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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. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
Streptokinase
Development of AF. after ETOH - develop AF---sudden cardia arrest
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

2. What is the most effective way to treat multivessel coronary artery blockade?
Development of AF. after ETOH - develop AF---sudden cardia arrest
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
CABG not angioplasty
Transvenous pacemaker

3. what medication cause pulmonary edema?
PPAR gamma receptor agonist pioglitazone.PPAR
Monitor EF after cardiotoxic chemo - bypass surgery
Pt with cardiogenic shock
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

4. complication of HRT
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Increases the risk of MI - thromboembolism - breast cancer - dementia
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.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture

5. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

6. sinus bradycardia after inf wall MI
Pt with cardiogenic shock
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker

7. What is kussmaul sign
If there is evidence of heart failure
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
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Coronary angio - identify blockage and tx with stent/bypass

8. baloon valvulotomy for AS
Lidcaine drip
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Post wall MI - occlusion of right coronary artery. tx with atropine
PPAR gamma receptor agonist pioglitazone.PPAR

9. how amiodarone affects on warfarin
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
CABG not angioplasty
2.5-3.5

10. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
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 -
Holocystolic murmur loudest at lower left sternal border

11. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
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
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

12. INR for mechanical prosthetic valve
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Scoliosis and pes planus
2.5-3.5

13. When to start thrombolytic therapry in MI
2.5-3.5
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

14. When to use dobutamine?
Pt with cardiogenic shock
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

15. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
If there is evidence of heart failure
Amiodarone;
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

16. spontaneous papillary muscle rupture
Elderly people with MI
When it is symptomatic. asso with dec cardiac output resulting hypotension
Holocystolic murmur loudest at lower left sternal border
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

17. What is mech of TCA overdose
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 -
TCA inhibit fast Na channel in His-purkinje system- -slow av conduction---reentrant arrythmia---VT or VF. tx with sodium bicarb drip and lidocaine drip
The dose should be adjusted such that TS H below 0.35
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

18. EKG shows ST elevation and suggest occlusion of major coronary artery.
2.5-3.5
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.

19. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Coronary angio - identify blockage and tx with stent/bypass
CABG not angioplasty

20. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Weight loss
If patient is started on rifampin or phenobarbital; they increases its metabolism

21. should we give thrombolytic in ST depression?
Transvenous pacemaker
No...except posterior or dorsal MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

22. sudden onset of HTN. How do you manage
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
If patient is started on rifampin or phenobarbital; they increases its metabolism
If there is evidence of heart failure

23. most effective non pharmacologic measure to decease blood pressure?
Weight loss
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
Increases the risk of MI - thromboembolism - breast cancer - dementia

24. What drugs precipitate digoxin toxicity?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
When it is symptomatic. asso with dec cardiac output resulting hypotension
Unexplained synocope - dizziness - near syncope - recurrent palpitation

25. How long it takes for digoxin to have significant effect on rate control
Increases the risk of MI - thromboembolism - breast cancer - dementia
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

26. bradycardia after MI with hypotension. what would you do?
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Defibrillation
Persistent brady after MI which is refractory to atropine tx
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

27. How to dx SVT? tx?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
No p wave - narrow qrs; first line of tx-adenosine
Weight loss
Within 24 hours

28. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pt with cardiogenic shock
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

29. When to use anticoag or aspiring in AF
PPAR gamma receptor agonist pioglitazone.PPAR
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

30. common complications of ca antagonists?
No...except posterior or dorsal MI
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.
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Streptokinase

31. Most important predictor for future cardiovascular events
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Within 24 hours
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

32. Indication of gemfibrozil?
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
When it is symptomatic. asso with dec cardiac output resulting hypotension
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Reduce hypertriglyceridemia; in liver

33. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Elderly people with MI
Reduce hypertriglyceridemia; in liver
Streptokinase

34. indication of radionuclide ventriculography
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Monitor EF after cardiotoxic chemo - bypass surgery

35. patient pw with new onset of heart failure and AF
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 -
Transvenous pacemaker
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

36. who should get coronary intervention after MI
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

37. INR goal for bileaflet mechnial valve
Amiodarone;
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Without AF; INR 2-3; with AF: 2.5-3.5
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

38. ehlers danlos
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
CABG not angioplasty
If patient is started on rifampin or phenobarbital; they increases its metabolism
Scoliosis and pes planus

39. when should you stop aspirin before procedure that has bleeding risk?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Amiodarone;
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

40. When to increase warfarin dose?
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Monitor EF after cardiotoxic chemo - bypass surgery
If patient is started on rifampin or phenobarbital; they increases its metabolism

41. drugs increases the effect of warfarin
Streptokinase
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
If there is evidence of heart failure

42. new onset LBBB - What is the next step
No...except posterior or dorsal MI
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Flecainamide
Weight loss

43. problem of WPW?
Pt with cardiogenic shock
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Without AF; INR 2-3; with AF: 2.5-3.5
Development of AF. after ETOH - develop AF---sudden cardia arrest

44. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Scoliosis and pes planus
Streptokinase
Amiodarone;
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm

45. when 24 hour holter monitoring and admission recommended?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Unexplained synocope - dizziness - near syncope - recurrent palpitation
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Streptokinase

46. what MI cause sinus brady?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
No p wave - narrow qrs; first line of tx-adenosine
Post wall MI - occlusion of right coronary artery. tx with atropine

47. torsade and unresponsive
Defibrillation
Holocystolic murmur loudest at lower left sternal border
No...except posterior or dorsal MI
Increases the risk of MI - thromboembolism - breast cancer - dementia

48. primordial prevention vs primary/secondary/tertiary prevention
No...except posterior or dorsal MI
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
No p wave - narrow qrs; first line of tx-adenosine
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.

49. How do you diagnose multifocal atrial tachy?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
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.
The dose should be adjusted such that TS H below 0.35

50. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
2.5-3.5