USMLE STEP 3 COMPLETE STUDY GUIDE
WITH PRACTICE QUESTIONS AND CCS
CASES
| GRADED A+ | GUARANTEED SUCCESS
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales Included
,Treatment for ACS: Things that lower mortality:
ASA-- instant platelet inhibitor
PCI
thrombolytics (if can't to PCI within 90 minutes or new LBBB)
statins
Clopidogrel (esp if asa allergy)
lower mortality in some cases
ace/arb (if low EF)
don't lower mortality but should still be done:
beta blocker
o2
morphine
nitrates
Alts:
CCB: beta blocker intol, cocaine or vasospasm
PAcemaker: AV blocks or bradycardia
lidocaine/ amiodarone: VT or VF
NSTEMI: 1. LMWH
1. first line treatment 2. GPIIb/IIIa inhibitors
2. best benefit
when do you use ACE/ARBs in ischemic cardiac disease cardiac failure (e.g. chf, systolic dysfunction or low ef).
Elderly woman with SOB + rales and edema: 1.EKG, CXR, echo, oximetry, monitoring unit, ABG, BMP
1. what tests do you order? 2. O2, morphine, nitrates, furosemide
2. what meds do you order? 3. CHF exacerbation
3. most likley dx: * transfer to ICU in CCS!*
4. if still symptomatic: 4. order an inotrope (milrinone, amrinone or dobutamine).
Valvular lesion ^VR .....dec VR ..grip.. amylN Valvular lesion ^VR .....dec VR ..grip.. amylN
(effect on M). (squat) (valsalva) (effect on M). (squat) (valsalva)
AS......... ..........X ............X ..........X .........X AS ...................^ .........dec ........dec .........^
AR ......... .........X ............X ..........X .........X AR ..................^ .........dec ........dec .........^
MS ......... .........X ............X ..........X .........X MS ...................^ .........dec.......... - ...........-
MR ......... .........X ............X ..........X .........X MR .................^ ..........dec .........^.......... dec
VSD ......... .......X ............X ..........X .........X VSD.................^ ..........dec .........^.......... dec
HOCM ........ ....X ............X ..........X .........X HOCM ...........dec ........^ ...........dec......... ^
MVP ..... ..........X ............X ..........X .........X MVP ..............dec ........^ ...........dec......... ^
what is the optimal treatment for: 1. Valsalva = diuretics (AS, AR, MS, MR, VSD)= L heart murmurs
1. murmurs that improve on valsalva (and which murmurs 2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
are these?) 3. diuretics
2. murmurs that improves with amyl nitrate (and which 4. repair (baloon for MS, replace for AS)
murmurs are these?)
3. best therapy for regurgitant lesions
4. best therapy for stenotic lesions
,75 yo M with hx HTN now with chest pain/ syncope. hear Dx: AS
a crescendodecrescendo systolic murmur at the 2nd R workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
intercostal space that radiates to the carotids. also do EKG and CxR (LVH)
what is the dx, w/u, tx? treatment: Diurese, but overdiuresis is best--> valve replacement is best
75 yo M with hx HTN now with SOB/ fatigue. You hear a Dx: AR
decrescendo-crescendo diastolic murmur at the LSB workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
what is the dx, w/u, tx and other physical findings? also do EKG and CxR (LVH)
treatment: ACE/ARB, nifedipine (add loop diuretic in CCS)--> surgery if EF <55%
and LV end systolic diameter >55 mm
75 yo immigrant M now with dysphagia and afib. You hear Dx: MS
an extra sound in diastole with S1>S2. workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
what is the dx, w/u, tx and other physical findings? also do EKG and CxR (LAH- straightening of LH border and elevation of L
mainstem bronchus)
treatment: diuretics (best initial, but don't alter progression)--> balloon
valvuloplasty (incl preg women)
75 yo M w/ PMH MI now with dyspnea on exertion. You Dx: MR
hear holosystolic murmur at the apex, radiating to axilla workup: TTE (best initial test), TEE (more accurate) also do EKG and CxR
what is the dx, w/u, tx and other physical findings?
treatment: ACE/ ARBS, Nifedipine (best initial, decreases rate of progression), add
loop diuretic in CCS--> surgery if EF <60% and LV end systolic diameter >45 mm
7 yo M now with no complaints, on exam You hear Dx: VSD
holosystolic murmur at the LLSB. workup: echo first--> cath (determine degree of L-->R shunting
what is the dx, w/u, tx and other physical findings? treatment: if mild, will close on its own.
7 yo M now with no complaints, on exam You hear fixed Dx: ASD
splitting of S2. workup: ?
what is the dx, w/u, tx and other physical findings? treatment: PCI, repair when shunt ratio >1.5:1
what to think about when you hear wide splitting of S2 RBBB
with delayed P2 PS
RVH
Pulm HTN
what to think about when you hear paradoxical delayed LBBB
A2? AS
LVH
HTN
75 yo M presents w/ SOB...w/u echo first! (may reveal cardiomyopathy, etc)
dilated cardiomyopathy: etiology: EtOH, Chagas, ischemia, adriamycin, radiation
etiology, w/u, tx and other physical findings? w/u: echo
treat: ACE/ARBs, beta blockers and spironolactone
dig for symptomatic tx
, 75 yo M presents w/ SOB + S4 gallop Hypertrophic cardiomyopathy
ddx, etiology, w/u, tx and other physical findings? w/u: echo
treat: diuretics + beta blockers
75 yo M presents w/ SOB + kussmaul's sign etiology, w/u, Restrictive cardiomyopathy
tx and other physical findings? kussmaul's sign: increase in JVP on inhalation
2/2: sarcoidosis, amyloidosis, hemochromatosis, cancer, myocardial fibrosis or
glycogen storage diseasese
w/u: echo, cath (rapid x and y descent) EKG (low voltage) endomyocardial biopsy
(most accurate dx test)
treat: diuretics
pericarditis w/u: EKG (ST elev, PR depression)
w/u and tx tx: NSAIDs--> 1-2 days later reassess--> give prednisone if still symptomatic-->
reassess
SOB, low BP and JVD pericardial tamponade
pericardial tamponade w/u: EKG (electrical alternans), echo (diastolic collapse of RH), RH cath
w/u, tx (equalization of all pressures)
tx: pericardiocentesis (best initial) most effective: pericardial window
NEVER GIVE: diuretics
aortic dissection if suspicion:
w/u, tx w/u: EKG, CXR (widened mediastinum), CTA (most accurate) = TEE= MRA
tx: beta blockers, --> ICU and surgical consultation--> surgical correction
75 yo M smoker presents w/ pain in calves on exertion. dx: PAD
PE notes smooth shiny skin with hair loss. w/u: ABI (best initial), Angiography (most accurate)
dx, w/u, tx, f/u tx: best initial: ASA, ACE (for bp control), exercise, cilostazol, statins (LDL <100)-->
bypass if gangrene or resting pain.
CCBs are ineffective!
f/u: several weeks.
75 yo M w/ HTN, MI, cardiomyopathy presents to office, dx: AF vs. Aflutter
w/ palpitations. w/u: EKG, if in hospital--> tele vs. holter (if HD stable).
dx, w/u, tx in CCA: echo, thyroid, electrolytes (K, Mg, Ca), (troponins, ck-mb if acute onset)
Tx:
unstable: syncrhonized cardioversion- convert in first screen (if SBP <90, CHF,
confusion or CP)--> TEE, anticoagulate.
stable: slow ventricular rate <100 with b-blocker, ccb or dig (iv if in ED)-->
anticoagulate with warfarin for INR 2-3
ABI: 1. >= 0.9
1. what's normal 2. > 10% = obstruction
2. what's PAD
WITH PRACTICE QUESTIONS AND CCS
CASES
| GRADED A+ | GUARANTEED SUCCESS
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive
Rationales Included
,Treatment for ACS: Things that lower mortality:
ASA-- instant platelet inhibitor
PCI
thrombolytics (if can't to PCI within 90 minutes or new LBBB)
statins
Clopidogrel (esp if asa allergy)
lower mortality in some cases
ace/arb (if low EF)
don't lower mortality but should still be done:
beta blocker
o2
morphine
nitrates
Alts:
CCB: beta blocker intol, cocaine or vasospasm
PAcemaker: AV blocks or bradycardia
lidocaine/ amiodarone: VT or VF
NSTEMI: 1. LMWH
1. first line treatment 2. GPIIb/IIIa inhibitors
2. best benefit
when do you use ACE/ARBs in ischemic cardiac disease cardiac failure (e.g. chf, systolic dysfunction or low ef).
Elderly woman with SOB + rales and edema: 1.EKG, CXR, echo, oximetry, monitoring unit, ABG, BMP
1. what tests do you order? 2. O2, morphine, nitrates, furosemide
2. what meds do you order? 3. CHF exacerbation
3. most likley dx: * transfer to ICU in CCS!*
4. if still symptomatic: 4. order an inotrope (milrinone, amrinone or dobutamine).
Valvular lesion ^VR .....dec VR ..grip.. amylN Valvular lesion ^VR .....dec VR ..grip.. amylN
(effect on M). (squat) (valsalva) (effect on M). (squat) (valsalva)
AS......... ..........X ............X ..........X .........X AS ...................^ .........dec ........dec .........^
AR ......... .........X ............X ..........X .........X AR ..................^ .........dec ........dec .........^
MS ......... .........X ............X ..........X .........X MS ...................^ .........dec.......... - ...........-
MR ......... .........X ............X ..........X .........X MR .................^ ..........dec .........^.......... dec
VSD ......... .......X ............X ..........X .........X VSD.................^ ..........dec .........^.......... dec
HOCM ........ ....X ............X ..........X .........X HOCM ...........dec ........^ ...........dec......... ^
MVP ..... ..........X ............X ..........X .........X MVP ..............dec ........^ ...........dec......... ^
what is the optimal treatment for: 1. Valsalva = diuretics (AS, AR, MS, MR, VSD)= L heart murmurs
1. murmurs that improve on valsalva (and which murmurs 2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
are these?) 3. diuretics
2. murmurs that improves with amyl nitrate (and which 4. repair (baloon for MS, replace for AS)
murmurs are these?)
3. best therapy for regurgitant lesions
4. best therapy for stenotic lesions
,75 yo M with hx HTN now with chest pain/ syncope. hear Dx: AS
a crescendodecrescendo systolic murmur at the 2nd R workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
intercostal space that radiates to the carotids. also do EKG and CxR (LVH)
what is the dx, w/u, tx? treatment: Diurese, but overdiuresis is best--> valve replacement is best
75 yo M with hx HTN now with SOB/ fatigue. You hear a Dx: AR
decrescendo-crescendo diastolic murmur at the LSB workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
what is the dx, w/u, tx and other physical findings? also do EKG and CxR (LVH)
treatment: ACE/ARB, nifedipine (add loop diuretic in CCS)--> surgery if EF <55%
and LV end systolic diameter >55 mm
75 yo immigrant M now with dysphagia and afib. You hear Dx: MS
an extra sound in diastole with S1>S2. workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
what is the dx, w/u, tx and other physical findings? also do EKG and CxR (LAH- straightening of LH border and elevation of L
mainstem bronchus)
treatment: diuretics (best initial, but don't alter progression)--> balloon
valvuloplasty (incl preg women)
75 yo M w/ PMH MI now with dyspnea on exertion. You Dx: MR
hear holosystolic murmur at the apex, radiating to axilla workup: TTE (best initial test), TEE (more accurate) also do EKG and CxR
what is the dx, w/u, tx and other physical findings?
treatment: ACE/ ARBS, Nifedipine (best initial, decreases rate of progression), add
loop diuretic in CCS--> surgery if EF <60% and LV end systolic diameter >45 mm
7 yo M now with no complaints, on exam You hear Dx: VSD
holosystolic murmur at the LLSB. workup: echo first--> cath (determine degree of L-->R shunting
what is the dx, w/u, tx and other physical findings? treatment: if mild, will close on its own.
7 yo M now with no complaints, on exam You hear fixed Dx: ASD
splitting of S2. workup: ?
what is the dx, w/u, tx and other physical findings? treatment: PCI, repair when shunt ratio >1.5:1
what to think about when you hear wide splitting of S2 RBBB
with delayed P2 PS
RVH
Pulm HTN
what to think about when you hear paradoxical delayed LBBB
A2? AS
LVH
HTN
75 yo M presents w/ SOB...w/u echo first! (may reveal cardiomyopathy, etc)
dilated cardiomyopathy: etiology: EtOH, Chagas, ischemia, adriamycin, radiation
etiology, w/u, tx and other physical findings? w/u: echo
treat: ACE/ARBs, beta blockers and spironolactone
dig for symptomatic tx
, 75 yo M presents w/ SOB + S4 gallop Hypertrophic cardiomyopathy
ddx, etiology, w/u, tx and other physical findings? w/u: echo
treat: diuretics + beta blockers
75 yo M presents w/ SOB + kussmaul's sign etiology, w/u, Restrictive cardiomyopathy
tx and other physical findings? kussmaul's sign: increase in JVP on inhalation
2/2: sarcoidosis, amyloidosis, hemochromatosis, cancer, myocardial fibrosis or
glycogen storage diseasese
w/u: echo, cath (rapid x and y descent) EKG (low voltage) endomyocardial biopsy
(most accurate dx test)
treat: diuretics
pericarditis w/u: EKG (ST elev, PR depression)
w/u and tx tx: NSAIDs--> 1-2 days later reassess--> give prednisone if still symptomatic-->
reassess
SOB, low BP and JVD pericardial tamponade
pericardial tamponade w/u: EKG (electrical alternans), echo (diastolic collapse of RH), RH cath
w/u, tx (equalization of all pressures)
tx: pericardiocentesis (best initial) most effective: pericardial window
NEVER GIVE: diuretics
aortic dissection if suspicion:
w/u, tx w/u: EKG, CXR (widened mediastinum), CTA (most accurate) = TEE= MRA
tx: beta blockers, --> ICU and surgical consultation--> surgical correction
75 yo M smoker presents w/ pain in calves on exertion. dx: PAD
PE notes smooth shiny skin with hair loss. w/u: ABI (best initial), Angiography (most accurate)
dx, w/u, tx, f/u tx: best initial: ASA, ACE (for bp control), exercise, cilostazol, statins (LDL <100)-->
bypass if gangrene or resting pain.
CCBs are ineffective!
f/u: several weeks.
75 yo M w/ HTN, MI, cardiomyopathy presents to office, dx: AF vs. Aflutter
w/ palpitations. w/u: EKG, if in hospital--> tele vs. holter (if HD stable).
dx, w/u, tx in CCA: echo, thyroid, electrolytes (K, Mg, Ca), (troponins, ck-mb if acute onset)
Tx:
unstable: syncrhonized cardioversion- convert in first screen (if SBP <90, CHF,
confusion or CP)--> TEE, anticoagulate.
stable: slow ventricular rate <100 with b-blocker, ccb or dig (iv if in ED)-->
anticoagulate with warfarin for INR 2-3
ABI: 1. >= 0.9
1. what's normal 2. > 10% = obstruction
2. what's PAD
