USMLE step 3 Study Guide

USMLE step 3 Study Guide

Clues to ischemic disease (Ans- dull pain 15-30 minutes occurs on exertion substernal radiates to jaw or left arm

PE findings for ischemic chest pain (Ans- S3 (dilated LV) S4 (hypertrophic LV) holosystolic murmur (MR) JVD Rales (CHF) Edema

Gen: distressed, SOB, clutching chest.

MI: diagnostic testing:

1. first test to do:

2. if choosing between testing and treatment:

3. first treatment to give:

4. Other tests to do:

5. most accurate test:

(Ans-

1. EKG

• treat first

3. ASA

• CK-MB, troponins, stress test, echo, angiography

5. CK-MB

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Treatment for ACS:

(Ans-

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:

• first line treatment
• best benefit

(Ans-

1. LMWH

• GPIIb/IIIa inhibitors

when do you use ACE/ARBs in ischemic cardiac disease (Ans- cardiac failure (e.g. chf, systolic dysfunction or low ef).

elderly woman with SOB + rales and edema:

• what tests do you order? 2 / 4

• what meds do you order?

3. most likley dx:

4. if still symptomatic:

(Ans- 1.EKG, CXR, echo, oximetry, monitoring unit, ABG, BMP

• O2, morphine, nitrates, furosemide
• CHF exacerbation

** transfer to ICU in CCS!**

• order an inotrope (milrinone, amrinone or dobutamine).

Valvular lesion ^VR .....dec VR ..grip.. amylN (effect on M). (squat) (valsalva)

AS......... ..........X ............X ..........X .........X

AR ......... .........X ............X ..........X .........X

MS ......... .........X ............X ..........X .........X

MR ......... .........X ............X ..........X .........X

VSD ......... .......X ............X ..........X .........X

HOCM ........ ....X ............X ..........X .........X

MVP ..... ..........X ............X ..........X .........X

(Ans- Valvular lesion ^VR .....dec VR ..grip.. amylN (effect on M). (squat) (valsalva) AS ...................^ .........dec ........dec .........^ AR ..................^ .........dec ........dec .........^ MS ...................^ .........dec.......... - ...........- MR .................^ ..........dec .........^.......... dec VSD.................^ ..........dec .........^.......... dec HOCM ...........dec ........^ ...........dec......... ^ MVP ..............dec ........^ ...........dec......... ^

what is the optimal treatment for:

• murmurs that improve on valsalva (and which murmurs are these?)
• murmurs that improves with amyl nitrate (and which murmurs are

these?)

• best therapy for regurgitant lesions
• best therapy for stenotic lesions 3 / 4

(Ans-

• Valsalva = diuretics (AS, AR, MS, MR, VSD)= L heart murmurs
• amyl nitrate = ACE inhibitor (AR, MR, VSD)
• diuretics
• repair (baloon for MS, replace for AS)

75 yo M with hx HTN now with chest pain/ syncope. hear a crescendodecrescendo systolic murmur at the 2nd R intercostal space that radiates to the carotids.what is the dx, w/u, tx?

(Ans- Dx: AS

workup: TTE (best initial test), TEE (more accurate) L heart cath (most

accurate), also do EKG and CxR (LVH)

treatment: Diurese, but overdiuresis is best--> valve replacement is best

75 yo M with hx HTN now with SOB/ fatigue. You hear a decrescendo- crescendo diastolic murmur at the LSB what is the dx, w/u, tx and other physical findings?

(Ans- Dx: AR

workup: TTE (best initial test), TEE (more accurate) L heart cath (most

accurate), 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 an extra sound in diastole with S1>S2.what is the dx, w/u, tx and other physical findings?

(Ans- Dx: MS

workup: TTE (best initial test), TEE (more accurate) L heart cath (most

accurate), 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)

• / 4