USMLE STEP 3 UPDATED STUDY GUIDE QUESTIONS AND
CORRECT ANSWERS
C
Clues to ischemic disease dull pain
15-30 minutes
occurs on exertion
substernal
radiates to jaw or left arm
PE findings for ischemic chest pain S3 (dilated LV)
S4 (hypertrophic LV)
holosystolic murmur (MR)
JVD
Rales (CHF)
Edema
Gen: distressed, SOB, clutching chest.
MI: diagnostic testing: 1. EKG
1. first test to do: 2. treat first
2. if choosing between testing and treatment: 3. ASA
3. first treatment to give: 4. CK-MB, troponins, stress test, echo, angiography
4. Other tests to do: 5. CK-MB
5. most accurate test:
, 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 2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
murmurs 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. Dx: AS
hear a crescendodecrescendo systolic murmur at the workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
2nd R 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
CORRECT ANSWERS
C
Clues to ischemic disease dull pain
15-30 minutes
occurs on exertion
substernal
radiates to jaw or left arm
PE findings for ischemic chest pain S3 (dilated LV)
S4 (hypertrophic LV)
holosystolic murmur (MR)
JVD
Rales (CHF)
Edema
Gen: distressed, SOB, clutching chest.
MI: diagnostic testing: 1. EKG
1. first test to do: 2. treat first
2. if choosing between testing and treatment: 3. ASA
3. first treatment to give: 4. CK-MB, troponins, stress test, echo, angiography
4. Other tests to do: 5. CK-MB
5. most accurate test:
, 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 2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
murmurs 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. Dx: AS
hear a crescendodecrescendo systolic murmur at the workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate),
2nd R 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
