard At LLSB.
b. An Early Systolic Murmur Which Increase With Jugular Pressure.
c. A Mid Systolic Murmur Heard Well In The Recombinant Position.
d. A Systolic Murmur Which Increase With Expiration.

74. What Is The First Line Therapy For Small Restrictive VSD In Asymptomatic 8years
Old Girl
A-Follow Up And Observation
B-Repair By Catheterization (Device)
C-Open Surgical Repair
D-Medical Treatment
Management Options Include:

●No Intervention – For Patients With Small Defects, These Patients Are Typically
Asymptomatic And Have A Reasonable Expectation Of Spontaneous Closure Or Decrease In
The Size Of The Defect Over Time.

●Medical Therapy – Medical Therapy Is Required For Patients With Symptoms Of Heart
Failure. For Patients With Moderate Defects, For Those With More Severe Symptoms, Surgical
Correction Is Usually Necessary And Medical Management Is Aimed At Reducing Symptoms In
The Interim.
●Closure Of The Defect – For Patients Who Are Not Adequately Managed By Medical
Therapy, And In Those At Risk For Long-Term Significant Sequelae (Eg, Pulmonary
Hypertension Or Valvar Damage) Surgical Repair Is Generally Warranted.

CLOSURE INTERVENTIONS Indications :

●Persistent Symptoms Despite Maximal Medical Therapy

●Moderate Or Large Defects Associated With Pulmonary Hypertension (Ie, PAP >50 Percent Of
Systemic Arterial PreSsure).
●Persistent Left-To-Right Shunt With Associated Left Ventricular (LV) Dilation (Ie, Ratio Of
Pulmonary To Systemic Blood Flow [Qp:Qs] >2:1) In The Absence Of Symptoms.
●Subpulmonic And Membranous Defects With Associated Aortic Valve Prolapse And Aortic
Regurgitation.
●Double-Chambered Right

Contraindications :

If PAP Is Suprasystemic

If Pulmonary Vascular Resistance (PVR) Is >12 Wood Units (WU

Surgical Repair —

-Direct Patch Closure Under Cardiopulmonary Bypass Is The Procedure Of Choice.

More detailed :
Our Approach To Managing Infants With
Small Vsds
●Patients Should Follow-Up At Three
To Four Weeks To Detect Any Signs
Or Symptoms Of :Increased Left
Ventricular Volume Overload.
The Exception Is Trivial Muscular
Vsds
.--> If Initial Imaging And Doppler
Demonstrate A Very Small, Very
Restrictive Defect Follow-Up Three
To Six Months Of Age
Moderate to large vsd
Become Symptomatic Within The First
Months Of Life As Pulmonary Vascular
Resistance (PVR) Declines.
Asymptomatic Patients —
Regular F/U Throughout The First Year
To Assess Evidence Of Pulmonary
Hypertension.
#If The Murmur Is Gone But The Pulmonic
Component Of Second Heart Sound (S2) Is
 ●Between Visits With The
Cardiologist, Routine Care Is Provided
By The Primary Care Provider. If The
Patient Becomes Symptomatic (Eg,
Poor Weight Gain, Tachypnea), The
Patient Should Be Promptly Referred
To The Specialist
●If At The Six-Month Visit The
Murmur Is Gone,Repeat
Echocardiogram Is Not Necessary,
Unless Clinical Concerns Arise (Eg,
Endocarditis).
●Patients Who Continue To Have A
Murmur, But Asymptomatic And
Growing Well At The Six-Month Visit,
F/U At 12 Months Of Age.
●If At The 12-Month The Murmur Is
Gone, Repeat Echocardiogram Is Not
Necessary, Unless Clinical Concerns
Arise (Eg, Endocarditis).
If There Is No Evidence Of A Defect,
No Additional Follow-Up Is Necessary
●If The Murmur Persists At The 12-
Month Cardiology Visit And The
Patient Remains Asymptomatic And
Clinically Stable 
#No Further Intervention Is Required.
Echocardiographic Follow-Up At
Three Years Of Age For Patients With
Membranous Defects.
#In Those With A Muscular Defect, No
Echocardiography Is Required If The
Patient Remains Asymptomatic.
●Asymptomatic Patients With Residual
Small Defects F/U Every Two To Five
Years
●Medical Therapy Is Initiated In Any
Symptomatic Patient.
However, Heart Failure Is Not
Expected In Association With Small
Vsds,.
Https://Www.Uptodate.Com/Contents/Management-Of-Isolated-Ventricular-Septal-Defects-In-
Infants-And-Children
Increased In Intensity Echocardiogram To
Estimate Pulmonary Artery Pressure (PAP).:
PAP <50 Percent Of Systemic Arterial
Pressure, The Risk Of Developing
Pulmonary Hypertensive Vascular Disease
(PHVD) Is Low
Patients With PAP ≥50 Percent Of Systemic
Arterial Pressure Are At Risk Of Developing
PHVD And They Should Be Referred For
Surgical Closure.
#For Patients Who Remain Asymptomatic
After The First Year Of Life Without
Evidence Of Pulmonary Hypertension Or
LV Dilation, Follow-Up Every One To Two
Years With An Echocardiographic
Symptomatic Patients — , Medical
Intervention May Postpone And Possibly
Avoid The Need For Surgical Correction.
The Goals Of Therapy Are To Alleviate
Heart Failure Symptoms And Normalize
Growth.
Management Of Symptomatic Patients
Includes Nutritional Support And
Pharmacologic Treatment Of Heart Failure
(Eg, Diuretic Therapy).
Nutritional Support — These Infants Have
Increased Caloric Needs Due To An
Increased Metabolic Demand And May
Need A Caloric Intake That Is
>150 Kcal/Kg Per Day. The Caloric Density
Is Increased By The Addition Of
Carbohydrate And/Or Medium-Chain
Triglyceride Preparations To Conventional
Formula
75. Drug Of Choice As A Chronic Treatment For Reciprocal Antidromic Tachycardia Is :
A-Atenolol
B-Propranolol
C-Amiodarone
D-? Digoxin
Atrioventricular Reentrant Tachycardia = Reciprocal , Two Major Types Of This Arrhythmia In
Persons With An AV Accessory Pathway Are Orthodromic And Antidromic AVRT. The Width
Of The QRS Complex Can Usually Distinguish Between These Paroxysmal Arrhythmias:

Treatment Of Orthodromic AVRT Treatment Of Antidromic AVRT

 In Patients Who Are  Stable Patients May Respond To Drug

Haemodynamically Stable Vagal
Manoeuvres May Be Successful,
Followed By Adenosine Or Calcium-
Channel Blockers, And DC
Cardioversion May Be Considered If
Non-Repsonsive To Medical Therapy.
 In A Haemodynamically Unstable
Patient Urgent Synchronised DC
Cardioversion Is Required.
Therapy Including Amiodarone,
Procainamide Or Ibutilide, But May
Require DC Cardioversion
 Haemodynamically Unstable Patient
Urgent Synchronised DC Cardioversion
Is Require

Https://Lifeinthefastlane.Com/Ecg-Library/Pre-Excitation-Syndromes/

76. 1 Month Old Baby ……Scenario ….Then Dx With Severe Coarctation Of Aorta , ?
Long Segment….Next :
A-Surgical Coarectectomy Sever and long segment always nedd
B-Stenting surgical coarctation
C-Ballooning Bu dr magda

Neonates: with critical coarctation, an infusion with prostaglandin E1 (alprostadil) until

corrective surgery can be performed with a dose of 0.025 to 0.05 mcg/kg per minute and increase
as needed to a maximum dose of 0.1 mcg/kg per minute. For patients with heart failure,
administration of inotropic agents Palliative balloon angioplasty may be considered to
stabilize a critically ill patien

Older infants and young children — surgical correction has been the primary treatment of
native coarctation at most centers; however, there has been an increased use of balloon
angioplasty as noted by the 2011 AHA pediatric guidelines for transcatheter intervention for
congenital heart disease [24]. The decision between balloon angioplasty versus surgical
repair is determined by the multidisciplinary team

Older children and adults — For larger patients (weight >25 kg), transcatheter intervention
with stenting has become the preferred

Balloon Angioplasty Is A Percutaneous Alternative To Surgical Repair For Older Infants And
Young Children (Greater Than Four Months) ,However, Stent Placement Has Replaced
Balloon Angioplasty As The Procedure Of Choice In Older Children And Adults With
Native Coarctation.

Https://Www.Uptodate.Com/Contents/Management-Of-Coarctation-Of-The-Aorta

newborn infant, or neonate, is a child under 28 days of age

http://www.who.int/topics/infant_newborn/en/
77. Down Syndrome ,Previous Echo Showed Large ASD , Now His ECG Is Showing RVH,
Right Axis Deviation, Right Atrial Dilataion . Wha T Will You Do
A. Catheter Lab
B. CXR Dr . huda said :
Asd primum usually with  with superior axis deviation
 need surgyry
Asd secondum with  right axis deviation  manage by
cath
Asd

78. An Irritable 12-Month-Old Male Has A 1-Week History Of High Fevers And Macular
Truncal Rash. Examination Reveals Bulbar Conjuctivitis, Bright Red Cracked Lips,
And Cervical Adenopathy. What Is The Most Appropriate Next Step?

a) Initiate Airborne Barrier Precautions

b) Intravenous Antibiotics
c) Intravenous Antibiotics For The Infant And Oral Antibiotics For All Household
Members

d) Intravenous Gammaglobulin
e) Intravenous Corticosteroids
Intravenous Immunoglobulin (IVIG) Is The Standard Treatment For Kawasaki
Disease[113] And Is Administered In High Doses With Marked Improvement Usually Noted
Within 24 Hours. If The Fever Does Not Respond, An Additional Dose May Have To Be
Considered. In Rare Cases, A Third Dose May Be Given To The Child. IVIG By Itself Is Most
Useful Within The First Seven Days Of Onset Of Fever, In Terms Of Preventing Coronary
Artery Aneurysm.
Corticosteroids Have Also Been Used,[117] Especially When Other Treatments Fail Or Symptoms
Recur, But In A Randomized Controlled Trial, The Addition Of Corticosteroid To Immune
Globulin And Aspirin Did Not Improve Outcome
Https://En.Wikipedia.Org/Wiki/Kawasaki_Disease#Treatment
Gamma Globulins Are A Class Of Globulins, Identified By Their Position After Serum
Protein Electrophoresis. The Most Significant Gamma Globulins Are Immunoglobulins
(Antibodies), Although Some Immunoglobulins Are Not Gamma Globulins, And Some
Gamma Globulins Are Not Immunoglobulins.
Https://En.Wikipedia.Org/Wiki/Gamma_Globulin
79. 3 Y.O Girl Prefers Squatting Position After Exercise Looks Mildly Cyanosed :
a. TOF
b. PS
c. TGA
P 129 IN PRE TEST Q 177
80. 2 Y.O Referred To You Because Of Suspected Cardiomegally By CXR , You Reviewed
The CXR An Exp. Film With Cardiac Size 50% Of Thoracic Size What You Do:
a. Repeat CXR Insp. Film
b. ECHO
c. ECG
d. Chest CT
He CTR Is Measured On A PA Chest X-Ray, And Is The Ratio Of Maximal Horizontal Cardiac
Diameter To Maximal Horizontal Thoracic Diameter (Inner Edge Of Ribs / Edge Of Pleura). A
Normal Measurement Should Be <0.5.
If The Patient Is Symptomatic Then Echocardiography Is Required But The Yield Of
Echocardiography Is Low If Performed Just For An Increased CTR 3.In Some Situations, An
Increased Cardiothoracic Ratio On A PA Radiograph May Be A Result Of A
Prominent Epicardial Fat Pad And/Or Due To Expiration Rather Than Cardiomegaly

https://radiopaedia.org/articles/cardiothoracic-ratio

81. In Which Condition Is TOF Prophylaxis Against Infective Endocadits: Required?

a. Cystoscopy.
b. Endoscopy.
c. Bronchial Biopsy.
d. U. Catheterization.
e. Insertion Of Ear Tube.

Patients At Highest Risk — IE

●Prosthetic Heart Valves, Including Mechanical, Bioprosthetic, And Homograft Valves

(Transcatheter-Implanted As Well As Surgically Implanted Valves Are Included)
 ●Prosthetic Material Used For Cardiac Valve Repair, Such As Annuloplasty Rings And
Chords
●A Prior History Of IE
●Unrepaired Cyanotic Congenital Heart Disease
●Repaired Congenital Heart Disease With Residual Shunts Or Valvular Regurgitation At
The Site Or Adjacent To The Site Of The Prosthetic Patch Or Prosthetic Device
●Repaired Congenital Heart Defects With Catheter-Based Intervention Involving An
Occlusion Device Or Stent During The First Six Months After The Procedure
●Valve Regurgitation Due To A Structurally Abnormal Valve In A Transplanted Heart

Relevant Procedures

Dental Work — That Involve Manipulation Of Gingival Tissue Or The Periapical Region Of
The Teeth Or Perforation Of The Oral Mucosa, Such As Tooth Extractions Or Drainage Of A
Dental Abscess; This Includes Routine Dental Cleaning [1,19].

Respiratory Tract — Associated With Respiratory Tract Procedures Prophylaxis Is Suggested

Only For Procedures Involving Incision Or Biopsy Of The Respiratory Tract Mucosa;
Examples Include Tonsillectomy, Adenoidectomy, Or Bronchoscopy With Biopsy ,

Genitourinary And Gastrointestinal Tracts — No Routine Prophylaxis For Gastrointestinal

(GI) Or Genitourinary (GU) Procedures

Https://Www.Uptodate.Com/Contents/Antimicrobial-Prophylaxis-For-Bacterial-Endocarditis
82. A 13-Year-Old Boy Suddenly Complains Of Left-Sided Chest Pain, Shortness Of
Breath, And Pain In The Left Shoulder While Playing Basketball. Findings On Physical
Examination Include Tachypnea, Tachycardia, Splinting With Respirations, And
Diminished Breath Sounds On The Left Side Of The Chest. Of The Following, The
MOST Likely Diagnosis Is
a. Bacterial Pneumonia
b. Cardiac Arrhythmia
c. Myocarditis
d. Splenic Injury
e. Spontaneous Pneumothorax
Spontaneous Pneumothorax : History And Physical Examination Remain The Keys To Making
The Diagnosis Of Pneumothorax.

 Respiratory Distress (Considered A Universal Finding) Or Respiratory Arrest

 Tachypnea (Or Bradypnea As A Preterminal Event)
 Asymmetric Lung Expansion: Mediastinal And Tracheal Shift To Contralateral Side (Large
Tension Pneumothorax)
 Distant Or Absent Breath Sounds: Unilaterally Decreased/Absent Lung Sounds
Common, But Decreased Air Entry May Be Absent Even In Advanced State Of
Pneumothorax
 Minimal Lung Sounds Transmitted From Unaffected Hemithorax With Auscultation At
Midaxillary Line
 Hyperresonance On Percussion: Rare Finding; May Be Absent Even In An Advanced State
 Decreased Tactile Fremitus
 Adventitious Lung Sounds: Ipsilateral Crackles, Wheezes
Ardiovascular Findings May Include The Following:
 Tachycardia: Most Common Finding; If Heart Rate Is Faster Than 135 Beats/Min,
Tension Pneumothorax Likely
 Pulsus Paradoxus
 Hypotension: Inconsistently Present Finding; Although Typically Considered A Key Sign
Of Tension Pneumothorax, Hypotension Can Be Delayed Until Its Appearance
Immediately Precedes Cardiovascular Collapse
 Jugular Venous Distention: Generally Seen In Tension Pneumothorax; May Be Absent If
Hypotension Is Severe
 Cardiac Apical Displacement: Rare
Http://Emedicine.Medscape.Com/Article/424547-Overview

83. 3 Years Old With Blood Pressure Of 180/100, Agitated And Confused, The Best Drug
To Use Is:
a. Lasix Infusion This pt is agitated and confused=hypertensive
b. Sodium Nitroprusside Infusion encephalopathy organ affected =emergency
c. Propranolol Orally labetolol
d. Long-Acting Nifedipine nicardipine
nitroprusside
All shuld be iv
By nephrologist consultant
Pda :. A Widened Pulse Pressure May Be Noted When The Blood Pressure Is Obtained.
The Apical Impulse Is Laterally Displaced;
A Thrill May Be Present In The Suprasternal Notch Or In The Left Infraclavicular Region
 The First Heart Sound (S 1) Is Typically Normal, And The Second Heart Sound (S 2) Is
Often Obscured By The Murmur; Paradoxical Splitting Of S 2
 The Murmur May Be Only A Systolic Ejection Murmur, Or Crescendo/Decrescendo
Systolic Murmur That Extends Into Diastole
Http://Emedicine.Medscape.Com/Article/891096-Clinical#B3
Table. Pharmaceutical Agents Used In The Treatment Of Congestive Heart Failure
Http://Emedicine.Medscape.Com/Article/2069746-Treatment#D10

Managing Acute Congestive Heart Failure In The Older Child

Admit To The ICU For Diuresis With IV Furosemide. For Patients With Significant
Hypotension, IV Dopamine (5-10 Mcg/Kg/Min) Or Milrinone (0.3-1 Mcg/Kg/Min) Infusion
Nitrates (Nitroprusside, Nitroglycerin) Or Nesiritide May Be Useful In Patients With
Elevated Pulmonary Capillary Wedge Pressure And Pulmonary Congestion Due To Their
Venous Dilating Effects.
Http://Emedicine.Medscape.Com/Article/2069746-Treatment#D12

84. The Use Of Blood Pressure Cuff With Width That Covers Half Of The Upper Arm
Length Will Result In:
a. Erroneous High Blood Pressure
b. Erroneous Low Blood Pressure
c. Appropriate Blood Pressure Reading If The Child Is >12 Years Old
d. Accurate Reading If Palpation Method Is Used
e. Risk Of Vascular Damage Is Used Repeatedly
He Most Common Error When Using Indirect Blood Pressure Measuring Equipment Is Using
An Incorrectly Sized Cuff. A BP Cuff That Is Too Large Will Give Falsely Low Readings,
While An Overly Small Cuff Will Provide Readings That Are Falsely High. Recommending
That The Bladder Length And Width (The Inflatable Portion Of The Cuff) Should Be 80 Percent
And 40 Percent Respectively, Of Arm Circumference
Https://Www.Ems1.Com/Ems-Products/Medical-Monitoring/Articles/1882581-5-Errors-That-
Are-Giving-You-Incorrect-Blood-Pressure-Readings

85. Regarding Tetralogy Of Fallot, What Is The Procedure For ?

a. Glenn Procedure
b. Fontan Procedure
c. BT Shunt Procedure
d. Total Correction
 Glenn Shunt Is The Second Of Three Surgeries (Following The Norwood Procedure And
Preceding The Fontan Procedure) Used To Treat Hypoplastic Left Heart Syndrome,
Blalock-Thomas-Taussig Shunts Are Not Normally Performed On Infants With TOF Except
For Severe Such As TOF With Pulmonary Atresia
Total Repair On Infants Has Had Success
Https://En.Wikipedia.Org/Wiki/Tetralogy_Of_Fallot#Treatment
Now, Tetralogy Of Fallot Usually Is Fully Repaired In Infancy. However, Some Babies Are Too
Weak Or Too Small To Have The Full Repair. They Must Have Temporary Surgery First.
Https://Www.Nhlbi.Nih.Gov/Health/Health-Topics/Topics/Tof/Treatment

86. Which Is True Regarding Tetralogy Of Fallot (TOF):

a. Cannot Diagnose Before 6 Months Of Age
b. Murmur Is Caused By Ventricular Septal Defect (VSD)
c. Cyanotic Spell Is More When Awaking
d. Treatment Is Conservatively
. Infants With Pulmonary Atresia May Become Profoundly Cyanotic As The Ductus Arteriosus
Closes Unless Bronchopulmonary Collaterals Are Present.
Most Infants With Tetralogy Of Fallot (TOF) Are Smaller Than Expected For Age. Cyanosis Of
The Lips And Nail Bed Is Usually Pronounced At Birth
#After Age 3-6 Months, The Fingers And Toes Show Clubbing.
#sYstolic Ejection Murmur (SEM) Is Heard Over The Pulmonic Area And Left Sternal Border.
When The Right Ventricular (RV) Outflow Tract Obstruction (RVOTO) (Eg, From Pulmonary
Atresia) ).
The S2 Is Usually Single (The Pulmonic Valve Closure Is Not Heard). During Cyanotic
Episodes, Murmurs May Disappear,
Http://Emedicine.Medscape.Com/Article/2035949-Clinical#B3
Hypoxic Spell, Hypercyanotic Spell

Posture Which Reduce Spell Are

1. Quite Standing
2. Squatting
3. Knee Chest Position
4. Parents Hold The Infant Leg Flexed To Chest
5. Standing Crossed Legs
6. Lying Down.
Http://Bilagi.Org/Blog/2012/03/30/Hypoxic-Spell-Hypercyanotic-Spell-Tet-Spell-Of-Tetralogy-
Of-Fallot-Tof
87. The Most Common Congenital Cardiac Defect In Patient With Down Syndrome Is:
a. Atrial Septal Defect (ASD)
b. Ventricular Septal Defect (VSD)
c. Transposition Of Greater Arteries (TGA)
d. AVSD "Endocardial Cushion Defect"
e. Truncus Arteriosus

88. Which One Of The Following Is A Feature Of Cardiac Tamponade?

 a. Bradycardia
b. Loud Heart Sound
c. Decrease Central Venous Pressure
d. Pulsus Alternans
e. Hypertension
Caused By The Accumulation Of Fluid In The Pericardial Space, Resulting In Reduced
Ventricular Filling And Subsequent Hemodynamic Compromise. The Condition Is A Medical
Emergency May Present With Dyspnea, Tachycardia, And Tachypnea. Cold And Clammy
Extremities From Hypoperfusion,
Beck Triad
: Increased Jugular Venous Pressure, Hypotension, And Diminished Heart Sounds.
Pulsus Paradoxus :(Or Paradoxical Pulse) Is An Exaggeration (>12 Mm Hg Or 9%) Of The
Normal Inspiratory Decrease In Systemic Blood Pressure.
Kussmaul Sign : As A Paradoxical Increase In Jugular Venous Distention And Pressure During
Inspiration. The Kussmaul Sign Is Usually Observed In Patients With Constrictive Pericarditis,
But It Is Occasionally Is Observed In Patients With Effusive-Constrictive Pericarditis And
Cardiac Tamponade.
Http://Emedicine.Medscape.Com/Article/152083-Clinical#B3

 Pulsus Alternans = Alteration Of Weak And Strong Pulse Beats (Not Relate Cycle
Length)Physical Finding With Arterial Pulse Waveform

CAUSES

 Large Pericardial Effusion

 Left Ventricular Failure
 Asthma

Https://Lifeinthefastlane.Com/Ccc/Pulsus-Alternans/
Central Venous Pressure (CVP) Is The Blood Pressure In The Venae Cavae, Near The Right
Atrium Of The Heart. CVP Reflects The Amount Of Blood Returning To The Heart And The
Ability Of The Heart To Pump The Blood Back Into The Arterial System
Https://En.Wikipedia.Org/Wiki/Central_Venous_Pressure

CAUSES OF RAISED CVP

 Right Ventricular Failure

 Tricuspid Stenosis Or Regurgitation
 Pericardial Effusion Or Constrictive Pericarditis
 Superior Vena Caval Obstruction
 Fluid Overload
 Hyperdynamic Circulation
 High PEEP Settings
 Https://Lifeinthefastlane.Com/Ccc/Cvp-Measurement/

89. A 2-Month-Old Infant Has Severe Dyspnea And Cyanosis. Chest Roentgenogram
Reveals Minimal Cardiomegaly And A Diffuse Reticular Pattern Of The Lung Fields.
Which Of The Following Best Explains These Findings?

a) Acute Viral Myocarditis

b) Hypoplastic Left Heart Syndrome
c) Pulmonary Artery Atresia
d) Total Anomalous Pulmonary Drainage With Venous Obstruction
e) Transposition Of The Great Arteries
Answer : Dr magda may be the question
not correct because usually
present early 3-4 weeks
D most likely

90. 6 Day Old Newborn With These Cardiac Cath Result:

O2 Sat BP
RA 60% ?
RV 61% 110/60

LA 85% 65/33

LV 84% 64/32
Aorta 84% 66/35
Pulmonary 85% 65/35

Dx:
a. TOF
b. Truncus Arteriosus
c. Tricuspid Artesia With Intact Septum Dr . huda : this case has :
d. ? 1- High rv pressure ps
2- Low sat in LV  THAT MEAN
THER IS SHUNT RT TO LT
(LARGE VSD )

- ANSWER : TOF
Blue If Sa Ao less 94 %
1- Sat In Pa >Ao Tga (Pa =Lv In Sat And Pressure )/ Ao=Rv In Sat And Pressure / Rv
>Lv In Pressure
2- Rt Heart (Ra, Rv , Pa ) Sat Increase With High Pa Pressure  Tapvr
3- Lt Heart (La, Lv ) Sat Decreased With Normal Pa Pressure+ High Ra Pressure  Ta
 4- Pa Less Than Rv In Pressure --: Rt Ventricle Obstruction
i. Tof : Rv=Lv In Pressure
ii. Ps : Rv>Lv In Pressure
5- Pa >Rv In Pressure --: (Rt->Lt Shunt ) :
iii. Avsd : Rv Less Than Lv In Pressure
iv. Esseinger : Rv > Lv In Pressure
Normal Value :
-Svc : Sat = 75% Pressure 0-5
- Rv : Sat 75% , Pressure 3
- Rv : Sat : 75% , Pressure 25/3
- Pa: Sat 75%, Pressure 75/25
- La : Sat 98 % Pressure 8
- Lv : Sat 98%, Pressure 110/8
Ao : Sat 98% Pressure : 110/60

Dr Samed Alsalemi

91. A 6 Years Old Child Is Known To Have Cyanotic Congenital Heart Disease Had A
Dental Extraction 3 Weeks Ago And Now Have Fever For The Last 2 Weeks. His Liver
Is Palpable 4cm And Spleen Just Palpable. What Is The Best Initial Management Step?
a) 3 Blood Cultures From Different Sites
b) Empiric Intravenous Antibiotics
c) Echocardiography
THIS CASE IS IE

92. A 2 Years Old Child Known To Have Tetralogy Of Fallot Is Least Likely To Present
With Which Of The Following:
a) Cerebral Thrombosis
b) Cerebral Abscess
c) Heart Failure
d) Polycythemia
Complication Of Tof
Cyanotic Spells

Paradoxical Emboli

Progressive Pulmonary Regurgitation And Right Ventricular Failure

Ventricular Arrhythmias

Atrial Arrhythmias

Sudden Cardiac Death

Congestive Heart Failure

Http://Bestpractice.Bmj.Com/Best-Practice/Monograph/701/Follow-Up/Complications.Html
Hemoglobin And Hematocrit Values Are Usually Elevated In Proportion To The Degree Of
Cyanosis. Prolonged Cyanosis Causes Reactive Polycythemia That Increases The Oxygen-
Carrying Capacity
Http://Emedicine.Medscape.Com/Article/2035949-Workup
“Tetralogy Of Fallot” AND “Brain Abscess” Yield Less Than 10 Articles In The Last 10 Year
Https://Www.Esciencecentral.Org/Journals/Brain-Abscess-In-Uncorrected-Tetralogy-Of-Fallot-
Diagnosed-During-Preparationfor-Computed-Cardiac-Angiotomography-2329-9517-
1000193.Php?Aid=41044

93. An Infant Presented To You With History Of Diminished Feeding And Sweating With
Feeding.He Looks Sick And Unstable With Heart Rate Of 240 Bpm. What Is The Best
Management Option?
a) Adenosine
b) Cardioversion
Svt Presentation : Infants Present With Fussiness, Irritability, Poor Feeding, Tachypnea,
Diaphoresis With Feeds, And Hepatic Congestion. Older Children And Adolescents,.
Http://Www.Healio.Com/Pediatrics/Journals/Pedann/2014-11-43-11/%7b2f9e610b-7dbe-407b-
8639-C7b848d32673%7D/Supraventricular-Tachycardia-In-Infancy-And-Childhood
94. In Infant Presents With Poor Feeding And Perspirations. On Examination He Have
Gallop rhythm And Crackles At Lung Bases. His Liver Is Palpable 4 Cm. What Is The
Best Initial step To Do?
a) Chest X-Ray
b) Blood Culture
c) NS Bolus
d) Digoxin
Acute Presentation Of The Ill Newborn Or Infant With Congestive Heart Failure Warrants
Immediate Concern Regarding Potential Sepsis Or Ductal-Dependent Congenital Heart
Disease. The Initial Management Involves The Usual Assessment Of The Patient's Airway,
Breathing, And Circulation (Abcs); Achieving IV Access; Laboratory Testing, Including A
Blood Culture; And Empiric Antibiotic Therapy. Management Of Low Cardiac Output Can Be
Initiated By Using A Dopamine Infusion Of 5-10 Mcg/Kg/Min;
Http://Emedicine.Medscape.Com/Article/2069746-Treatment#D11

95. A 5-Year-Old Girl Presents With Fever And Headache. Imaging Of The Brain Reveals
A Ring Enhancing Lesion. Which Of The Following Is The Most Likely Underlying
Condition In This Child?
a) Chronic Renal Failure
b) Idiopathic Or Familial Epilepsy
c) Congenital Cyanotic Heart Disease
d) Chronic Or Recurrent Tonsillitis
e) Langerhans Cell Histiocytosis
The Differential For Ring Enhancing Cerebral Lesions Includes:

 Cerebral Abscess
 Tuberculoma
 Subacute Infarct /Haemorrhage
Https://Radiopaedia.Org/Articles/Cerebral-Ring-Enhancing-Lesions
 The Most Common Blood-Borne Infections Known To Cause A Brain Abscess Are:

 Cyanotic Heart Disease - A Heart Defect, Present At Birth (Congenital), That Results In
Low Blood Oxygen Levels.
 Pneumonia, Bronchiectasis And Other Lung Infections
 Peritonitis.
 Cystitis
 Direct Contagion - Account For Between 45% And 50% Of Brain Abscesses. The Infection
Starts Off Inside The Skull, Perhaps In The Nose Or Ear And Spreads Into The Brain.
Examples Include Otitis Media (Middle Ear Infection), Sinusitis, Or Mastoiditis (Infection Of
The Bone Behind The Eye).).
 Direct Trauma - Account For About 10% Of Brain Abscesses
 Http://Www.Medicalnewstoday.Com/Articles/185614.Php
96. During A Regular Checkup Of An 8-Year-Old Child, You Note A Loud First Heart
Sound With A Fixed And Widely Split Second Heart Sound At The Upper Left Sternal
Border That Does Not Change With Respirations. The Patient Is Otherwise Active And
Healthy. Which Of The Following Heart Lesions Most Likely Explains These Findings?
a) Atrial Septal Defect (ASD)
b) Ventricular Septal Defect (VSD)
c) Isolated Tricuspid Regurgitation
d) Tetralogy Of Fallot
e) Mitral Valve Prolapse
Defect (ASD) Can Undiagnosed For Decades Due To Subtle Physical Examination Findings
And A Lack Of Symptoms. Even Isolated Defects Of Moderate-To-Large Size May Not Cause
Symptoms In Childhood. However, Some May Have Symptoms Of Easy Fatigability, Recurrent
Respiratory Infections, Or Exertional Dyspnea.
Http://Emedicine.Medscape.Com/Article/162914-Clinical
 S 1 Is Typically Split, And May Be Increased In Intensity, Reflecting Forceful Right
Ventricular Contraction And Delayed Closure Of The Tricuspid Leaflets.
 S 2 Is Often Widely Split And Fixed Because Of Reduced Respiratory Variation Due To
Delayed Pulmonic Valve Closure
Http://Emedicine.Medscape.Com/Article/162914-Clinical#B2
97. A Normal 6-Month-Old Infant Has A Continuous Cardiac Murmur And Bounding
Peripheral Pulses. What Step Should Be Taken Next?
a) Karyotype Evaluation
b) Surgical Or Catheter Correction Of The Defect
c) Life-Long Endocarditis Prophylaxis For At Risk Procedures
d) Repeating Examination At The Age Of 12 Months
e) Reassuring Of The Parents
Pda Common Symptoms

 Tachycardia
 Dyspnea
 Continuous "Machine-Like" (Also Described As "Rolling-Thunder"
 Cardiomegaly
 Left Subclavicular Thrill
 Bounding Pulse
 Widened Pulse Pressure
 Poor Growth[1]

Https://En.Wikipedia.Org/Wiki/Patent_Ductus_Arteriosus

# Premature Infants — In Preterm Infants, Inhibitors Of Prostaglandin Synthesis, Such

As Indomethacin And Ibuprofen, Are Used As The Initial Interventions For PDA Closure.
#Symptomatic Management With Digoxin And Furosemide. If Fails Surgical Ligation Is The
Treatment Of Choice,

#Asymptomatic Infants Without Heart Failure Are Observed Until They Are Large
Enough To Undergo Percutaneous Closure

#Infants And Children >5 Kg — Percutaneous Occlusion Is Generally Preferred In Infants

And Children Who Weigh ≥5 Kg #PDA Closure Is Not Recommended In Patients With
Severe And Irreversible PAH #Antibiotic Prophylaxis Is Not Necessary For Medical Or Dental
Procedures..

Https://Www.Uptodate.Com/Contents/Management-Of-Patent-Ductus-Arteriosus
98. A Child Have Operated His Ventricular Septal Defect (VSD) Before 2 Weeks And Now
Presents With 3 Day Fever 39.4oc And Tachypnea And A Chest Pain That Increases
Upon Lying Down And Is Relieved By Sitting, This Condition Is Most Likely
Associated With Which Of The Following:
a) Splinter Hemorrhages
b) Pulsus Paradoxus
c) Prolonged QT Segment
d) Pulsus Alternans
e) Weak Peripheral Pulses
It Is Suggested That The Surgery For Ventricular Septal Defect May Itself Initiate Bacterial
Endocarditis As Noted In Three Of Our Cases.
Http://Circ.Ahajournals.Org/Content/Circulationaha/34/1/127.Full.Pdf
Classic Signs Of IE Are Found In As Many As 50% Of Patients. They Include The Following:
 Petechiae - Common But Nonspecific Finding (See The Image Below)
 Subungual (Splinter) Hemorrhages - Dark Red Linear Lesions In The Nailbeds
 Osler Nodes - Tender Subcutaneous Nodules Usually Found On The Distal Pads Of The
Digits
 Janeway Lesions - Nontender Maculae On The Palms And Soles
 Roth Spots - Retinal Hemorrhages With Small, Clear Centers; Rare And Observed In
Only 5% Of Patients.
 Signs Of Neurologic Disease Occur In As Many As 40% Of Patients. Embolic Stroke
With Focal Neurologic Deficits Is The Most Common Etiology. Other Etiologies Include
Intracerebral Hemorrhage And Multiple Microabscesses. [1]
 Signs Of Systemic Septic Emboli Are Due To Left Heart Disease And Are More
Commonly Associated With Mitral Valve Vegetations. Multiple Embolic Pulmonary
Infections Or Infarctions Are Due To Right Heart Disease.
 Signs Of Congestive Heart Failure, Such As Distended Neck Veins, Frequently Are Due
To Acute Left-Sided Valvular Insufficiency.
 Splenomegaly May Be Present.
Http://Emedicine.Medscape.Com/Article/216650-Clinical#B2