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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 MI cause sinus brady?
Post wall MI - occlusion of right coronary artery. tx with atropine
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Lidcaine drip
The dose should be adjusted such that TS H below 0.35

2. Difference between cardioversion and defibrillation
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
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
Streptokinase

3. Indication of gemfibrozil?
When it is symptomatic. asso with dec cardiac output resulting hypotension
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Reduce hypertriglyceridemia; in liver

4. When rhythm control strategy is suprior than rate control in the Tx of AF
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
VSD; can be asymptomatic to large with significant L to R shunt

5. When to use anticoag or aspiring in AF
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
CABG not angioplasty
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

6. should we give thrombolytic in ST depression?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
No...except posterior or dorsal MI
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

7. sudden onset of HTN. How do you manage
VSD; can be asymptomatic to large with significant L to R shunt
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
Unexplained synocope - dizziness - near syncope - recurrent palpitation
Defibrillation

8. most effective non pharmacologic measure to decease blood pressure?
Amiodarone;
Weight loss
Elderly people with MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

9. what causes non sustained ventricular tachy (>3 or more consecutive beat >120/m)?
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Holocystolic murmur loudest at lower left sternal border
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.
Urgent transvenous pacing or IV atropine.. must be treated. even mild brady

10. When to use digoxin in AF
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
If there is evidence of heart failure
Weight loss

11. how rhematic feber - thyrotoxicosis - marfans - ehler danlos complicate cardiovascular systme
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Rheumatic causes MR; thyrotoxicosis presents with high output failure; marfans-chronic - progressive MR; Ehlers-acute MR due to rupture of chorda tendenie.....ehlers---rupture
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS

12. When to treat sinus brady after acute MI
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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
When it is symptomatic. asso with dec cardiac output resulting hypotension

13. when should you stop aspirin before procedure that has bleeding risk?
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Within 24 hours
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.

14. 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.
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause
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

15. patient with new onset CHF - What is next best step?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
When it is symptomatic. asso with dec cardiac output resulting hypotension
Pt with cardiogenic shock

16. paroxysmal AF without structural HD
PPAR gamma receptor agonist pioglitazone.PPAR
CABG not angioplasty
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Flecainamide

17. What is most congenital heart malformation?
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.
VSD; can be asymptomatic to large with significant L to R shunt
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.

18. How to dx SVT? tx?
Defibrillation
No p wave - narrow qrs; first line of tx-adenosine
When it is symptomatic. asso with dec cardiac output resulting hypotension
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.

19. when NSTEMI without comorbidiites should get PCI?
Within 24 hours
Flecainamide
1. MI/CAD 2. LVH 3. dilated cardiomyo 4. MVR; tx order EKG - cardiac enzymes - Echo (most common in ward)
When it is symptomatic. asso with dec cardiac output resulting hypotension

20. sinus bradycardia after inf wall MI
Transient resolves in 24-48h. no tx or atropine; if pulmonary edema - rales or other signs of CHF - transvenous pacing
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.
Coronary angio - identify blockage and tx with stent/bypass
No...except posterior or dorsal MI

21. stable angina with heart failure
Go for coronary angio. high likelyhood of severe coronary artery disease
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion

22. What is poor R wave progression?
If R wave in lead v1 to V4 are in the same size. cause: LVH - RVH - copd - anterior infarcion - conduction defects - cardiomyopat
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
R/o IHD which is the most common causes of CHF. stress test if indicated or angio
No...except posterior or dorsal MI

23. treatment mobitz type 2 block (loss of QRS every 2nd /3rd beat)?
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Elderly people with MI
Most likely secondary. if young rule out renal cause. look at BUN/Cr; then look for pheocromo - cushing. then look for renovascular cause

24. What is beck's triad?
Holocystolic murmur loudest at lower left sternal border
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
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.

25. s/s carotid dissection
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation
CABG not angioplasty
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

26. What drugs precipitate digoxin toxicity?
Streptokinase
Duplex doppleer us if renal function impaired. if normal renal function - MR angio
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.

27. primordial prevention vs primary/secondary/tertiary prevention
When valve area is <0.7 - patient is sympotmatic - LVH >15 mm
Elderly people with MI
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.
Go for coronary angio. high likelyhood of severe coronary artery disease

28. location of VSD/MR mumur
Holocystolic murmur loudest at lower left sternal border
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

29. How to treat a a patient with tCA overdose
Lidcaine drip
2.5-3.5
Weight loss
Within 24 hours

30. torsade and unresponsive
Increases the risk of MI - thromboembolism - breast cancer - dementia
Defibrillation
Cause reflex sympathetic activation - increases heart rate and ventricular contractility which worsen the situation
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours

31. cocaine induced vasospasm leading to myocardial ischemia - initial tx?
Pt with marked palpitaion - diszzines - dyspnoea - or hemodynamic instability.
Elderly people with MI
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
Duplex doppleer us if renal function impaired. if normal renal function - MR angio

32. who should get coronary intervention after MI
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
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
Extra conduction pathway connects atria and ventricles. impulses run faster in accessory pathway than AV node. ventricles excited prematurely - shorter pr interval - slurred QRS
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

33. What is the most effective way to treat multivessel coronary artery blockade?
Go for coronary angio. high likelyhood of severe coronary artery disease
CABG not angioplasty
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

34. the dose levothyroxine in thyroid cancer remission
The dose should be adjusted such that TS H below 0.35
Without AF; INR 2-3; with AF: 2.5-3.5
Elderly people with MI
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

35. when 24 hour holter monitoring and admission recommended?
Elderly people with MI
Medical emergency. go for PCI without measuring card enzumes which will take several hours to be elevated.
High suspicion of MI. LAD occlusion leading to LBBB - next step angio
Unexplained synocope - dizziness - near syncope - recurrent palpitation

36. When to use dobutamine?
Monitor EF after cardiotoxic chemo - bypass surgery
Persistent brady after MI which is refractory to atropine tx
DM. equivalent to CAD. any additional risk factors such as hypertension and smoking has synergistic effect
Pt with cardiogenic shock

37. indication of radionuclide ventriculography
Monitor EF after cardiotoxic chemo - bypass surgery
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
When it is symptomatic. asso with dec cardiac output resulting hypotension
Unilateral headache - horner syndrom (miosis - ptosis and anhidrosis) dx MRA if it is unclear do catheter angio tx anticoagulation

38. What is mech of TCA overdose
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
Increases the risk of MI - thromboembolism - breast cancer - dementia
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
Do cardiact stress test; 50-75% of CHF have coronary disease etiology

39. When to start thrombolytic therapry in MI
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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
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.
Monitor EF after cardiotoxic chemo - bypass surgery

40. common complications of ca antagonists?
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.
VSD; can be asymptomatic to large with significant L to R shunt
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

41. paroxysmal AF with structural HD
Holocystolic murmur loudest at lower left sternal border
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.
Amiodarone;
Unexplained synocope - dizziness - near syncope - recurrent palpitation

42. drugs increases the effect of warfarin
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
When it is symptomatic. asso with dec cardiac output resulting hypotension
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin

43. baloon valvulotomy for AS
Go for coronary angio. high likelyhood of severe coronary artery disease
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
Reduce hypertriglyceridemia; in liver
STEMI - NSTEMI with high risk e.g. heart failure - angina - persistent arrythmia.

44. ehlers danlos
Scoliosis and pes planus
High procedural morbidity and transient efficacy; considered only in selected clinical settings eg patient with hemodynamic instability
If patient has >1mm st elevation in two contiguous leads and presents within 12 /24 hours
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.

45. INR for mechanical prosthetic valve
Persistent brady after MI which is refractory to atropine tx
7 days. coz aspirin cause platelet dysfunction that can last more than a week.
If symptomatic (hypotension - hx of syncope) place transvenous pacemaker
2.5-3.5

46. patient with unstable angina - chest pain - ekg changes but card enzymes normal - next step
Coronary angio - identify blockage and tx with stent/bypass
It slows metabolism and increases warfarin level. the dose needs to be decreased by 25%
Pulseless electrical activity. ekg shows cardiac rhythm but no cardiac output. no measurable pusle/BP.
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.

47. what medication cause pulmonary edema?
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Increases the risk of MI - thromboembolism - breast cancer - dementia
VAQ verapamil - amiodarone and quinidine; they inhibits renal tubula secretion of digoxin; patient presents with n/v/visual disturbance/confusion
PPAR gamma receptor agonist pioglitazone.PPAR

48. new onset LBBB - What is the next step
Streptokinase
Nitrate/ca channel blocker - aspirin - benzo; if no improvement angio
5.5 hours. thats Why not preferred in acute setting; diltiazen or beta blockers esmolol - metoprolol - propranolol should be used
High suspicion of MI. LAD occlusion leading to LBBB - next step angio

49. when we say QT prolonged?
Only AF with no other comorbidity- aspirin. AF with heart failure - CAD - HTN - Dm - >75 give warfarin
Lidcaine drip
If it is more than half of the RR interval - cause: antiarrythmic drugs - TCA - hypokalemia - stroke - seizure
Elderly people with MI

50. In cocaine induced vasospasm - if angio shows any thrombus - next step?
Streptokinase
Hypotension - distant heart sound - Inc jugular venous pressure suggestive of pericardial tamponade.
Cephalosporin - ciprofloxacin - erythromycin - fluconzol - amiodarone;
Bilat dependent edema. mechanisms not known. arterial dilatation may cause this.