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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. patient with new onset CHF - What is next best step?
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
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.
Holocystolic murmur loudest at lower left sternal border
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

2. What is kussmaul sign
Unexplained synocope - dizziness - near syncope - recurrent palpitation
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
If there is evidence of heart failure
If patient is started on rifampin or phenobarbital; they increases its metabolism

3. what medication cause pulmonary edema?
Go for coronary angio. high likelyhood of severe coronary artery disease
Post wall MI - occlusion of right coronary artery. tx with atropine
VSD; can be asymptomatic to large with significant L to R shunt
PPAR gamma receptor agonist pioglitazone.PPAR

4. wpw syndrome
Development of AF. after ETOH - develop AF---sudden cardia arrest
Monitor EF after cardiotoxic chemo - bypass surgery
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
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.

5. What is the most effective way to treat multivessel coronary artery blockade?
Within 24 hours
CABG not angioplasty
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Scoliosis and pes planus

6. When to treat sinus brady after acute MI
Post wall MI - occlusion of right coronary artery. tx with atropine
Holocystolic murmur loudest at lower left sternal border
Elderly people with MI
When it is symptomatic. asso with dec cardiac output resulting hypotension

7. When to start thrombolytic therapry in MI
PPAR gamma receptor agonist pioglitazone.PPAR
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

8. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Coronary angio - identify blockage and tx with stent/bypass
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

9. should we give thrombolytic in ST depression?
Defibrillation
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.
Flecainamide
No...except posterior or dorsal MI

10. When to increase warfarin dose?
Elderly people with MI
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If patient is started on rifampin or phenobarbital; they increases its metabolism

11. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
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.
If symptomatic (hypotension - hx of syncope) place 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
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

12. Difference between cardioversion and defibrillation
No p wave - narrow qrs; first line of tx-adenosine
PPAR gamma receptor agonist pioglitazone.PPAR
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
Pt with cardiogenic shock

13. paroxysmal AF without structural HD
Flecainamide
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady
If patient is started on rifampin or phenobarbital; they increases its metabolism
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

14. what MI cause sinus brady?
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
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
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used

15. complication of HRT
Increases the risk of MI - thromboembolism - breast cancer - dementia
Development of AF. after ETOH - develop AF---sudden cardia arrest
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Monitor EF after cardiotoxic chemo - bypass surgery

16. ehlers danlos
Scoliosis and pes planus
Transvenous pacemaker
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

17. When to use digoxin in AF
Weight loss
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
If there is evidence of heart failure

18. when 24 hour holter monitoring and admission recommended?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Reduce hypertriglyceridemia; in liver
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
Unexplained synocope - dizziness - near syncope - recurrent palpitation

19. INR for mechanical prosthetic valve
Within 24 hours
If there is evidence of heart failure
2.5-3.5
Unexplained synocope - dizziness - near syncope - recurrent palpitation

20. sudden onset of HTN. How do you manage
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

21. What is beck's triad?
PPAR gamma receptor agonist pioglitazone.PPAR
The dose should be adjusted such that TS H below 0.35
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

22. sinus bradycardia after inf wall 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
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
If there is evidence of heart failure

23. torsade and unresponsive
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Without AF; INR 2-3; with AF: 2.5-3.5
Defibrillation
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

24. indication of radionuclide ventriculography
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Monitor EF after cardiotoxic chemo - bypass surgery
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

25. when we say QT prolonged?
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
Within 24 hours
Lidcaine drip
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

26. EKG shows ST elevation and suggest occlusion of major coronary artery.
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
Persistent brady after MI which is refractory to atropine tx
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
Holocystolic murmur loudest at lower left sternal border

27. paroxysmal AF with structural HD
Amiodarone;
If patient is started on rifampin or phenobarbital; they increases its metabolism
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

28. How to treat a a patient with tCA overdose
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Lidcaine drip
Holocystolic murmur loudest at lower left sternal border
Go for coronary angio. high likelyhood of severe coronary artery disease

29. Why nitroprusside cannot be used alone in aortic dissection
Streptokinase
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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.

30. What is poor R wave progression?
If patient is started on rifampin or phenobarbital; they increases its metabolism
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
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

31. What is mech of TCA overdose
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
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
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
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

32. baloon valvulotomy for AS
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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.
CABG not angioplasty
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability

33. location of VSD/MR mumur
Elderly people with MI
2.5-3.5
Coronary angio - identify blockage and tx with stent/bypass
Holocystolic murmur loudest at lower left sternal border

34. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Pt with cardiogenic shock
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)

35. When to replace aortic valve
No p wave - narrow qrs; first line of tx-adenosine
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure

36. s/s carotid dissection
VSD; can be asymptomatic to large with significant L to R shunt
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
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.

37. Indication of gemfibrozil?
Within 24 hours
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Reduce hypertriglyceridemia; in liver
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

38. patient with secondary htn - What is next step
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Persistent brady after MI which is refractory to atropine tx

39. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
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
Post wall MI - occlusion of right coronary artery. tx with atropine
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio

40. how amiodarone affects on warfarin
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.
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
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 patient is started on rifampin or phenobarbital; they increases its metabolism

41. When to use anticoag or aspiring in AF
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Defibrillation
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat

42. when should you stop aspirin before procedure that has bleeding risk?
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Scoliosis and pes planus
If patient is started on rifampin or phenobarbital; they increases its metabolism

43. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
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
CABG not angioplasty
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.

44. who should get coronary intervention after MI
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Coronary angio - identify blockage and tx with stent/bypass
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

45. drugs increases the effect of warfarin
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Without AF; INR 2-3; with AF: 2.5-3.5
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
R/o IHD which is the most common causes of CHF. stress test if indicated or angio

46. What is paroxysmal AF? How do you treat?
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
If patient is started on rifampin or phenobarbital; they increases its metabolism
Do cardiact stress test; 50-75% of CHF have coronary disease etiology
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 -

47. problem of WPW?
Development of AF. after ETOH - develop AF---sudden cardia arrest
No p wave - narrow qrs; first line of tx-adenosine
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Unexplained synocope - dizziness - near syncope - recurrent palpitation

48. 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.
Development of AF. after ETOH - develop AF---sudden cardia arrest
No...except posterior or dorsal MI
7 days. coz aspirin cause platelet dysfunction that can last more than a week.

49. 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
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Amiodarone;

50. In cocaine induced vasospasm - if angio shows any thrombus - next step?
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Streptokinase
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