2. 1-day-old infant appears dusky during feeding. O2 is
administered via nasal cannula, and 2 hours later she
develops tachypnea. Findings include: HR - 170 beats/min;
RR-80 /min; R arm BP - 48/30 mm Hg; R leg BP- 52/32
mm Hg; and pulse oximetry, 90% on oxygen.
1) If the diagnosis is HLHS describe physical findings of -
pulse , murmur , precordium and S2.
pulse , murmur , precordium and S2.
2) What was wrong in the management in the above
scenario
3) Mention 5 CHD presenting in the first week of life
4) Emergency management
3. Answer
1) HLHS- Duct dependent lesion -signs of shock, poor pulses
and metabolic acidosis, as systemic perfusion deteriorates,
thereby depriving the systemic circulation of adequate
perfusion. Hyperdynamic precordium and a loud, even
palpable single loud P2 (S2), No murmur
2) O2 acts as a pulmonary vasodilator stealing systemic
2) O2 acts as a pulmonary vasodilator stealing systemic
perfusion .
3) Duct dependant SBF –AS,Coarct, IAA
Duct dependant PBF- PA,HRHS. PA with intact IVS
Duct dependant TGA with intact IVS
Infradiaphramatic TAPVC
4) PGE1 to keep PDA open
4. Ductal Dependent lesions are all except:
1. Pulmonary atresia, intact IVS
2. TAPVC
3. Critical AS
4. HLHS
4. HLHS
5. VSD, Pulmonary atresia
5. A 5-day-old infant born at 31 weeks' gestation is on
ventilatory support. He has a grade 2 holosystolic murmur
that extends past the second heart sound. Pulses are
bounding. Precordial palpation is hyperdynamic.
Echocardiography reveals a large patent ductus without other
ductal-dependent congenital lesions.
1) When would one suspect PDA in preterm
1) When would one suspect PDA in preterm
2) Mention 3 complications of PDA in neonate
3) Contraindications for indomethacin
4) Pharmacological closure of PDA – medication & Dosage
6. Answer
1) Tachypnoea, tachycardia , RD, O2 dependancy ,
Continuous murmur , child not gaining wt,
Hyperdynamic precordium , bounding pulses.
2) Persistence of RD ( BPD), NEC,ICH, O2/ ventilator
dependency , Apnoea
dependency , Apnoea
3) Anaemia , Bleeding , electrolytes disturbances and
renal dysfunction
4) IV /Po indomethacin 0.2 mg /kg/ dose X 3 doses 12 hr
apart , Po ibuprofen , Po - mefanemic acid
7. You are examining a previously healthy 3-month-old boy
who recently began to fail to thrive. Physical examination
reveals tachypnea, gallop, and grade 1 systolic ejection
murmur. Chest radiography shows cardiomegaly and
increased pulmonary vascularity with pulse Ox of 90%
a) Differential diagnosis with most likely diagnosis
b) Presentations of children with increased PBF and CHD
8. a) Supracardiac TAPVC ,TGA with VSD ,Truncous
arteriosus , AV fistula
b) Tachypnoea , increased precordial activity , tachycardia,
Feeding problems, FTT, Repeated LRTI,
minimal Duskiness & Sweating
minimal Duskiness & Sweating
11. A 6year-old boy who has anorexia, abdominal
discomfort, and vomiting is noted to have marked
cardiomegaly on chest radiography.
In addition to jugular vein distention and hepatomegaly,
the clinical findings that are MOST suggestive of
congestive heart failure from a dilated cardiomyopathy
include
1) What does S3 and S4 gallop signify and which
1) What does S3 and S4 gallop signify and which
conditions are they seen
2) Define the following pulses and which conditions are
they seen – pulses alternans , pulses bigeminus,
pulses paradoxus , pulsus bisferiens
12. Answer
1) S3- signify – LV dilatation with dysfunction –CCF with high output
states , DCM with failure
S4 signifies – LV hypertrophy – long standing HT, HOCM, AS
2 )Pulses alternans- LV systolic dysfunction apical pulse twice the
2 )Pulses alternans- LV systolic dysfunction apical pulse twice the
palpable radial pulse .
A bigeminal pulse - beats grouped in pairs- atrial / ventricular ectopics –
apparent on palpation and auscultation
Pulsus paradoxus is a decrease in the strength of the palpated pulse (or
a decrease in measured blood pressure) during inspiration-Cardiac
tamponade.
Pulses bisferiens- palpable pulse that feels “double-peaked” with each
systolic contraction- HOCM
15. When examining a healthy 3-year-old boy during a
health supervision visit, you hear a grade 2 systolic
ejection murmur most clearly at the upper left
sternal border.
1) DD of ESM in second left ICS
2) Auscultatory findings in ASD
2) Auscultatory findings in ASD
3) Types of ASD
4) Children with ASD & moderate to severe
Pulmonary hypertension which associated
conditions should be ruled out
16. Answer
1. ASD, increased PBF, AS, PS and CoA
2. ESM , soft , Wide fixed split , low-
pitched, audible diastolic murmur at the
lower left sternal border with a rumbling
quality due to increased Tricuspid valve
quality due to increased Tricuspid valve
flow.
3. Ostium Primum , Ostium secundum /
PFO, Sinus Venosus ASD, Coronary
sinus ASD
4. Large ASD, TAPVC, PAPVC,
Cortriatriatrum, Mitral valve abnormalities
17. A previously healthy 4-month-old boy has been irritable
and has had a decreased appetite for 2 days. Findings
include: HR -240 beats/min; RR - 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.
1. List narrow complex tachycardias
1. List narrow complex tachycardias
2. Difference between autonomic focus Vs Reentrant
tachycardias .
3. ECG s during management
4. Initial management if child collapsed vs stable
5. Drugs for long term management
18. Answer
1. Sinus tachycardia , PSVT,EAT, MAT , AF, Afib, JET
2. Automatic -Warm up-cool down phenomenon , non
pharmac and pharmacological and electrical
conversion effective .
3. ECG during SVT and resting State , ECG during
3. ECG during SVT and resting State , ECG during
pharmac / electrical cardioversion
3. synchronized direct current cardioversion 0.5 -2 J/kg/ vs
vagal maneuvers- CSM, Ice pack , IV adenosine 0.2
mg/kg/dose , undiluted push followed by saline bolus
4. Beta blocker , amiodarone , Digoxin (after r/o WPW, )
verapamil ( > 1 yr of age )
19. Following an uncomplicated delivery, a 3.7 kg term
infant develops cyanosis in the first hour of life.
Findings at 3 hours of age include: cyanosis; heart
rate, 140 beats/min; respiratory rate, 56
breaths/min; no heart murmurs; pulse oximetry in
room air, 70% saturation in the right hand and 75%
in the foot; in 100% FIO2 via head-hood oxygen,
saturation increases to 90% in the foot; chest
saturation increases to 90% in the foot; chest
radiography, normal.
1. Clinical Differentials
2. Describe Hyperoxia test
3. Causes of Differential cyanosis /Reversed
differential
20. Pre and post-ductal oxygen saturations
– If pre-ductal sat higher than post-ductal sat
(differential cyanosis)
Left heart abnormalities (such as aortic arch
hypoplasia, critical aortic stenosis, interrupted
aortic arch)
Persistent pulmonary hypertension
Persistent pulmonary hypertension
– If post-ductal sat higher than pre-ductal (reverse
differential cyanosis)
TGA with CoA or TGA with IAA
TGA with supersystemic pulmonary vascular
resistance
21. All of these may characterize a
patient with Tet Spells except
1. Loud ejection systolic murmur audible
during spell
2. Seizures if prolonged spell
3. Prior to spells, baseline sats were 90%
3. Prior to spells, baseline sats were 90%
4. Patient has iron deficiency with a hct of
52%
5. Patient had viral diarrhoea for 3 days
22. Which statement(s) about coarctation is false:
1. The obstruction is usually opposite PDA
2. 50% have bicuspid aortic valve
3. There is increased LV afterload
4. The E and 3 signs are seen on an
4. The E and 3 signs are seen on an
Echocardiogram
5. There is apex-pulse deficit
6. There is radio-femoral delay
23. A 14-year-old girl falls during a race. She is unconscious,
cyanotic, and has no pulse, but spontaneously revives within
seconds. Both patient and family histories are benign. Results of
physical examination,
1. Causes of Sudden cardiac death in children
2. Appropriate tests been excluded
3. Arrhythmias associated with syncope
26. Severe PS is characterized by all of the following
except:
1. Increased RV pressure
2. Exertional dyspnea and fatigue
3. A R-L shunt
4. Loud P2
4. Loud P2
5. RVH on ECG
27. All statements regarding dTGA are true except:
1. Severe hypoxia is present
2. Atrial septostomy is usually crucial
3. RV pressures usually drop in the 1st few
weeks of life
weeks of life
4. Arterial switch is performed within the 1st
2 weeks of life
5. If the baby presents at 6 months of life,
no treatment is possible
28. A 16 month old is seen for 2 days h/o irritability
& fever up to 104 F, otitis is diagnosed &
antibiotic therapy initiated. After 4 days of Rx,
he continues to have high fever and irritability.
Additionally he develops conjunctival injection,
erythema of hands & feet.
a] Criteria for diagnosis ?
a] Criteria for diagnosis ?
b] unusual presentations of the disease ?
C) Phases of the disease ,coronary affected at
which stage ?
d] What is long term outlook?
29. ECG
Read following statements and mark true (T) or False (F)
for each
• Leads II, III and aVF record changes on the inferior or
diaphragmatic surface of the heart
• Leads I and aVL record changes from the lateral border
of the heart
of the heart
• Chest leads overlie the interventicular septum and
anterior wall of the right ventricle
• Ventricular depolarization is the source of the changes
in electrical potentials which cause the P wave
• T wave is due to ventricular repolarization
31. 4 areas to auscultate
• Apex Area-Supine
• Apex Area-Left Ducubitus
• Aortic Area
• Pulmonic Area
• Pulmonic Area
32. Single S1 S2 Split S1
Mid-Systolic
Click
Normal Normal Mitral Valve Prolapse
Early Systolic Murmur Mid-Systolic Murmur Late Systolic Murmur Holosystolic Murmur
Acute Mitral
Regurgitation
Mitral
Regurgitation due to
CAD (Coronary
Artery Disease)
Mitral Regurgitation
due to MVP (Mitral
Valve Prolapse)
Classic Mitral
Regurgitation
-or-
Ventricular Septal
Defect when heard
along the left sternal
border
33. Apex Area - Left Ducubitus, Listening with the bell of stethoscope
S4 Gallop S3 Gallop
Systolic Click with Late Systolic
Murmur
Left Ventricular
Hypertrophy
Both Normal and
Cardiomyopathy
Mitral Valve
Prolapse with
Mitral
Regurgitation
S4 and Mid-Systolic Murmur S3 and Holosystolic Murmur
Mitral Opening Snap and Diastolic
Murmur
Ischemic
Cardiomyopathy with
Mitral Regurgitation
Dilated
Cardiomyopathy
with Mitral
Regurgitation
Mitral Stenosis
34. Aortic Area - Sitting, Listening with the bell of stethoscope
Normal S1 S2
Systolic Murmur with
Absent S2
Early Diastolic
Murmur
Supine
Normal
Severe Aortic
Stenosis
Systolic and Diastolic Murmurs
Combined Aortic Stenosis and
Regurgitation
35. Pulmonic Area - Supine, Listening with the diaphragm of stethoscope
Single S2
Split S2
Persistent Split S2 Transient
Normal in Elderly Complete Right Bundle
Branch Block (On
ECG)
Norma
l
Ejection Systolic Murmur with
Transient Splitting S2
Ejection Systolic Murmur with Persistent
Split S2 and Ejection, Systolic Murmur
Ejection Systolic Murmur with Sing le
S2 and Ejection Click
Innocent
Murmur
Arterial Septal
Defect
Pulmonary Valve
Stenosis
top
36.
37. A healthy 8-month-old boy has had intermittent episodes of
intense cyanosis of the hands, lower arms, and feet since
birth. The infant appears alert and playful during the episodes.
At other times, his arms and legs are pink but have a "mottled"
appearance. Physical examination reveals no remarkable
findings other than mottling of the extremities.
1) Causes of episodic acrocyanosis
1) Causes of episodic acrocyanosis
2) Diagnostic tests for this child
38. Answer
1) Episodic acrocyanosis of the hands and feet ,
episodic arrhythmia ,Methemoglobinemia, .Cyanotic
spells , Seizures ,.
2) Ambulatory ECG, ABG/ Meth HB to detect
2) Ambulatory ECG, ABG/ Meth HB to detect
methemoglobinemia , Echocardiography to detect
congenital heart disease, EEG to detect a seizure
disorder
39. Scars
Deformities
Central Cyanosis
Malar Flush
Hands Nailfold Infarction
Splinter Haemorrhages
Clubbing
Capillary Refill Time
Oslar’s Nodes
Janeway Lesions
Palmar Erythema
Palmar Xanthomata
Peripheral Temp
Tar Staining
Tar Staining
Peripheral Cyanosis
Pulses Comment on: Rate, Rhythm, Character
Radial
Collapsing Pulse
Radial-Radial Delay
Brachial
Carotid
Head and Neck JVP
Conjuctival Pallor
Corneal Arcus
Xanthalasmas
Lips/Tongue Central Cyanosis
40. Scars
Deformities
Central Cyanosis
Malar Flush
Hands Nailfold Infarction
Splinter Haemorrhages
Clubbing
Capillary Refill Time
Oslar’s Nodes
Janeway Lesions
Palmar Erythema
Palmar Xanthomata
Peripheral Temp
Tar Staining
Tar Staining
Peripheral Cyanosis
Pulses Comment on: Rate, Rhythm, Character
Radial
Collapsing Pulse
Radial-Radial Delay
Brachial
Carotid
Head and Neck JVP
Conjuctival Pallor
Corneal Arcus
Xanthalasmas
Lips/Tongue Central Cyanosis
41. A 3.8 kg male infant develops cyanosis at 6 hrs. Sats in
arm 70%, legs 76%. On 100% O2, sats remain 70% in the
hands but 90% in the foot.
• The findings are consistent with
1. PPHN
2. Pulmonary atresia
3. TTNB
3. TTNB
4. dTGA
5. Truncus Arteriosus
42. 1. A 4 yr old boy growing on 25th% for
height and weight and developing
normally, shows on clinical examination,
a quiet precordium, normal regular HR,
normal S1 and split S2 with a 2/6 systolic
ejection murmur, which is louder on
supine position. There is no radiation of
supine position. There is no radiation of
the murmur to the neck.
What is the next step?
43. 2. You are about to discharge a term well
infant after an uncomplicated delivery after
2 days hospitalisation. At discharge, baby’s
skin appears mottled, there is mild
tachypnea, with difficulty in feeling
peripheral pulses with no audible murmur.
a] What is most likely etiology of these
a] What is most likely etiology of these
findings?
b] What will be your next step?
c] What are common presentations of CHD
in infancy?
44. 3. A teenage boy has had a recent episode of
syncope. The loss of consciousness was
sudden and without premonitory symptoms.
a] What are the causes of syncope? What is
the likely causes of it?
b] What initial cardiac workup is necessary?
b] What initial cardiac workup is necessary?
45. 4. On routine preschool examination in a 5
year old boy, a continuous murmur is noted.
a] What is diagnostic possibilities?
b] The murmur becomes less prominent when
the head is turned to left. What is most likely
the head is turned to left. What is most likely
diagnosis?
c] What further workup is required?
46. 5. A 2 day old term baby develops a systolic
murmur. There are no symptoms, chest x-
ray and ECG are normal. 2-D ECHO
shows moderately large VSD.
a] Why lack of symptoms, normal x-ray &
ECG not surprising?
b] What symptoms this child is likely to
b] What symptoms this child is likely to
develop in next 2-3 months?
c] What will be the signs of increasing LR
shunt in this infant?
d] What are indications of surgical
intervention?
e] Following surgery, what advice will you
47. 7. A 3 month old boy presents with 24 hours h/o
lethargy & irritability. Examination reveals HR-
290 bpm.
a] What is 1st step of evaluation?
b]What is possible diagnosis?
c] What is emergency treatment?
c] What is emergency treatment?
d] Following treatment HR falls to 120 bpm. Ecg
is normal. What long term treatment based on
risk of recurrence can be started?
e] HR falls to 120 bpm and ECG shows WPW
pattern. Enumerate prophylactic treatment
against recurrence?
48. 8. A 16 month old is seen for 2 days h/o
irritability & fever up to 104 F, otitis is
diagnosed & antibiotic therapy initiated. After 4
days of Rx, he continues to have high fever
and irritability. Additionally he develops
conjunctival injection, erythema of hands &
feet, strawberry tongue.
feet, strawberry tongue.
a] What investigation will be useful?
b] What is probable etiology of child’s disease?
c] Once diagnosed, what will be your next step?
d] When does coronary get affected?
e] What is long term outlook?
49. Located in the 2nd to 4th left interspaces, and if loud, to the apex and
perhaps to the right sternal border. A diaphargm is used to hear this
murmur. The murmur may have a blowing crescendo and may be mistaken
for breath sounds. It is heard best when the patient is sitting leaning
forward with breath held after exhalation. Heard in early distole.
A. aortic regurgitation
B. stills murmur
C. ventricular septal defect
D. pulmonic regurg
50. Location. Lower left sternal border
Radiation. To the right of the sternum, to the xiphoid
area, and perhaps to the left mid-clavicular line, but
not into the axilla
not into the axilla
Intensity. Variable
Pitch. Medium
Quality. Blowing, holosystolic
A. tricuspid regurgitation
B. mitral valve prolapse
C. aortic regurgitation
D. pulmonic regurgitation
51. • Chromosome 22q11.2 deletion
syndrome
• DiGeorge syndrome
• Velocardiofacial syndrome
• Velocardiofacial syndrome
• Conotruncal anomaly face
• Some CHARGE
The majority of patients with DiGeorge syndrome,
VCFS, CTAF have hemizygous deletions of
chromosome 22q11.2. The nomenclature is not
synonymous.
53. A 14 years old boy in your practice is followed
periodically for bicuspid aortic valve. He
presents to you with 3 week h/o fatigue and
off & on fever of 101 F.
a] What will you look for on physical
examination?
b] He has elevated WBC & ESR. What other
b] He has elevated WBC & ESR. What other
test you will ask for?
c] What organism are likely to grow on culture?
d] What treatment regime is ideal?
e] What risk this boy has for sudden
deterioration?
