Internal Medicine Review ABIM Part 1 Questions
And Answers
What is a positive stress test Correct Answer: Flat or Down sloping
St-segment depression >1 mm
Occurring 80 msec after j point
When to stop a stress test Correct Answer: St segment depression > 2 mm,
Ventricular tachycardia,
Drop in SBP > 15,
CP,
Dyspnea,
Lightheadedness
Stress test of choice with a LBBB or ventricular pacing? Correct Answer: Myocardial perfusion
imaging with adenosine,
NOT exercising!
When to not use doutamine for stress Correct Answer: History of VT,
Severe HTN,
Low BP,
Poor echo images
When to not use adenosine for stress Correct Answer: Bronchospasm,
Severe valvular dysfunction,
Severe carotid stenosis,
2nd degree heart block, t
Heophylline dependent
Normals for PA catheter pressures Correct Answer: RA <8
RV 30/8
PCWP 3-12
PAP 12--12
Diastolic pressures
Elevated & equalized
In all chambers,
Low BP Correct Answer: tamponade
Or restrictive pericarditis
Elevated RA and PA pressures,
Decreased or nl PCWP,
Hypotension Correct Answer: RV MI
Elevated PCWP, RA pressure
Decreased SBP/cardiac output Correct Answer: cardiogenic shock
,High RA,
PA very elevated
High PCWP
Nl SBP Correct Answer: mitral stenosis with RV failure
Elevated PAP, RAP
Nl PCWP, SBP Correct Answer: pulmonary HTN
Decr in SBP>10mmhg with nl inspiration;
Palpated as weakened pulse with inspiration &
More heart contractions to pulse beats Correct Answer: pulsus paradoxus:
Constrictive or restrictive pericarditis,
Asthma,
Tension pneumothorax
What gives you pulsus bisferiens
(two systolic peaks per cycle) Correct Answer: Aortic regurgitation,
HOCM
What causes pulsus alternans Correct Answer: Severe LV dysfunction
What causes pulsus tardus Correct Answer: Aortic stenosis
How do positional maneuvers affect blood flow and murmurs Correct Answer: -standing/valsalva:
Decreased cardiac filling,
Decreases most murmurs
Except MVP and HOCM
-squatting/ lying down:
Increase cardiac volume,
Increased murmurs
Except MVP, HOCM
-sustained handgrip:
Increases systemic resistance
Decreases murmur in HOCM, AS
What causes a physiologic split S2 Correct Answer: Increased blood volume in the RV
Prolongs systole and
Delays pulmonary valve closure
What causes a fixed split S2 Correct Answer: Pulmonary stenosis,
PE,
LV pacer,
RBBB,
MR (early AV closure),
ASD,
RV failue
What causes a paradoxic split S2 Correct Answer: LBBB,
,RV pacing,
HOCM
What causes an S3? Correct Answer: Rapid LV filling:
Acute ventricular decompensation,
Severe AR or MR
What are the parts of the venous waveform? Correct Answer: A wave - atrial contraction
X descent - atria relax, RV fills rapidly
Bottom of x descent is TC valve closure
V wave - ventricle contacting against closed TC valve
Y descent - TC valve opens,
Passive emptying into ventricle
What gives elevated a and v waves Correct Answer: Pulmonary HTN,
RV infarction
Large r side v waves Correct Answer: Septal rupture
Large v waves Correct Answer: TR (right),
MR (left)
Rapid x and y descent Correct Answer: Constrictive pericarditis,
Restrictive cardiomyopathy,
Tamponade
(x descent only, loss of y descent)
Large a waves Correct Answer: TS,
Severe RVH (on right),
MS
Cannon a waves Correct Answer: AV disassociation -
Complete heart block,
Ventricular pacing
Slow Y descent Correct Answer: Delayed atrial emptying - TS
Most important prognostic factor with CAD Correct Answer: Degree of LV dysfunction
Causes of resting ST elevation Correct Answer: MI,
Pericarditis,
LV aneurysm,
LBBB,
Ventricular pacing,
LVH,
Early repolarization
, Hibernating myocardium Correct Answer: myocardium near the infarction may be underperfused but
not necrotic-
The metabolism of the cells adapts to low energy supplies & are nonfunctional
Until perfusion is restored
Reperfusion injury Correct Answer: the re-estab of blood flow after a coronary artery is blocked,
Which may further damage the heart tissue due to the formation of O2 free radicals
Stunned myocardium Correct Answer: prolonged post ischemic dysfunction,
Salvaged by reperfusion,
Several days
NSTEMI have _____ initial mortality,
But have the _____ one year mortality as a STEMI Correct Answer: Lower,
Same
NSTEMI have a higher risk of these vs. STEMI Correct Answer: Persistent angina,
Reinfarction, and
Death within several months
MR due to papillary muscle rupture is most common with MI in this region Correct Answer: Inferior
Types of arrythmias with IWMI Correct Answer: Junctional escape,
Mobitz I,
And they are usually temporary
Types of arrythmias with AWMI Correct Answer: Mobitz II,
BBB.
More of the myocardium is involved
Contraindications for B-blockers Correct Answer: Bradycardia, hypotension,
2nd or 3rd degree AVB,
Pulmonary edema,
Asthma.
NOT DM
When to use non-dihydropyridne ccbs in ACS Correct Answer: Contraindications to B blockers,
Continued ischemia,
But NO LV dysfunction
When to use fibrinolytics in ACS Correct Answer: Not with UA/NSTEMI:
Increases mortality
Use in STEMI,
New LBBB if no contraindications
And immediate PCI not available
What to give pt with UA/NSTEMI Correct Answer: Plavix
Lipid and BP control
DC nsaids except ASA
And Answers
What is a positive stress test Correct Answer: Flat or Down sloping
St-segment depression >1 mm
Occurring 80 msec after j point
When to stop a stress test Correct Answer: St segment depression > 2 mm,
Ventricular tachycardia,
Drop in SBP > 15,
CP,
Dyspnea,
Lightheadedness
Stress test of choice with a LBBB or ventricular pacing? Correct Answer: Myocardial perfusion
imaging with adenosine,
NOT exercising!
When to not use doutamine for stress Correct Answer: History of VT,
Severe HTN,
Low BP,
Poor echo images
When to not use adenosine for stress Correct Answer: Bronchospasm,
Severe valvular dysfunction,
Severe carotid stenosis,
2nd degree heart block, t
Heophylline dependent
Normals for PA catheter pressures Correct Answer: RA <8
RV 30/8
PCWP 3-12
PAP 12--12
Diastolic pressures
Elevated & equalized
In all chambers,
Low BP Correct Answer: tamponade
Or restrictive pericarditis
Elevated RA and PA pressures,
Decreased or nl PCWP,
Hypotension Correct Answer: RV MI
Elevated PCWP, RA pressure
Decreased SBP/cardiac output Correct Answer: cardiogenic shock
,High RA,
PA very elevated
High PCWP
Nl SBP Correct Answer: mitral stenosis with RV failure
Elevated PAP, RAP
Nl PCWP, SBP Correct Answer: pulmonary HTN
Decr in SBP>10mmhg with nl inspiration;
Palpated as weakened pulse with inspiration &
More heart contractions to pulse beats Correct Answer: pulsus paradoxus:
Constrictive or restrictive pericarditis,
Asthma,
Tension pneumothorax
What gives you pulsus bisferiens
(two systolic peaks per cycle) Correct Answer: Aortic regurgitation,
HOCM
What causes pulsus alternans Correct Answer: Severe LV dysfunction
What causes pulsus tardus Correct Answer: Aortic stenosis
How do positional maneuvers affect blood flow and murmurs Correct Answer: -standing/valsalva:
Decreased cardiac filling,
Decreases most murmurs
Except MVP and HOCM
-squatting/ lying down:
Increase cardiac volume,
Increased murmurs
Except MVP, HOCM
-sustained handgrip:
Increases systemic resistance
Decreases murmur in HOCM, AS
What causes a physiologic split S2 Correct Answer: Increased blood volume in the RV
Prolongs systole and
Delays pulmonary valve closure
What causes a fixed split S2 Correct Answer: Pulmonary stenosis,
PE,
LV pacer,
RBBB,
MR (early AV closure),
ASD,
RV failue
What causes a paradoxic split S2 Correct Answer: LBBB,
,RV pacing,
HOCM
What causes an S3? Correct Answer: Rapid LV filling:
Acute ventricular decompensation,
Severe AR or MR
What are the parts of the venous waveform? Correct Answer: A wave - atrial contraction
X descent - atria relax, RV fills rapidly
Bottom of x descent is TC valve closure
V wave - ventricle contacting against closed TC valve
Y descent - TC valve opens,
Passive emptying into ventricle
What gives elevated a and v waves Correct Answer: Pulmonary HTN,
RV infarction
Large r side v waves Correct Answer: Septal rupture
Large v waves Correct Answer: TR (right),
MR (left)
Rapid x and y descent Correct Answer: Constrictive pericarditis,
Restrictive cardiomyopathy,
Tamponade
(x descent only, loss of y descent)
Large a waves Correct Answer: TS,
Severe RVH (on right),
MS
Cannon a waves Correct Answer: AV disassociation -
Complete heart block,
Ventricular pacing
Slow Y descent Correct Answer: Delayed atrial emptying - TS
Most important prognostic factor with CAD Correct Answer: Degree of LV dysfunction
Causes of resting ST elevation Correct Answer: MI,
Pericarditis,
LV aneurysm,
LBBB,
Ventricular pacing,
LVH,
Early repolarization
, Hibernating myocardium Correct Answer: myocardium near the infarction may be underperfused but
not necrotic-
The metabolism of the cells adapts to low energy supplies & are nonfunctional
Until perfusion is restored
Reperfusion injury Correct Answer: the re-estab of blood flow after a coronary artery is blocked,
Which may further damage the heart tissue due to the formation of O2 free radicals
Stunned myocardium Correct Answer: prolonged post ischemic dysfunction,
Salvaged by reperfusion,
Several days
NSTEMI have _____ initial mortality,
But have the _____ one year mortality as a STEMI Correct Answer: Lower,
Same
NSTEMI have a higher risk of these vs. STEMI Correct Answer: Persistent angina,
Reinfarction, and
Death within several months
MR due to papillary muscle rupture is most common with MI in this region Correct Answer: Inferior
Types of arrythmias with IWMI Correct Answer: Junctional escape,
Mobitz I,
And they are usually temporary
Types of arrythmias with AWMI Correct Answer: Mobitz II,
BBB.
More of the myocardium is involved
Contraindications for B-blockers Correct Answer: Bradycardia, hypotension,
2nd or 3rd degree AVB,
Pulmonary edema,
Asthma.
NOT DM
When to use non-dihydropyridne ccbs in ACS Correct Answer: Contraindications to B blockers,
Continued ischemia,
But NO LV dysfunction
When to use fibrinolytics in ACS Correct Answer: Not with UA/NSTEMI:
Increases mortality
Use in STEMI,
New LBBB if no contraindications
And immediate PCI not available
What to give pt with UA/NSTEMI Correct Answer: Plavix
Lipid and BP control
DC nsaids except ASA
