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USMLE Step3 Cardiovascular

Subjects : health-sciences, usmle-step-3

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. How do you diagnose multifocal atrial tachy?
Look for predisposing condition: hypoxia - COPD - hypokalemia - hypomagnesemia - CAD - medications like theophyline - aminophylline - isoproterenol; look at EKG: p wave of 3 different morphologies - narrow qrs. tx underlying cause.
AF episode-- relieved with Diltiazem. ..then patient is asymptomatic but pulse irregularly irregular. recurrent episode of AF. treat with amiodarone. this is also best drug if AF is due to structural HD. eg CAD - CCF due to cardiomyo - HTN with LVH -
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

2. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Go for coronary angio. high likelyhood of severe coronary artery disease

3. What is poor R wave progression?
Holocystolic murmur loudest at lower left sternal border
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
If patient is started on rifampin or phenobarbital; they increases its metabolism

4. patient with secondary htn - What is next step
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
PPAR gamma receptor agonist pioglitazone.PPAR

5. patient with new onset CHF - What is next best step?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

6. What is kussmaul sign
Elderly people with MI
Normally jvp falls with inspiration due to reduced pressure in the expanding thoracic cavity and expansion of right ventricle duing diastole. in pericardial tamponade - impaired filling of ventricle leads to backflow of blood into venous system leadi
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Cardioversion is a synchonized shock of an unorganized tachyarrythmia AF or PSVT. defibrillation is to stop heart momentarily so unorganized activity such as ventricular fibillation is stopped. there will be a brief period of asystole and then normal

7. ehlers danlos
Scoliosis and pes planus
Lidcaine drip
Cardioversion is a synchonized shock of an unorganized tachyarrythmia AF or PSVT. defibrillation is to stop heart momentarily so unorganized activity such as ventricular fibillation is stopped. there will be a brief period of asystole and then normal
When it is symptomatic. asso with dec cardiac output resulting hypotension

8. primordial prevention vs primary/secondary/tertiary prevention
Increases the risk of MI - thromboembolism - breast cancer - dementia
Primordial prevention is the prevention of risk factors; action undertaken before onset of disease- primary prevention; action halts progression of disease-secondary; disease advanced - action taken to limit impairment and disabilities.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

9. How to treat a a patient with tCA overdose
Normally jvp falls with inspiration due to reduced pressure in the expanding thoracic cavity and expansion of right ventricle duing diastole. in pericardial tamponade - impaired filling of ventricle leads to backflow of blood into venous system leadi
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Lidcaine drip
Look for predisposing condition: hypoxia - COPD - hypokalemia - hypomagnesemia - CAD - medications like theophyline - aminophylline - isoproterenol; look at EKG: p wave of 3 different morphologies - narrow qrs. tx underlying cause.

10. When to use transvenous pacing?
Persistent brady after MI which is refractory to atropine tx
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Cardioversion is a synchonized shock of an unorganized tachyarrythmia AF or PSVT. defibrillation is to stop heart momentarily so unorganized activity such as ventricular fibillation is stopped. there will be a brief period of asystole and then normal
The dose should be adjusted such that TS H below 0.35

11. What is the most effective way to treat multivessel coronary artery blockade?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pt with cardiogenic shock
CABG not angioplasty

12. when should you stop aspirin before procedure that has bleeding risk?
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

13. Indication of gemfibrozil?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Defibrillation
Reduce hypertriglyceridemia; in liver
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

14. stable angina with heart failure
Go for coronary angio. high likelyhood of severe coronary artery disease
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Flecainamide
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

15. s/s carotid dissection
Elderly people with MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
VSD; can be asymptomatic to large with significant L to R shunt
Pt with cardiogenic shock

16. spontaneous papillary muscle rupture
Elderly people with MI
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

17. patient pw with new onset of heart failure and AF
Pt with cardiogenic shock
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
2.5-3.5

18. Difference between cardioversion and defibrillation
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Cardioversion is a synchonized shock of an unorganized tachyarrythmia AF or PSVT. defibrillation is to stop heart momentarily so unorganized activity such as ventricular fibillation is stopped. there will be a brief period of asystole and then normal
VSD; can be asymptomatic to large with significant L to R shunt
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

19. how amiodarone affects on warfarin
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Without AF; INR 2-3; with AF: 2.5-3.5

20. sudden onset of HTN. How do you manage
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Go for coronary angio. high likelyhood of severe coronary artery disease

21. When to start thrombolytic therapry in MI
Lidcaine drip
The dose should be adjusted such that TS H below 0.35
Unexplained synocope - dizziness - near syncope - recurrent palpitation
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

22. wpw syndrome
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
2.5-3.5
Go for coronary angio. high likelyhood of severe coronary artery disease
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

23. paroxysmal AF with structural HD
Flecainamide
Amiodarone;
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

24. What is most congenital heart malformation?
Amiodarone;
Weight loss
VSD; can be asymptomatic to large with significant L to R shunt
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

25. when we say QT prolonged?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
When it is symptomatic. asso with dec cardiac output resulting hypotension
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Without AF; INR 2-3; with AF: 2.5-3.5

26. location of VSD/MR mumur
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Holocystolic murmur loudest at lower left sternal border
Normally jvp falls with inspiration due to reduced pressure in the expanding thoracic cavity and expansion of right ventricle duing diastole. in pericardial tamponade - impaired filling of ventricle leads to backflow of blood into venous system leadi
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

27. complication of HRT
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Increases the risk of MI - thromboembolism - breast cancer - dementia
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

28. new onset LBBB - What is the next step
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

29. what MI cause sinus brady?
Post wall MI - occlusion of right coronary artery. tx with atropine
If there is evidence of heart failure
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

30. How to dx SVT? tx?
AF episode-- relieved with Diltiazem. ..then patient is asymptomatic but pulse irregularly irregular. recurrent episode of AF. treat with amiodarone. this is also best drug if AF is due to structural HD. eg CAD - CCF due to cardiomyo - HTN with LVH -
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Within 24 hours
No p wave - narrow qrs; first line of tx-adenosine

31. INR for mechanical prosthetic valve
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Transvenous pacemaker
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
2.5-3.5

32. what medication cause pulmonary edema?
Development of AF. after ETOH - develop AF---sudden cardia arrest
PPAR gamma receptor agonist pioglitazone.PPAR
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

33. most effective non pharmacologic measure to decease blood pressure?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Weight loss
Normally jvp falls with inspiration due to reduced pressure in the expanding thoracic cavity and expansion of right ventricle duing diastole. in pericardial tamponade - impaired filling of ventricle leads to backflow of blood into venous system leadi
VSD; can be asymptomatic to large with significant L to R shunt

34. What drugs precipitate digoxin toxicity?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Within 24 hours

35. who should get coronary intervention after MI
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
The dose should be adjusted such that TS H below 0.35
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

36. when NSTEMI without comorbidiites should get PCI?
2.5-3.5
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Holocystolic murmur loudest at lower left sternal border
Within 24 hours

37. When to increase warfarin dose?
If patient is started on rifampin or phenobarbital; they increases its metabolism
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Reduce hypertriglyceridemia; in liver
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

38. What is paroxysmal AF? How do you treat?
Streptokinase
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
AF episode-- relieved with Diltiazem. ..then patient is asymptomatic but pulse irregularly irregular. recurrent episode of AF. treat with amiodarone. this is also best drug if AF is due to structural HD. eg CAD - CCF due to cardiomyo - HTN with LVH -
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

39. should we give thrombolytic in ST depression?
No...except posterior or dorsal MI
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
If there is evidence of heart failure
Development of AF. after ETOH - develop AF---sudden cardia arrest

40. EKG shows ST elevation and suggest occlusion of major coronary artery.
Persistent brady after MI which is refractory to atropine tx
Within 24 hours
Holocystolic murmur loudest at lower left sternal border
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

41. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Lidcaine drip
Go for coronary angio. high likelyhood of severe coronary artery disease
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

42. drugs increases the effect of warfarin
Holocystolic murmur loudest at lower left sternal border
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Scoliosis and pes planus
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

43. What is PEA? How do you treat?
No...except posterior or dorsal MI
Post wall MI - occlusion of right coronary artery. tx with atropine
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

44. When to use dobutamine?
Post wall MI - occlusion of right coronary artery. tx with atropine
Pt with cardiogenic shock
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

45. What is beck's triad?
Without AF; INR 2-3; with AF: 2.5-3.5
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

46. torsade and unresponsive
Defibrillation
Post wall MI - occlusion of right coronary artery. tx with atropine
Coronary angio - identify blockage and tx with stent/bypass
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

47. When rhythm control strategy is suprior than rate control in the Tx of AF
Defibrillation
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Look for predisposing condition: hypoxia - COPD - hypokalemia - hypomagnesemia - CAD - medications like theophyline - aminophylline - isoproterenol; look at EKG: p wave of 3 different morphologies - narrow qrs. tx underlying cause.

48. When to replace aortic valve
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Defibrillation
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

49. paroxysmal AF without structural HD
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Flecainamide
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

50. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Go for coronary angio. high likelyhood of severe coronary artery disease
Coronary angio - identify blockage and tx with stent/bypass
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio