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Forums Pre PG Entrance NEET 2013 All india Exam

ECG MCQs

ELECTROCARDIOGRAM

1. Acute hyperkalemia is associated with which of the following electrocardiographic changes 1)

Prolongation of the ST segment (2) Prominent U waves(3) A decrease in the PR interval(4) QRS
widening
Ans. 4
bestdoc Hyperkalemia leads to partial depolarization of cardiac cells. As a result, there is slowing of the
Guest upstroke of the action potential as well as reduced duration of repolarization. The T wave becomes
peaked, the QRS complex widens and may merge with the T wave (giving a sine-wave
appearance), and the P wave becomes shallow or disappears. Prominent U waves are associated
with hypokalemia; ST-segment prolongation is associated with hypocalcemia.(Ref. Harrison, 15th
Edition, Vol. 1, Pg. 1269)

2. Osborn wave is seen in 1) Hyperthermia(2) Hypothermia(3) Hypercalcemia(4) Acute

pericarditis
Ans. 2
Osborn wave is a distinctive convex elevation of J point. J point is the iso electric point at the
junction of end of QRS complex and beginning of S-T segment.(Ref. Harrison, 15th Edition, Vol. 1,
Pg. 1269)

3. Which of the following is the primary sclero degenerative disease of conducting system: (1)
Levs disease(2) Lenegres disease(3) Romano Ward syndrome(4) Williams syndrome
Ans. 2
In Levs disease, there is calcification and sclerosis of the fibrous cardiac skeleton, which
frequently involves the aortic and mitral valves, the central fibrous body, and the summit of the
ventricular septum. Lenegres disease appears to be a primary sclerodegenerative disease within
the conducting system itself with no involvement of the myocardium or the fibrous skeleton of the
heart.(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1287)

4. With regard to supraventricular tachycardia, which is simplest for differentiating paroxysmal

atrial tachycardia with block from atrioventricular nodal reentry tachycardia 1) Oslers
manoeuver(2) Digoxin level(3) Carotid sinus massage(4) Presence or absence of anginal
symptoms
Ans. 3
Carotid sinus massage is simplest for differentiating paroxysmal atrial tachycardia (PAT) with
block from atrioventricular nodal re-entry tachycardia (AVNRT). This maneuver has no effect on
PAT except to increase the block temporarily, while it may have the effect of converting AVNRT.
Oslers maneuver consists of testing for palpability of a pulseless radial artery with the pressure of
the blood pressure cuff raised above the systolic blood pressure. If present, Oslers maneuver
explains systolic pseudohypertension. Digoxin level may be helpful in differentiating between the
two, because digoxin toxicity is a cause of PAT; however, it is a soft association and serves only
to rule out toxicity before further evaluation of the dysrhythmia

5. The site of origin of AV junctional complex is 1) AV node(2) Bundle of His(3) Bundle Branch
(right)(4) Left Bundle Branch
Ans. 2
The site of origin of AV junctional complex is thought to be in the bundle of HIS as the AV node in
vivo possesses no automaticity. (Ref. Harrison, 15th Edition, Vol. 1, Pg. 1293)

6. The J point on ECG is 1) End of Q wave and beginning of R wave(2) End of P wave and
beginning of PR interval(3) End of S wave and beginning of ST segment(4) End of PR interval
and beginning of R wave
Ans. 3
The J point is the junction of end of QRS complex and beginning of ST segment. (Ref. Harrison,
15th Edition, Vol. 1, Pg. 1293)

7. Every C rise in temp causes an increase in the heart rate by------------ beats/min 1) 9 (2)
8(3) 10(4) 12
Ans. 2
The sinus rate will increase by 8 beats per minute for every one-degree increase in temperature. A
diminution in oxygen saturation, as occurs at high altitudes or in association with congenital heart
disease, will also cause a sinus tachycardia.(Ref. Schamroth, 7th Edition, Pg. 328)

8. Flutter waves are best seen in 1) Lead II(2) Lead V1(3) (1) + (2)(4) Lead aVL
Ans. 3
Flutter waves are the regular, undulating closely placed waves seen in saw-tooth appearance in
atrial flutter. These are best seen in std-lead II and lead V1.(Ref. Schamroth, 7th Edition, Pg. 340)

9. A 67 years old man who has experienced recurrent episodes of dizziness over the last several
months is admitted to the hospital because of fainting episode. No evidence of acute myocardial
infraction is documented. On the evening of admission, the patient tells his nurse that
approximately 10 min earlier, he experienced several minutes of dizziness. His current rhythm
appears to be normal sinus; however, a monitoring strip obtained at the time of this episode
reveals absent QRS complexes every third beat. The PR interval, while slightly prolonged, is
constant from beat to beat. P waves are present at regular intervals. Which of the following is the
most appropriate therapeutic action : (1) Insertion of permanent cardiac pacemaker(2) Insertion
of temporary cardiac pacemaker followed by insertion of permanent cardiac pacemaker(3)
Administration of atropine, 2 mg IV(4) No specific therapy is required for this benign arrhythmia
Ans. 1
The electrocardiogram discloses sudden failure of atrial ventricular conduction without a
preceding change in the PR interval, Mobitz type II second-degree AV block, which usually reflects
significant disease of the conduction system. It may occur after a significant anterior myocardial
infarction or in Levs disease, which involves calcification and sclerosis of the fibrous cardiac
skeleton (frequently involving the aortic and mitral valves), or Lenegres disease, which involves
only the conducting system. Mobitz type II block is inherently unstable and tends to progress to
complete heart block with a slow, lower escape pacemaker. Therefore, pacemaker implantation is
necessary in this condition, particularly if the patient is symptomatic, as in this case.(Ref.
Harrison, 15th Edition, Vol.1, Pg. 1287)

10. The combination of right axis deviation + left ventricular diastolic overload with atrial
fibrillation is suggestive of 1) Mitral stenosis(2) Mitral incompetence(3) Aortic stenosis(4)
Pulmonary incompetence
Ans. 2
Electrocardiographic combinations Suggested diagnosis
1. Atrial fibrillationRight axis deviation Mitral stenosis
2. Left atrial P waveRight axis deviation Mitral stenosis
3. Atrial fibrillationRight axis deviationLeft ventricular diastolic overload Mitral incompetence
4. Very tall right atrial P waves in standard lead IIFirst-degree AV blockNormal QRS axis
Tricuspid stenosis
5. Left atrial P waveLeft ventricular systolic overload Hypertensive heart disease
(Ref. Schamroth, 7th Edition, Pg. 440)

11. The following are true about the position of heart in dextroversion, EXCEPT 1) Left ventricle
is anterior(2) Right ventricle is posterior (3) Right atrium is posterior(4) Left atrium is anterior
Ans. 4
DIFFERENCES BETWEEN DEXTROVERSION AND DEXTROCARDIA Dextroversion
Dextrocardia
1. Left ventricle Anterior On the right side
2. Right ventricle Posterior On the left
3. Left atrium On the left Posterior
4. Right atrium Posterior On the left
5. Aorta Left side Right side
6. Venae cavae Right side Left side
(Ref. P. J. Mehta, 3rd Edition, Pg. 42)

12. U wave is inverted in all, EXCEPT 1) Lead II, III(2) Acute pulmonary embolism(3) Acute
myocardial infarct(4) Lead V5, V6
Ans. 4
The U wave represents the slow repolarisation of the Purkinjes fibres, the papillary muscles or the
ventricular septum. It follows the T wave and precedes the P wave of the next cycle. It has the
same polarity as the T wave and hence it is upright in most of the leads.U waves tend to be
inverted in II, III, V1 and V2. It is transiently inverted during angina, acute pulmonary embolism,
left ventricular overload, digitalis effect and sometimes in myocardial infarction. In myocardial
infarction most of the changes may revert to normal and yet inverted U waves may persist. (Ref. P.
J. Mehta, 3rd Edition, Pg. 22-23)

13. All are ECG features of pulmonary embolism, EXCEPT 1) ST segment elevation in
precordial leads(2) Transient RBBB(3) T wave inversion in lead III and aVF(4) Absent P waves in
lead II and III
Ans. 4
The typical pattern of pulmonary embolism is as follows 1) A Q wave develops with ST elevation
and shallow T wave inversion in leads III and aVF(2) A prominent S wave with slightly depressed
ST segment and upright T wave occurs in leads I and II. This produces the classical SI QIII TIII
pattern associated with pulmonary embolism.(3) In the precordial leads there may be ST elevation
with T wave inversion over right ventricular leads and prominent S wave over left ventricular
leads.(4) Transient right bundle branch block may occur.(Ref. P. J. Mehta, 3rd Edition, Pg. 100)

14. Cardiotoxicity caused by radiotherapy and chemotherapy is best detected by 1) ECHO(2)

Endomyocardial biopsy(3) ECG(4) Radionucleide scan
Ans. 2
Myocardial fibrosis, as caused by radiotherapy, cannot be best diagnosed by anything less than a
tissue or endomyocardial biopsy.(Ref. Harrison, 15th Edition, Vol. 1)

15. A chronic alcoholic develops palpitations suddenly after alcohol binge. Which of the following
arrythmia is most commonly associated with alcohol binge in the alcoholics 1) Ventricular
fibrillations(2) Ventricular premature contractions(3) Atrial flutter(4) Atrial fibrillation
Ans. 4
Whenever the pulse is irregularly irregular, atrial fibrillation is almost always the
diagnosis.Arrhythmia occurring after a drinking binge is known as Holiday heart
syndrome.Arrhythmias to follow drinking binge in order of frequency :- Atrial fibrillation (MC)-
Atrial flutter- Ventricular premature contractionsThe most common cardiac effect of chronic
drinking is dilated cardiomyopathy.(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1360)

16. All of the following are true about ASD, EXCEPT 1) Right atrial hypertrophy(2) Right
ventricular hypertrophy(3) Pulmonary hypertension(4) Left atrial hypertrophy
Ans. 4
LA has two outflow tracts in ASD, viz.- Into L.V. through mitral valve- Into R.A. through ASDWith
two outflow tracts, the resistance against which the L.A. has to pump is decreased. This explains
absence of L.A. hypertrophy.Right atrial load, however is increased and so is the load to R.V. and
Pulmonary vessels. This explains R.A. and R.V. hypertrophy as well as pulmonary
hypertension.ECG with right axis deviation and R.V.H. suggests ostium secundum defect. Left axis
deviation suggests ostium primum defect.(Ref. Ghai, 5th Edition, Pg. 296)
17. All of the following are common causes of Atrial fibrillation, EXCEPT 1) Digitalis(2)
Thyrotoxicosis(3) Hypertension(4) Rheumatic fever
Ans. 3
CAUSES OF ATRIAL FIBRILLATION Common Uncommon
1. Rheumatic fever 1. Constrictive pericarditis
2. Coronary heart disease 2. Cor-pulmonale
3. Thyrotoxicosis 3. Bronchogenic carcinoma
4. Diphtheria 4. A.S.D.
5. Drugs. Digitalis, propranolol adrenaline, emetine 5. Hypertension
6. Excessive use of tea, coffee, tobacco and alcohol 6. Lone atrial fibrillation
7. W.P.W. Syndrome
8. Hypothermia
9. Diseased sino-atrial and atrio-ventricular nodes
(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1295)

18. Camel Hump P wave is seen in 1) Cardiac pacing(2) Left atrial enlargement(3)
Constrictive pericarditis(4) All of the above
Ans. 2
With left atrial enlargement, the P wave is prolonged due to delay of the left atrial or terminal
component of the P wave. The characteristic features will manifest in standard lead II, or in
standard lead I or even lead AVL when there is left axis deviation of the P wave. The P wave shows:
(i) a double peaked, notched or camel humped P wave, and (ii) an increased duration of the P
wave to longer than 0.11 sec. The duration of the notch the distance between the camel humps
is longer than 0.04 sec. (Ref. Schamroth, 7th Edition, Pg. 52)

19. In the absence of structural heart diseases, which of the following is more common 1)
RBBB(2) LBBB(3) AV junctional block(4) All of the above
Ans. 1
In subjects without structural heart diseases, RBBB is seen more commonly than LBBB. AV
junctional block is less common among these.(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1266)

20. If Mobitz type II block occurs with a normal QRS durations, the block is likely to be situated at
1) AV node(2) Bundle of His(3) Purkinje fibres(4) All of the above
Ans. 2
In Mobitz type II second degree AV block, conduction fails suddenly and unexpectedly without a
preceding change in PR interval. It is generally due to disease of the His Purkinje system and is
most often associated with a prolonged QRS duration. When Mobitz type II block occurs with a
normal QRS duration, an intra-His site of block should be expected.(Ref. Harrison, 15th Edition,
Vol. 1, Pg. 1287)

21. A 60 years old man complains that for an hour, he has been experiencing palpitations, a feeling
of unease, and vague chest pain. The peripheral pulse is difficult to count because of the uneven
amplitude and time span between beats; apical rate is 130 per minute, with only one heart sound
evidence in many of the beats, blood pressure (BP) is 115 130/ 60 75, imprecise because the
Korotkoff sound are inconsistent (his usual BP is 145/85). An ECG shows an electrical rate of 150,
with clearly identifiable narrow QRS complexes, but an irregular baseline and no identifiable P
waves. What is the first therapeutic goal in the treatment of this condition?(1) Achieve an increase
in the BP(2) Obtain relief of chest pain(3) Convert the rhythm to regular sinus rhythm(4) Obtain
reduced ventricular response
Ans. 4
Obtaining reduced ventricular response is the first therapeutic goal in the treatment of this man,
who is having a typical attack of acute atrial fibrillation. The rapid ventricular response is the
greatest threat at the outset. Conversion to regular sinus rhythm can await rate control. Agents
that can achieve rate reduction rapidly include digoxin, beta-blocking agents, and calcium
channel-blocking agents. Calcium channel blocking agents afford a fair chance of conversion to
regular sinus rhythm; beta-blocking agents should be avoided if the ventricular rate is 80 per
minute. If rate control is not established quickly, the criterion for hospitalization in this case is
met. The presenting rate is 110 in a patient with a disturbing complication (chest pain). Chest
pain represents relative coronary insufficiency, which exists as long as the excessive rate exists.
(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1295)

22. The causes of left axis derivation is all, EXCEPT 1) Left posterior hemiblock(2) Inferior wall
MI (3) Emphysema(4) WPW syndrome
Ans. 1
Causes of left axis deviation are 1) Left anterior hemiblock(2) Inferior wall M.I.(3)
Emphysema(4) WPW syndrome(5) V. tachycardia from a focus in apex of LV.(Ref. Schamroth, 7th
Edition, Pg. 44)

23. CVA T wave pattern is seen in 1) Hyperthemia(2) Sub arachnoid haemorrhage(3)

Cocaine poisoning(4) Strychinine poisoning
Ans. 2
CVA T-wave pattern is seen in intracranial bleed especially sub-arachnoid haemorrhage.It consists
of marked QT prolongation and deep, wide T-wave inversion. (Ref. Harrison, 15th Edition, Vol. 1,
Pg. 1269)

24. A 60 years old man is admitted to a hospital because of respiratory failure and tachycardia.
Rectal temperature is 38.3C (101F), respiratory rate is 32 breaths per minute, and blood
pressure is 100/60 mmHg. His admission electrocardiogram is shown below. Which of the
following measures would constitute the most appropriate management for this man : (1)
Electrical cardioversion after the blood pressure is raised(2) Supplemental oxygenation or
mechanical ventilation(3) Administration of quinidine(4) Administration of verapamil
Ans. 2
The rhythm demonstrated in the electrocardiogram presented is multifocal atrial tachycardia,
which is characterized by variable P-wave morphology and PR and RR intervals. Control of
multifocal atrial tachycardia, which usually is associated with severe pulmonary disease, comes
with improved ventilation and oxygenation. Carotid sinus massage, electrical cardioversion, and
the administration of digitalis, verapamil, or quinidine are of little benefit, although verapamil
may temporarily slow the ventricular rate. (Ref. Harrison, 15th Edition, Vol.1, Pg. 1300)

25. All of the following are true about VAT (ventricular activation time), EXCEPT 1) Upper
limit of normal VAT is 0.03 in V5 and V6(2) VAT is increased in Bundle branch block(3) It is from
the beginning of Q wave to the peak of R wave(4) It is time taken by impulse to transverse the
myocardium
Ans. 1
Ventricular activation time (VAT): The VAT is the time taken by an impulse to traverse the
myocardium from the endocardium to the epicardium. It is measured from the beginning of the Q
wave to the peak of the R wave. The upper limit of normal VAT is 0.03 sec in V1 and V2 and 0.05
sec in V5 and V6.Abnormalities: The VAT is increased in bundle branch block.(Ref. P. J. Mehta,
3rd Edition, Pg. 25)

26. Kirchoffs Law states that polarity of 1) Lead I + Lead II + Lead III = 0(2) I = II + III(3) II =
I + III(4) III = I + II
Ans. 1
Kirchoffs Law states that the algebraic sum of all the potential differences in a closed circuit
equals zero. If Einthoven had reversed the polarity of lead II (i.e. LL to RA instead of RA to LL),
the three bipolar leads would have formed a closed circuit and leads I + II + III = 0. Since the
polarity of lead II is reversed by Einthoven (probably to get an upright deflection in all the three
leads) I II + III = 0. i.e. II = I + III. This is Einthovens equation.(Ref. P. J. Mehta, 3rd Edition,
Pg. 13)

27. All are criteria for RVH, EXCEPT 1) R in V1 = 5mm(2) R/S ratio in V1 > 1(3) Right axis
deviation(4) S in V1 = 2mm
Ans. 1
Criteria for right ventricular hypertrophy(1) Right axis deviation greater than + 110o(2) R/S ratio
in V1 equal to or greater than 1or R/S ratio in V6 less than 1.(3) R in V1 = 7 mm or S in V1 = 2 mm.
(4) With RBBB an R1 wave greater than 10 mm suggest RVH as it represents enhanced and late
forces of right ventricular depolarization. (Ref. P. J. Mehta, 3rd Edition, Pg. 42)

28. ECG of the patient of hypothyroidism has all, EXCEPT 1) Low voltage ECG(2) T wave
elevation in lead II, III(3) Prolong PR interval(4) None of the above
Ans. 2
Through myxoedema cannot be diagnosed on an ECG, it can be suspected because of the following
characteristic changes that it causes on an ECG 1) Sinus bradycardia(2) Low voltage(3) Flat or
shallow inversion of T waves(4) Prolonged PR interval.(Ref. P. J. Mehta, 3rd Edition, Pg. 104)

29. QT prolongation is seen in all, EXCEPT 1) Hypothermia(2) Digitalis toxicity(3)

Hypocalcemia(4) Romano Ward syndrome
Ans. 2
QT interval is shortened in digitalis toxicity QT interval Prolonged 1. Hypocalcemia 2.
Hypothermia 3. CNS insult-intracerebral haemorrhage 4. Antiarrythmic drugs Quinidine
Procainamide Disopyramide Phenothiazines 5. Hypokalemia 6. Hereditary causes With deafness
(Jervell syndrome) Without deafness (Romano Ward syndrome) Shortened 1. Hypercalcemia 2.
Digitalis toxicity

30. Hypocalcemia is characterized by all of the following features, EXCEPT 1) Numbness and
tingling of circum oral region(2) Hyperactivity tendon reflexes(3) Shortening of Q-T interval in
ECG(4) Carpopedal spasm
Ans. 3
The QT interval on ECG is prolonged in hypocalcemia and shortened in
hypercalcemia.Manifestations of chronic hypocalcemia Neuromuscular and Neurological Mental
changes Miscellaneous Cardiovascular
Muscle spasms Irritability Respiratory arrest Arrhythmias
Carpopedal spasms Depression Increased ICT with papilloedema Prolonged QT interval
Facial grimacing Psychosis Intestinal cramps Reduced effectiveness of digitalis
Laryngeal spasms Chronic malabsorption
Convulsions, tingling
Low serum calcium leads to increased excitability of peripheral nerves and hence hyperactive
tendon reflexes is a distinctive finding.Chvosteks or Trousseaus sign can be used to confirm
latent tetany when signs of overt tetany are lacking. Chvosteks Sign Trousseaus Sign
Tapping over the branches of the facial nerve as they emerge from the parotid gland produces
twitching of the facial muscles Inflation of Sphygmomanometer cuff on the upper arm to more
than systolic BP is followed by carpal spasm within 3 minutes
(Ref. Harrison, 15th Edition, Vol. 2, Pg. 2220)

31. Einthovens equation states that polarity of 1) I = II + III(2) II = I + III(3) III = I + II(4) I +
II + III = 0
Ans. 2
Kirchoffs Law states that the algebraic sum of all the potential differences in a closed circuit
equals zero. If Einthoven had reversed the polarity of lead II (i.e. LL to RA instead of RA to LL),
the three bipolar leads would have formed a closed circuit and leads I + II + III = 0. Since the
polarity of lead II is reversed by Einthoven (probably to get an upright deflection in all the three
leads) I II + III = 0. i.e. II = I + III. This is Einthovens equation.(Ref. P. J. Mehta, 3rd Edition,
Pg. 13)

32. The normal value of Q Tc interval is 1) 0.33 0.38 sec(2) 0.39 0.43 sec(3) 0.43 0.48
sec(4) 0.28 0.33 sec
Ans. 2
The Q-TC may be regarded as a constant, K. Thus: The normal value of K is 0.39 sec 0.04 sec.
The normal range is thus from 0.35 sec to 0.43 sec.The value of the Q TC or K corresponds to the
Q T duration at a heart rate of 60 per minute, for, at this rate, the R R interval is 1.0 sec and,
since the square root of 1.0 sec is still 1.0 sec, the Q T will be constant.(Ref. Schamroth, 7th
Edition, Pg. 29)
33. Which of the following is not an indicator for permanent pacing, if ECF has AV block 1) 2nd
degree block, permanent, asymptomatic(2) 2nd degree block, intermittent with bradycardia(3)
Asymptomatic 1st degree block at Bundle of His(4) Asymptomatic 2nd degree block of AV node
Ans. 4
AFTER MYOCARDIAL INFARCTION Class I (Pacemaker compulsory)
1. Persistent advanced second-degree AV block or complete heart block after acute myocardial
infarction with block in the His-Purkinje system (bilateral bundle branch block)
2. Transient advanced AV block and associated bundle branch block.
Class II (Pacemaker may be needed)
1. Persistent advanced block at the AV node.
Class III (Pacemaker not necessary)
1. Transient AV conduction disturbances in the absence of intraventricular conduction defects.
2. Transient AV block in the presence of isolated left anterior hemiblock.
3. Acquired left anterior hemiblock in the absence of AV block
4. Persistent first-degree AV block in the presence of bundle branch block not demonstrated
previously.
(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1290)

34. Wide QRS complex with prolonged duration is an invariable feature of 1) AV nodal block(2)
Intra HIS bundle block(3) Infra HIS bundle block(4) All of the above
Ans. 3
Prolonged QRS complex with a prolonged duration is an invariable feature of infra - HIS block
(distal HIS and Purkinje system block)It may be a feature of AV nodal block and intra HIS block
but may be absent in many cases. (Ref. Harrison, 15th Edition, Vol. 1, Pg. 1286)

35. All of the following are causes of prolong Q-T interval, EXCEPT 1) Vagal stimulation(2)
Procainamide(3) Quinidine(4) Hypothermia
Ans. 1
Causes of prolonged Q-TC are 1) Romano Ward syndrome(2) Jervell Lange Nielson
syndrome(3) Torsade-de pointes(4) Hypocalcemia(5) Hypothermia(6) Acute myocarditis(7) Acute
MI(Ref. Schamroth, 7th Edition, Pg. 328)

36. The most common arrythmia in a patient of acute cor pulmonale is 1) Sinus tachycardia(2)
Atrial premature complex(3) Ventricular tachycardia(4) Ventricular fibrillation
Ans. 1
Acute cor pulmonale due to pulmonary embolism for example, may be associated with a normal
ECG or a variety of abnormalities. Sinus tachycardia is the most common arrhythmia, although
other tachyarrhythmias, such as atrial fibrillation or flutter, may occur. The QRS axis may shift to
the right, sometimes in concert with the so-called S1Q3T3 pattern (prominence of the S wave in
lead I, Q wave in lead III, with T-wave inversion in V1 to V4 (right ventricular strain) simulating
acute anterior infarction. A right ventricular conduction disturbance may appear.(Ref. Harrison,
15th Edition, Vol. 1, Pg. 1265)

37. Generalized low voltage ECG is seen in all, EXCEPT 1) Hypopitutarism(2)

Hypothyroidism(3) Emphysema(4) None of the above
Ans. 4
Generalized low voltage ECG may be due to : (1) Incorrect standardization(2) Emphysema(3)
Obesity or thick chest wall(4) Pericardial effusion or constrictive pericarditis(5) Myxoedema(6)
Hypopituitarism(Ref. Schamroth, 7th Edition, Pg. 444)

38. The electrocardiogram shown below is consistent with which of the following clinical
situations : (1) A 55 years old man complaining of crushing substernal chest pain(2) A 25 years old
woman with acute renal failure resulting from plus nephritis(3) 27 years old man with prolonged
neutropenia after induction therapy for AML who is receiving Amphotericin B. (4) A 57 years old
woman with metastatic breast cancer receiving etidronate
Ans. 3
This ECG reveals an abnormal increase in the amplitude of the U wave, a small deflection
following the T wave that usually has the same polarity as the T wave. Recognition of a
pronounced U wave is important, for it may represent increased susceptibility to a torsades de
pointes type of ventricular tachycardia. Prominent U waves are most commonly seen after the use
of ant arrhythmic drugs such as quinidine, procainamide, and disopyramide or are due to
hypokalemia. The latter condition would be typical of a patient receiving amphotericin B, which
typically produces severe renal potassium wasting as a result of renal tubular damage.(Ref.
Harrison, 15th Edition, Vol.1, Pg. 1265)

39. The most common cause of ventricular extrasystolic bigeminal rhythm is 1) Acute MI(2)
Digoxin(3) Fever(4) Atrial fibrillation
Ans. 2
Digitalis intoxication is the commonest cause of ventricular extra systolic bigeminal rhythm and
the advent of this rhythm during digitalis administration is an absolute indication to stop therapy.
Digitalis intoxication will rarely, if ever, cause ventricular extrasystolic bigeminal rhythm in a
normal heart. (Ref. Schamroth, 7th Edition, Pg. 356)

40. Match the following changes of ST segment with the disease condition : a) Mirror image of
correction mark 1) Pericarditis
b) Raised with convexity upwards 2) Myocardial injury
c) Raised with concavity upwards 3) Digitalis
d) Depress with convexity upwards 4) Strain patterns
(1) a 3 , b 4, c 2, d 1(2) a 3, b 2, c 1, d 4(3) a 2, b 4, c 1, d 3(4) a 2, b 1, c
3, d 4
Ans. 2
The ST segment is: (1) Sagging in coronary artery disease. (2) Mirror image of correction mark in
digitalis effect. (3) Depressed and convex upward in strain pattern.ST SEGMENT DEPRESSION
(a) Ischaemic, (b) Strain pattern, (c) Digitalis effect (4) Raised with convexity upwards in
myocardial injury. (5) Raised with concavity upwards in pericarditis. ST SEGMENT ELEVATION
(a) Myocardial injury (b) Pericarditis (Ref. P. J. Mehta, 3rd Edition, Pg. 42)

41. Ta wave is due to 1) Atrial repolorization(2) Ventricular repolarization(3) Replorization of

Interventricular septum(4) Repolarization of posterobasal part of right ventricle
Ans. 1
Ta OR Pt wave: The Ta wave is produced by atrial repolarization. This wave is usually not seen in a
normal ECG as it merges with the QRS complex. It may be seen in AV block where the P waves
may not be followed by the QRS complexes.(Ref. P. J. Mehta, 3rd Edition, Pg. 21)

42. E.C.G features of mitral stenosis may include 1) Right axis deviation(2) P mitrale pattern
on lead II(3) Atrial fibrillation(4) All of the above
Ans. 4
ECG does not play a major role in the diagnosis of valvular diseases. Mitral stenosis is probably
the only one in which a specific pattern is present. The typical pattern in mitral stenosis is 1)
Right axis deviation(2) Left atrial enlargement. P mitrale pattern with wide and notched P wave in
lead II and biphasic P wave in lead V1. P mitrale may be absent in presence of atrial fibrillation.(3)
Right ventricular hypertrophy.(Ref. P. J. Mehta, 3rd Edition, Pg. 99)

43. Lead V5 is placed at 1) Anterior axillary line in 5th i.c.s.(2) Mid axillary line in 5th
intercoastal space(3) Mid clavicular line in 5th i.c.s.(4) Mid clavicular line in 4th i.c.s.
Ans. 1
The six precordial unipolar leads detect the electrical potential at specific points on the chest wall
in the horizontal plane of the body. The common precordial positions used are as follows:V1 :
Fourth intercostals space at the right sternal border.V2 : Fourth intercostals space at the left
sternal borderV3 : Equidistant between V2 and V4V4 : Fifth left intercostals space in the mid-
clavicular line V5 : In the anterior axillary line in the same horizontal plane as V4.V6 : In the mid-
axillary line in the same horizontal plane as V4.(Ref. P. J. Mehta, 3rd Edition, Pg. 16)

44. ST elevation is seen in all of the following conditions, EXCEPT 1) Coronary artery spasm(2)
Myocardial infraction(3) Ventricular aneurysm(4) Constrictive pericarditis
Ans. 4
ST segment elevation is seen in Acute pericarditis not constrictive pericarditis. In Constrictive
pericarditis ECG findings are :- Low voltage QRS complexes in all leads- No major ST segment
change- Acute Myocardial Infarction- Elevation of ST segment- Tall and wide T waves- Increased
amplitude of R wave- Q waves Coronary artery spasm Gives ECG pattern similar to transmural
ischemia i.e. ST segment elevation, the difference being that it is transient and does not lead to
formation of Q waves.Ventricular aneurysms Ventricular aneurysms can also be seen in normal
hearts in a condition known as early repolarization or J point elevation. (Ref. Harrison, 15th
Edition, Vol. 1, Pg. 1371)

45. At the end of isometric ventricular relaxation phase : (1) Corresponds to T wave in ECG(2)
Atrioventricular valves open(3) Corresponds to peak C wave in JVP(4) Atrioventricular valves
close
Ans. 2
a. At the end of iso volumetric relaxation phase, AV valves open, so as to allow blood to flow
rapidly into ventricles (ventricular filling phase).b. AV valves close at the beginning of iso
volumetric relaxation.c. Peak of c wave corresponds to the end of iso volumetric contraction.d.
T waves in ECG begin slightly before the end of ventricular contraction and end with the end of
iso-volumetric relaxation phase. (Ref. Guyton, 10th Edition, Pg. 99)

46. P tricuspidale is seen in all, EXCEPT 1) Triscuspid stenosis (2) Tricuspid regurgitation(3)
Mitral stenosis with pulmonary hypertension(4) None of above
Ans. 4
When the P wave in the frontal plane leads is notched, and the first component is increased in
amplitude and taller than the second component, the manifestation is sometimes referred to as a P
tricuspidale. This reflects biatrial enlargement and is frequently seen with tricuspid valve disease,
as well as with mitral valve disease when associated with pulmonary hypertension.(Ref.
Schamroth, 7th Edition, Pg. 328)

47. The rate of discharge in case of Bundle of His pacemaker is 1) 60 80 / min(2) 40 60 /

min(3) 30 40 / min(4) 20 30 / min
Ans. 2
The escape pacemaker following AV nodal block is usually in the His bundle, which generally has a
stable rate of 40 to 60 beats per minute and is associated with a QRS complex of normal duration
(in the absence of a preexisting intraventricular conduction defect). This contrasts with escape
rhythms arising in the distal His-Purkinje system, which have lower intrinsic rates (25 to 45 beats
per minute), manifest wide QRS complexes with prolonged duration, and are unstable.(Ref.
Harrison, 15th Edition, Vol. 1, Pg. 1286)

48. Which of the following finding on ECG is an indication for a pace maker implantation in a
patient after myocardial infarction 1) Bilateral Bundle Branch Block with second degree AV
block(2) Persistent advanced AV block(3) Left anterior hemiblock + AV block(4) Persistent first
degree block with BBB
Ans. 1
AFTER MYOCARDIAL INFARCTION Class I (Pacemaker compulsory)
1. Persistent advanced second-degree AV block or complete heart block after acute myocardial
infarction with block in the His-Purkinje system (bilateral bundle branch block)
2. Transient advanced AV block and associated bundle branch block.
Class II (Pacemaker may be needed)
1. Persistent advanced block at the AV node.
Class III (Pacemaker not necessary)
1. Transient AV conduction disturbances in the absence of intraventricular conduction defects.
2. Transient AV block in the presence of isolated left anterior hemiblock.
3. Acquired left anterior hemiblock in the absence of AV block
4. Persistent first-degree AV block in the presence of bundle branch block not demonstrated
previously.
(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1290)
49. The most common manifestation of SA node dysfunction is 1) Fatigue(2) Dizziness(3)
Palpitation(4) Dyspnoea
Ans. 2
Although marked ( 50 beats per minute) sinus bradycardia may cause fatigue and other
symptoms due to inadequate cardiac output, more commonly sinus node dysfunction is manifest
as paroxysmal dizziness, presyncope or syncope. These symptoms usually result from abrupt,
prolonged sinus pauses caused by failure of sinus impulse formation (sinus arrest) or block of
conduction of sinus impulses to the surrounding atrial tissue (sinus exit block).(Ref. Harrison,
15th Edition, Vol. 1, Pg. 1285)

50. When an ECG of an uncommon patient showed ventricular tachycardia, defibrillatory shocks
of 200J, 300J and 360 J is given. Subsequent choice of drug in the case is 1) Procainamide(2)
Lidocaine(3) Epinephrine(4) Bertylium
Ans. 2
The most appropriate management of cardiac arrest induced by VT is an initial 200-J
defibrillation. Additional shocks at higher energies, up to a maximum of 360 J, should be
attempted in the event of an initial failure to abolish the VT. Whether the initial defibrillation
attempt is successful or not, lidocaine should be given intravenously as a 1 mg/kg bolus, to be
followed in 2 min by the same dose if the arrhythmia is persistent. Second-line drugs that can be
used in the event of lidocaine failure include intravenous procainamide and bretylium. If
persistent ventricular fibrillation (VF) is the cause of the event epinephrine may be administered
every 5 min.(Ref. Harrison, 15th Edition, Vol.1, Pg. 1303)

51. Causes of Tall symmetrical T waves are all, EXCEPT 1) Recovering inferior wall myocardial
infarct(2) Hyperacute anterior wall myocardial infarct(3) Prinzmetal Angina(4) None of the above
Ans. 4
Causes of tall T-wave in precordial leads are 1) Recovering inferior wall myocardial infarct.(2)
Hyperacute stage of anterior wall myocardial infarct.(3) True posterior wall myocardial infarct(4)
Prinzmetals angina(Ref. Schamroth, 7th Edition, Pg. 444)

52. A 62 years old woman was started on a regimen of quinidine sulfate because of asymptomatic
ventricular couplets. One week later, she was admitted to the hospital after a syncopal episode.
Serum electrolyte concentrations were normal. The arrhythmia shown below appeared transiently
on her cardiac on he cardiac monitor. The recommended course at this time to : (1) Discontinue
the administration of quinidine and observe(2) Begin the intravenous administration of
procainamide 2 mg/min(3) Administer sodium bicarbonate, 70 meq, intravenously(4) Administer
potassium chloride, 10 meq, intravenously over 1 h
Ans. 1
The rhythm strip shows polymorphic ventricular tachycardia characteristic of torsades de pointes
(twisting of the points). This life-threatening rhythm is associated with prolongation of the QT
interval, resulting in this case from the administration of quinidine. The appropriate therapy is to
discontinue the offending agent and withhold other agents that prolong the QT interval, such as
procainamide. Hypokalemia can prolong the QT interval and result in this rhythm; however, this
patient had normal serum electrolyte concentrations.(Ref. Harrison, 15th Edition, Vol.1, Pg. 1304)

53. The following findings on ECG is suggestive of very tall Right atrial P waves + normal QRS +
1st degree heart block 1) Mitral stenosis(2) Tricuspid stenosis(3) Pulmonary stenosis(4)
Tricuspid incompetence
Ans. 2
Electrocardiographic combinations Suggested diagnosis
1. Atrial fibrillation Right axis deviation Mitral stenosis
2. Left atrial P wave Right axis deviation Mitral stenosis
3. Atrial fibrillation Right axis deviation Left ventricular diastolic overload Mitral incompetence
4. Very tall right atrial P waves in standard lead II First-degree AV block Normal QRS axis
Tricuspid stenosis
5. Left atrial P wave Left ventricular systolic overload Hypertensive heart disease
(Ref. Schamroth, 7th Edition, Pg. 440)
54. PR segment is 1) Beginning of P to the end of R wave(2) End of P wave to beginning of R
wave(3) End of P wave to beginning of QRS(4) Beginning of P wave to the beginning of R wave
Ans. 3
PR segment: The PR segment is from the end of the P wave to the beginning of QRS complex. It is
normally isoelectric.(Ref. P. J. Mehta, 3rd Edition, Pg. 26)

55. Each mm of ECG along the horizontal axis correspond to 1) 0.1 sec(2) 0.2 sec(3) 0.4 sec(4)
0.04 sec
Ans. 4
The paper upon which the ECG is recorded is ruled in lines 1 mm. apart both horizontally and
vertically. Each fifth line in both directions is heavier than the rest. The vertical axis represents
voltage. With normal standardization, each 1 mm represents 0.1 mV. The horizontal axis
represents time. With normal speed, 1 mm represents 0.04 sec, i.e. each 5 mm represents 0.2 sec,
and in one minute the ECG paper moves by 300 thick lines or 1,500 mm.(Ref. P. J. Mehta, 3rd
Edition, Pg. 17)

56. All of the following are seen in the ECG of a patient in anxiety, EXCEPT 1) Prolong PR
interval(2) Sinus tachycardia(3) ST segment elevation(4) T wave inversion
Ans. 3
Anxiety state and hyperventilation may at times cause the following abnormalities in the ECG. (1)
Sinus tachycardia (2) ST segment depression and T wave inversion in V3 V6 (3) Prolonged PR
interval (4) Arrhythmias(Ref. P. J. Mehta, 3rd Edition, Pg. 43-44)

57. ECG of an hypothermic patients shows all, EXCEPT 1) Atrial fibrillation(2) Prolong PR
interval(3) Prolong QT interval(4) Narrow QRS complex
Ans. 4
Hypothermia: When the body temperature falls below 30oC the following changes occur in an
ECG 1) Prolonged RR, PR, QRS and QT intervals (2) Elevation of J deflections(3) Atrial
fibrillation(Ref. P. J. Mehta, 3rd Edition, Pg. 105)

58. LVH is commonly seen with 1) ASD with fossa - ovalis(2) Pure mitral stenosis(3) Carcinoid
syndrome(4) Aortic incompetence
Ans. 4
The total volume ejected by the ventricle (forward stroke + volume of blood that regurgitates back
into L.V.) is increased in A. R.Also, here, the entire L.V. stoke volume is ejected into a high-
pressure zone, the aorta.This leads to dilatation of LV, followed by deterioration of LV function i.e.
LVF.Considerable thickening of LV wall (LV hypertrophy) also occurs with chronic AR.The left
ventricular diastolic pressure is normal in isolated Mitral Stenosis.Mitral stenosis leads to elevated
left atrial pressure, elevated pulmonary venous and capillary pressures, with resultant increase in
right ventricular afterload and ultimately LV failure.An ASD allows shunting of blood from LA to
RA and then to RV. It is Rt side of the heart that is primarily involved. No haemodynamic effects
are seen on L.V.Carcinoid syndrome may cause valvular heart disease by causing endocardial
fibrosis.However it is the right side of the heart that is usually involved.Proximal side of tricuspid
and pulmonary valves are involved, leading to tricuspid insufficiency or pulmonary stenosis and
thereby secondary Right sided heart failure. (Ref. Harrison, 15th Edition, Vol. 1, Pg. 1343,1352,
597)

59. All of the following statements regarding the ECG in acute pericarditis are true, EXCEPT 1)
T wave inversions develop before ST elevation return to baseline(2) Global ST segment elevation is
seen in early pericarditis(3) Sinus tachycardia is a common finding(4) PR segment depression is
present in majority of patients
Ans. 1
After several days the ST segment returns to normal and only then do the T waves become
inverted.ACUTE PERICARDITIS ACUTE MI
Elevation of ST segment with concavity upwards Elevation of ST segment with convexity upwards
T wave remains uprightAfter several days T waves become inverted but this occurs only when ST
segments return to base line T wave inversionT wave inversion occurs within hours, before the ST
segment returns to baseline
No significant change in QRS complexes- Some reduction in voltage may occur with massive
pericardial effusions. QRS change occur- Development of Q waves- Notching and loss of R wave
amplitude- T wave inversion
Depression of PR segment is also common and reflects atrial involvement
Atrial premature beats and Atrial fibrillation may occur
(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1366)

60. A 62 years old man loses consciousness in the street, and resuscitative efforts are undertaken.
In the emergency room an electrocardiogram is obtained, part of which is shown below. Which of
the following disorders could account for this mans presentations : (1) Hypokalemia(2)
Hyperkalemia(3) Digitalis toxicity(4) Intracerebral hemorrhage
Ans. 4
The electrocardiographic T wave represents myocardial repolarization, and its configuration can
be altered nonspecifically by metabolic abnormalities, drugs, neural activity, and ischemia through
a dispersion effect on the activation or repolarization of action potentials. Although myocardial
ischemia and subendocardial infarction can produce deep, symmetric T wave inversions, which
would result in tachyarrhythmias and syncope, noncardiac phenomena such as intracerebral
hemorrhage can similarly affect ventricular repolarization. Hyperkalemia is manifested by tall,
peaked T waves, not inverted ones.(Ref. Harrison, 15th Edition, Vol.1)

61. P wave are is best seen in 1) Lead I (2) Lead II(3) aVF (4) V2, V3, V4
Ans. 2
The normal P wave is usually best seen and studied in standard lead II because the frontal plane P
wave axis is usually directed to the positive pole of this lead. The P wave in standard lead II is
pyramidal in shape with a somewhat rounded apex. Its limbs are smooth with no irregularities.
(Ref. Schamroth, 7th Edition, Pg. 49)

62. The normal HV interval is 1) 0 15 ms(2) 15 35 msec(3) 35 55 msec(4) 60 80 msec

Ans. 3
The interval from local atrial depolarization in the His bundle recording to the onset of
depolarization of the His bundle deflection is called the AH interval (normal = 60 to 125 ms) and
represents an indirect method of assessing AV nodal conduction time. The interval from the
beginning of the His bundle deflection to the earliest onset of ventricular activation, as measured
from any of multiple surface electrocardiogram (ECG) leads or the intracardiac ventricular
electrogram, is called the HV interval (normal = 35 to 55 ms) and represents conduction time
through the His-Purkinje system. (Ref. Harrison, 15th Edition, Vol. 1, Pg. 1284)

63. Prolongation of P R interval (> 0.245) with normal QRS complex is due to delay in
conduction through 1) Atrium(2) AV node(3) Bundle of His(4) All of the above
Ans. 2
Prolongation of P-R interval may be due to atrial, AV nodal or His-Purkinje conduction delay. In
presence of a normal duration QRS with a prolonged P-R interval of > 0.24 S, the delay is
invariably in the AV node.In case of QRS prolongation with a near normal P-R interval, the cause
lies in the His-Purkinje system.(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1287)

64. The normal AH interval is 1) 20 40 ms(2) 40 60 ms(3) 60 90 ms(4) None of the

above
Ans. 3
The interval from local atrial depolarization in the His bundle recording to the onset of
depolarization of the His bundle deflection is called the AH interval (normal = 60 to 125 ms) and
represents an indirect method of assessing AV nodal conduction time. The interval from the
beginning of the His bundle deflection to the earliest onset of ventricular activation, as measured
from any of multiple surface electrocardiogram (ECG) leads or the intracardiac ventricular
electrogram, is called the HV interval (normal = 35 to 55 ms) and represents conduction time
through the His-Purkinje system.(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1284)

65. Rate of discharge of impulse from the Purkinje fibre is 1) 40/ min(2) 30/ min(3) 50/ min(4)
60/ min
Ans. 3
The SA node has the fastest inherent discharge rate, which usually ranges from 79 to 80 beats per
minute. The inherent rate of potential AV nodal pacemaking cells is about 60 beats per minute.
The inherent rate of pacemaking cells in the bundle of His is about 50 beats per minute. The
inherent rate of the Purkinje cells of the ventricular muscle is about 30 40 beats per minute.
(Ref. Schamroth, 7th Edition, Pg. 322)

66. Clues to the presence of atrioventricular nodal block (as opposed to trifascicular block) include
which of the following 1) Clinical evidence of inferior myocardial infarction(2) No change in the
escape rhythm with exercise(3) An escape focus rate rate slower than 40 beats per minute(4) A
widdened QRS complex as the escape focus
Ans. 1
The escape focus in atrioventricular nodal block is relatively high in the conduction system in an
area of vagal innervation. Thus, a beneficial response to vagolytic drugs such as atropine and to
exercise is usually apparent. The rate at the escape focus is relatively rapid, and the QRS complex
is narrow. Unless complete heart block persists, some Wenckebach periodicity can be observed.
Inferior myocardial infarction, mitral valve surgery, and digitialis toxicity can lead to
atrioventricular nodal block. (Ref. Harrison, 15th Edition, Vol.1, Pg. 229)

67. Scotts criteria for LVH are all, EXCEPT 1) R in lead I + S in lead III is more than 25 mm(2)
S in V1 + R in V5 > 35 mm(3) S in V2 + R in V6 > 45 mm(4) R in aVF > 20mm
Ans. 3
I. Scotts criteria for LVH are as follows : 1. Limb leads R in I + S in III : More than 25 mm R in
aVL : More than 11 mm R in aVF : More than 20 mm S in aVR : More than 14 mm 2. Precordial
lead S in V1 or V2 + R in V5 or V6 = More than 35 mm R in V5 or V6 = More than 25 mm R + S in
any precordial lead = More than 45 mm (Ref. P. J. Mehta, 3rd Edition, Pg. 49 50)

68. Causes of raised ST segment are all, EXCEPT 1) LBBB (2) Hyperthermia(3) Prinzmetal
angina(4) D. C. cardioversion
Ans. 2
Causes of Raised ST segment1. Acute Myocardial infarction2. Prinzmetal angina3. Ventricular
aneurysm4. Pericarditis5. Early Repolarisation6. LBBB or LV hypertrophy7. Hyperkalaemia8.
Hypothermia9. Cerebro-vascular haemorrhage10. Acute cor pulmonale11. D C cardioversion12.
Myocarditis13. Myocardial tumour (Ref. P. J. Mehta, 3rd Edition, Pg. 28)

69. ECG of patient with chronic cor pulmonale shows all, EXCEPT 1) Right axis deviation(2)
Low voltage ECG(3) Prominent P - pulmonale(4) None of the above
Ans. 4
Chronic cor-pulmonale, most often seen in emphysema, is characterized by the following ECG
changes :1. Prominent P-pulmonale in leads II, III and aVF suggesting right atrial enlargement.2.
Marked clockwise rotation.3. Right axis deviation is usually present. At times there may be - 90%
axis or marked left axis deviation. The axis tends to be vertically up or down (-90% or + 90)
because in emphysema the QRS vector is predominantly posterior and relative little deviation up
or down would swing the frontal axis through 180.4. Right ventricular hypertrophy.5. Low
voltage of QRS complexes in precordial leads. (Ref. P. J. Mehta, 3rd Edition, Pg. 102)

70. All of the following electrocardiographic finding may represent manifestations of digitalis
intoxication, EXCEPT 1) Bigeminy(2) Junctional tachycardia(3) Atrial flutter(4) Atrial
tachycardia variable block
Ans. 3
Digitalis causes disturbance in cardiac rhythm. Various manifestations are :- Ventricular
premature beats- Bigeminy- Ventricular Tachycardia- Ventricular Fibrillation- A. V. Block of
varying degree of severity may occur. Non paroxysmal atrial tachycardia with variable A. V block is
characteristic of Digitalis intoxication. Digitalis is profibrillatory but its administration does not
cause Atrial Flutter. (Ref. Harrison, 15th Edition, Vol. 1, Pg. 1327)

71. A female patient Chandni develops chest pain which is not associated with exercise and chest
auscultations shows multiple non ejection clicks. The investigation which is used to diagnose the
disease is 1) Echocardiography(2) Pyrophosphate scan(3) Thallium 201 scan(4) ECG
Ans. 1
The history of the female suggests the diagnosis of mitral valve prolapse. Echocardiography is the
investigation of choice for MVP.Mitral valve prolapse : (also known as Barlows Syndrome or
Floppy Valve Syndrome)It occurs most commonly in females Most patients are
asymptomaticMost important finding is the mid or late nonejection systolic click which occurs 0.
14 sec or more after the S1 (None that ejection clicks are seen in congenital or pulmonary stenosis)
Late Systolic murmur (crescendo decresendo murmur).Click and murmur occurs earlier with :
Standing : Valsalva ManoeuverClick is delayed with : Squatting : Isometric ExerciseLaboratory
examination :ECG is normal.Two Dimentional Echocardiography is very effective. (Ref. Harrison,
15th Edition, Vol. 1, Pg. 1348)

72. The initial positive deflection in the jugular venous pulse (a wave) can be accentuated in which
of the following conditions 1) Tricuspid regurgitation(2) Multiple pulmonary emboli(3) Atrial
fibrillation(4) Reentrant paroxysmal supra-ventricular tachycardia (PSVT)
Ans. 2
Large a waves indicate contraction of the right atrium against increased resistance, as might occur
with obstruction at the tricuspid valve (tricuspid stenosis) or more commonly with increased
resistance to right ventricular filling. Right ventricular filling could be impaired in pulmonary
stenosis or in any condition that causes pulmonary hypertension, such as multiple pulmonary
emboli. The a wave also will be pronounced if the right atrium contracts while the tricuspid valve
is closed by right ventricular systole, as would be the case in atrioventricular dissociation,
complete heart block, or junctional rhythm. The a wave is absent in patients with atrial fibrillation,
since no organized atrial contraction occurs. There is delay in the normal a wave pattern in a
patient with first degree AV block. (Ref. Harrison, 15th Edition, Vol.1, Pg. 1256)

73. All of the following causes AV conduction block, EXCEPT 1) Cardiac mesotheliomas(2)
Sarcoidosis(3) Amyloidosis(4) None of the above
Ans. 4
A variety of diseases and drugs can influence AV nodal conduction. These include acute processes
such as myocardial infarction (particularly inferior), coronary spasm (usually of the right coronary
artery), digitalis intoxication, excesses of beta and/ or calcium blockers, acute infections such as
viral myocarditis, acute rheumatic fever, infectious mononucleosis, and miscellaneous disorders
such as Lyme disease, sarcoidosis, amyloidosis, and neoplasms, particularly cardiac
mesotheliomas. AV nodal block may also be congenital. (Ref. Harrison, 15th Edition, Vol.1, Pg.
1287)

74. With incomplete bundle branch block, the QRS duration / interval is 1) 90 100 ms(2) 100
120 ms(3) 120 140 ms(4) > 140 ms
Ans. 2
With complete bundle branch block, QRS interval is > 120 milliseconds in duration.With
incomplete bundle branch block, QRS interval is between 100 to 120 milliseconds. (Ref. Harrison,
15th Edition, Vol.1. Pg. 1266)

75. The site of 2 : 1 antrioventricular block which improves conduction an administration of

atropine is 1) AV node(2) Bundle of His(3) Purkinje fibres(4) All of the above
Ans. 1
Site of 2: 1 Atrioventricular Block Characteristic Observation Site of Block
1. QRS width BBB anywhereNormal QRS in AV node or His bundle
2. PR interval of conducted P wave > 0.30 s in AV node 0.16 s in HPS or His bundle
3. Atropine or exercise Improve conduction in AV nodeWorsen conduction in HPS or His
bundle
4. CSP Worsen conduction in AV nodeImprove conduction in HPS or His bundle
5. Retrograde conduction Present - in HPS or His bundleAbsent may be anywhere
(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1289)

76. Factors that increase the susceptibility of APCS are all, EXCEPT 1) b - blocker(2)
Tobacco(3) Alcohol(4) None of the above
Ans. 1
Most APC are asymptomatic & do not require treatment except for removal of the factors that can
trigger APC.These include adrenergic drugs, alcohol & tobacco.These should be deminated from
regular use. (Ref. Harrison, 15th Edition, Vol.1, Pg. 1293)

77. The cause of right axis deviation are all, EXCEPT 1) Left pneumothorax(2) Anterolateral
MI(3) Inferior MI(4) Left posterior fascicular block
Ans. 3
The causes of Right axis deviation are 1) Left Pneumothorax(2) Left posterior fascicular
block(3) Anterolateral MI(4) Normally in children & young adults(5) Dextrocardia (Ref. Harrison,
15th Edition, Vol. 1, Pg. 1265)

78. HOCM has all of the following ECG findings, EXCEPT 1) Short P R interval(2) Short Q
T interval(3) Left anterior hemiblock(4) Left atrial enlargement
Ans. 2
Hypertrophic cardiomyopathy may present with the following electrocardiographic manifestations
:1. Ventricular hypertrophy2. Intraventricular conduction defects; left anterior hemiblock and
bundle branch block.3. Left and/or right atrial enlargement4. A short P R interval5. An
electrocardiographic presentation resembling the Wolff Parkinson White syndrome.6.
Prolongation of the Q T interval7. Disturbances of cardiac rhythm (Ref. Schamroth, 7th Edition,
Pg. 309 310)

79. U wave is best seen in 1) Lead II(2) V2, V3(3) aVF, lead III(4) V5, V6
Ans. 2
The U wave is a small rounded deflexion which occurs immediately after the T wave. It is normally
in the same direction as the T wave. It is usually best seen in leads V2 to V4. The deflexion may be
so small as to make accurate recognition difficult. The genesis of the U wave is uncertain and
remains controversial. (Ref. Harrison, 15th Edition, Vol. 1, Pg. 22)

80. Sawtooth Appearance of ECG is seen in 1) Atrial fibrillation(2) Ventricular fibrillation(3)

Atrial flutter(4) (1) + (3)
Ans. 3
The cardinal sign of atrial flutter is the presence of regular, undulating, closely spaced but
relatively wide atrial deflexions or flutter F waves affecting the whole baseline and resulting in
a regular, corrugated or saw tooth appearance.Flutter waves are best seen in standard lead II
and lead V1.(Ref. Schamroth, 7th Edition, Pg. 340)

81. Absent P wave are seen in all, EXCEPT 1) Atrial fibrillation(2) Hypokalemia(3) AV nodal
rhythm(4) None of above
Ans. 2
Absent P waves may be due to :1. SA block2. Atrial fibrillation3. Hyperkalaemia4. AV nodal
rhythm (the P waves may be hidden within the QRS complexes). (Ref. Schamroth, 7th Edition, Pg.
443)

82. The normal QRS interval is less than 1) 0.08 sec(2) 0.1 sec(3) 0.12 sec(4) 0.06 sec
Ans. 2
The QRS interval is the time taken for ventricular depolarization. It is measured from the
beginning of the Q wave to the end of the S wave. The upper limit of a normal QRS interval is 0.1
sec.Abnormalities : The QRS interval greater than 0.12 seconds indicates bundle branch block or
intraventricular conduction defect. (Ref. P. J. Mehta, 3rd Edition, Pg. 25)

83. Normal duration of P wave is 1) 0.06 0.07 s(2) 0.08 0.09 s(3) 0.11 0.12 s(4) 0.13
0.14 s
Ans. 2
The duration of P wave is in the range of 0.08 second to 0.10 seconds but not greater than 0.11
seconds. The maximum amplitude is 2.5 mm. (Ref. Schamroth, 7th Edition, Pg.49)

84. All are ECG features of WPW syndromes, EXCEPT 1) Delta wave(2) Long PR interval(3)
Wide QRS complex(4) None of the above
Ans. 2
The diagnostic triad of WPW syndrome is :1. Wide QRS complex2. Short PR interval3. Delta waves
(due to securing of initial part of QRS). (Ref. Harrison, 15th Edition, Vol.1, Pg.1266)

85. A patient with 2 : 1 AV Block, on carotid sinus pressure showed worsening of conduction. The
site of block is 1) AV node(2) Bundle of His(3) Left Bundle Branch(4) Right Bundle Branch
Ans. 1
Site of 2: 1 Atrioventricular Block Characteristic Observation Site of Block
1. QRS width BBB anywhereNormal QRS in AV node or His bundle
2. PR interval of conducted P wave > 0.30 s in AV node 0.16 s in HPS or His bundle
3. Atropine or exercise Improve conduction in AV nodeWorsen conduction in HPS or His
bundle
4. CSP Worsen conduction in AV nodeImprove conduction in HPS or His bundle
5. Retrograde conduction Present - in HPS or His bundleAbsent may be anywhere
(Ref. Harrison, 15th Edition, Vol. 1, Pg. 1289)

86. Sinus tachycardia is said to be present when the heart rate is more than : (1) 90 beats / per
min(2) 100 beats / per min(3) 110 beats / per min(4) 80 beats / per min
Ans. 2
In adults, the normal sinus rate under basal conditions is 60 to 100 beats per minute. Sinus
bradycardia is said to exist when the sinus rate is less than 60 beats per minute, and sinus
tachycardia when it exceeds 100 beats per minute. (Ref. Harrison, 15th Edition, Vol. 1, Pg. 1285)

87. Very prominent U wave is a marker of increased susceptibility to 1) M. I.(2)

Hypokalemia(3) Torsade de pointes(4) Atrial flutter
Ans. 3
An abnormal increase in U wave amplitude is most commonly due to Quinidine, disopyramide,
procainamide or hypokalemia.Very prominent U wave is an indicator of increased susceptibility to
torsades de-pointes.(Ref. Harrison, 15th Edition, Vol. 1, Pg. 22)

88. If the P P interval in more than five large square, the rate is less than ---------------- 1) 40/
min(2) 50/ min(3) 60/ min(4) 80/ min
Ans. 3
A useful rule of thumb1. If the R R or P P interval is less than three large squares, the rate is
over 100 per minute and connotes a sinus tachycardia.2. If the R R or P P interval is more than
five large squares, the rate is less than 60 per minute and connotes a sinus bradycardia. (Ref.
Schamroth, 7th Edition, Pg. 321)

89. All of the following are seen in acute rheumatic fever, EXCEPT 1) Prolonged P R
interval(2) Short Q T interval(3) Second degree block(4) None of the above
Ans. 2
Acute rheumatic fever is frequently associated with : (1) Sinus tachycardia(2) Non-paroxysmal AV
nodal tachycardia idionodal tachycardia(3) Prolonged P R interval(4) Second degree AV
block(5) Prolonged Q T interval. (Ref. Schamroth, 7th Edition, Pg. 444)

90. All of the following are seen in uraemia, EXCEPT 1) Prolong P R interval(2) Prolong Q T
interval(3) Prolong S T segment(4) Tall T waves
Ans. 1
Uraemia presents with the manifestations of hypocalcaemia in association with hyperkalaemia
and/or acidosis. The hypocalcaemia causes a prolongation of the S T segment and thereby the Q
T interval. The hyperkalaemia causes the tall T waves. (Ref. Schamroth, 7th Edition, Pg. 253)

91. Causes of increased PR interval are all, EXCEPT 1) Mumps (2) Measles(3) ASD(4) Digitalis
Ans. 2
The PR interval is measured from the beginning of the P wave to the beginning of the QRS
complex and hence the term PQ interval is more accurate. It represents the time interval between
atrial and ventricular depolarization and hence includes the time taken for atrial depolarization,
atrial repolarisation and the delay of excitation in the AV node. The normal PR interval ranges
from 0.12 - 0.20 seconds.Abnormalities : The PR interval is1. Increased in rheumatic fever,
ischaemic heart disease, following digitalis or quindine therapy, with ASD and mumps. (Ref. P. J.
Mehta, 3rd Edition, Pg. 24)

92. Causes of depressed ST segment 1) Acute pulmonary embolism(2) MVP(3) Quinidine

effect(4) Ventricular aneurysm
Ans. 4
Causes of Depressed ST segment 1. Acute subendocardial ischaemia2. Acute subendocardial
infarction3. Digitalis effect and toxicity4. L. V. hypertrophy and strain5. Hypokalaemia6.
Quinidine effect7. Acute myocarditis8. Acute pulmonary embolism9. Shock10. Mitral valve
prolapse11. Cerebro vascular haemorrhage12. Following selective coronary arteriography13.
Cardiomyopathy14. Secondary ST. T changes following BBB and WPW syndrome15. Reciprocal
changes in right precordial leads in posterior wall myocardial infarction16. Functional.
Hyperventilation and orthostatic change.(Ref. P. J. Mehta, 3rd Edition, Pg. 28)

93. All of the following Are useful in differentiating acute pericarditis from acute MI, EXCEPT
1) ST elevation with concavity upwards(2) Reciprocal ST changes in opposite leads(3) Absent Q
waves(4) None of the above
Ans. 2
Differences between acute pericarditis and acute myocardial infarction Acute pericarditis Acute
myocardial infarction
1. Reciprocal ST changes between I and III Absent. Elevated ST segment in both the leads.
Present. ST segment elevated in one and depressed in the other
2. Shape of ST segment Concave upwards Convex upwards
3. Q waves Absent Present
4. Evolution of changes In weeks In months
(Ref. P. J. Mehta, 3rd Edition, Pg. 104)

94. A previously healthy 58 years old man is admitted to the hospital because of an acute inferior
myocardial infraction. Within several hours, he becomes oliguric and hypotensive (blood pressure
is 90/60 mmHg). Insertion of a pulmonary artery (Swan Ganz) catheter reveals the following
pressures : pulmonary capillary wedge 4 mm Hg; pulmonary artery 22/4 mmHg: and mean
right atrial 11 mmHg. This man would bet be treated with 1) Fluids (2) Digoxin(3)
Dopamine(4) Intraaortic balloon counterpulsation
Ans. 1
Pulmonary Artery pressure 22/4 mmHgPulmonary Capillary Wedge pressure - 4
mmHgPulmonary artery pressure denotes right atrial pressure and pulmonary capillary wedge
pressure denotes left atrial pressure.The man described in the question most probably has inferior
myocardial infarction because right atrial pressure is elevated out of proportion to left atrial
pressure.Cardiac output is depressed on the basis of an insufficient left heart filling pressure. The
best treatment consists of administration of fluids. (Ref. Harrison, 15th Edition, Vol.1)

95. Digoxin is contraindicated in 1) Atrial fibrillation(2) Congestive heart failure(3)

Hypertrophic Obstructive Cardio-myopathy(4) Supraventricular tachycardia
Ans. 3
Digitalis, diuretics, nitrates and b adrenergic agonists are best avoided during treatment of
hypertrophic cardiomyopathy, particularly in patients with known left ventricular outflow tract
pressure gradients. (Ref. Harrison, 14th Edition, Vol. 1, Pg. 1331)

96. Sudden cardiac death is accurately described by which if the following statements 1)
Ventricular tachycardia or ventricular fibrillation during the convalescent phase (3 days to 8
weeks) after a myocardial infarction is not a risk factor for subsequent sudden cardiac death(2)
The presence of VPCs in a patient convalescing from a myocardial infarction increases the risk of
sudden cardiac death(3) If only one person is present to provide basic life support, chest
compressions should be performed at a rate of 80 per minute, and breaths twice in succession
every 15 s(4) Assuming there is no spontaneous pulse, a 400-J shock should be delivered
immediately upon recognition of ventricular tachycardia or ventricular fibrillation
 Ans. 3
Frequent premature ventricular complexes (defined as > 30 per minute), salvos or nonsustained
ventricular tachycardia, and a low ejection fraction (< 20%) are associated with an increased risk
of sudden cardiac death. Advanced forms (triplets or longer) are more predicative of risk than is
even a high density of unifocal premature beats. It is unclear whether suppressing ectopic activity
can reduce risk. Conventional techniques of cardiopulmonary resuscitation require lung inflation
every 15 s and chest compressions 80 times per minute if only one provider is present. In the case
of ventricular fibrillation or ventricular tachycardia in a pulseless patient, the first shock should be
delivered at 200 J, followed by additional higher energy shocks (up to 360 J in the absence of a
response). Intravenous sodium bicarbonate, formerly recommended, is no longer considered
routinely necessary and may
bestdoc, Dec 20, 2004 #1

THANKS A LOT

BRAVO

Guest, Dec 20, 2004 #2

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Thanks

What a Marathon effort !

Thanks.
Guest, Jan 9, 2005 #3
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