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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. What is most congenital heart malformation?
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
VSD; can be asymptomatic to large with significant L to R shunt
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
PPAR gamma receptor agonist pioglitazone.PPAR

2. When to use transvenous pacing?
Persistent brady after MI which is refractory to atropine tx
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

3. should we give thrombolytic in ST depression?
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
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Within 24 hours

4. who should get coronary intervention after MI
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
Holocystolic murmur loudest at lower left sternal border
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

5. ehlers danlos
If patient is started on rifampin or phenobarbital; they increases its metabolism
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Scoliosis and pes planus
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

6. Indication of gemfibrozil?
Reduce hypertriglyceridemia; in liver
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
If patient is started on rifampin or phenobarbital; they increases its metabolism

7. patient with new onset CHF - What is next best step?
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
Lidcaine drip
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

8. INR for mechanical prosthetic valve
Persistent brady after MI which is refractory to atropine tx
No p wave - narrow qrs; first line of tx-adenosine
2.5-3.5
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing

9. most effective non pharmacologic measure to decease blood pressure?
Post wall MI - occlusion of right coronary artery. tx with atropine
Weight loss
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.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation

10. drugs increases the effect of warfarin
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Increases the risk of MI - thromboembolism - breast cancer - dementia
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
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 -

11. When to use dobutamine?
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Pt with cardiogenic shock
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
When it is symptomatic. asso with dec cardiac output resulting hypotension

12. How long it takes for digoxin to have significant effect on rate control
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

13. when should you stop aspirin before procedure that has bleeding risk?
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
No p wave - narrow qrs; first line of tx-adenosine
Streptokinase
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

14. What is paroxysmal AF? How do you treat?
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 it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
No...except posterior or dorsal MI

15. When to replace aortic valve
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
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.
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Post wall MI - occlusion of right coronary artery. tx with atropine

16. what medication cause pulmonary edema?
Without AF; INR 2-3; with AF: 2.5-3.5
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
PPAR gamma receptor agonist pioglitazone.PPAR
No p wave - narrow qrs; first line of tx-adenosine

17. what MI cause sinus brady?
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
Post wall MI - occlusion of right coronary artery. tx with atropine

18. spontaneous papillary muscle rupture
Elderly people with MI
No p wave - narrow qrs; first line of tx-adenosine
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%

19. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
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
Coronary angio - identify blockage and tx with stent/bypass
Monitor EF after cardiotoxic chemo - bypass surgery
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%

20. wpw syndrome
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.
Go for coronary angio. high likelyhood of severe coronary artery disease
Flecainamide
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

21. indication of radionuclide ventriculography
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Monitor EF after cardiotoxic chemo - bypass surgery
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

22. stable angina with heart failure
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
The dose should be adjusted such that TS H below 0.35
Go for coronary angio. high likelyhood of severe coronary artery disease

23. What is poor R wave progression?
Streptokinase
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
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

24. location of VSD/MR mumur
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Holocystolic murmur loudest at lower left sternal border
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 -

25. What is PEA? How do you treat?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
VSD; can be asymptomatic to large with significant L to R shunt
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Pt with cardiogenic shock

26. patient with secondary htn - What is next step
When it is symptomatic. asso with dec cardiac output resulting hypotension
Monitor EF after cardiotoxic chemo - bypass surgery
Without AF; INR 2-3; with AF: 2.5-3.5
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

27. What is the most effective way to treat multivessel coronary artery blockade?
CABG not angioplasty
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
When it is symptomatic. asso with dec cardiac output resulting hypotension
Amiodarone;

28. Most important predictor for future cardiovascular events
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
VSD; can be asymptomatic to large with significant L to R shunt
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

29. When to use digoxin in AF
Amiodarone;
If there is evidence of heart failure
2.5-3.5
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

30. the dose levothyroxine in thyroid cancer remission
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
The dose should be adjusted such that TS H below 0.35
Flecainamide

31. What is mech of TCA overdose
Increases the risk of MI - thromboembolism - breast cancer - dementia
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
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
Without AF; INR 2-3; with AF: 2.5-3.5

32. What drugs precipitate digoxin toxicity?
Without AF; INR 2-3; with AF: 2.5-3.5
Elderly people with MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

33. new onset LBBB - What is the next step
Coronary angio - identify blockage and tx with stent/bypass
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

34. In cocaine induced vasospasm - if angio shows any thrombus - next step?
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.
Streptokinase
Development of AF. after ETOH - develop AF---sudden cardia arrest
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

35. sudden onset of HTN. How do you manage
No p wave - narrow qrs; first line of tx-adenosine
No...except posterior or dorsal MI
Increases the risk of MI - thromboembolism - breast cancer - dementia
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

36. When rhythm control strategy is suprior than rate control in the Tx of AF
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

37. when NSTEMI without comorbidiites should get PCI?
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Increases the risk of MI - thromboembolism - breast cancer - dementia
Within 24 hours
Without AF; INR 2-3; with AF: 2.5-3.5

38. paroxysmal AF with structural HD
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
2.5-3.5
Amiodarone;
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.

39. How to dx SVT? tx?
No p wave - narrow qrs; first line of tx-adenosine
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
Increases the risk of MI - thromboembolism - breast cancer - dementia
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

40. What is kussmaul sign
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
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Lidcaine drip

41. torsade and unresponsive
Monitor EF after cardiotoxic chemo - bypass surgery
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Defibrillation
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect

42. s/s carotid dissection
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
VSD; can be asymptomatic to large with significant L to R shunt
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

43. When to treat sinus brady after acute MI
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
When it is symptomatic. asso with dec cardiac output resulting hypotension
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

44. EKG shows ST elevation and suggest occlusion of major coronary artery.
Reduce hypertriglyceridemia; in liver
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Monitor EF after cardiotoxic chemo - bypass surgery
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

45. paroxysmal AF without structural HD
Flecainamide
Coronary angio - identify blockage and tx with stent/bypass
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 has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

46. when we say QT prolonged?
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%
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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

47. sinus bradycardia after inf wall MI
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Streptokinase
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
Flecainamide

48. patient pw with new onset of heart failure and AF
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Transvenous pacemaker
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Elderly people with MI

49. common complications of ca antagonists?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

50. When to increase warfarin dose?
PPAR gamma receptor agonist pioglitazone.PPAR
If patient is started on rifampin or phenobarbital; they increases its metabolism
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.