Usmle Step 2 Medicine Quick Review

Front 1

What are the pathognomonic clinical features of stable angina?

Back 1

Substernal chest pain brought on by exertion/emotion lasting less than 10-15 minutes and relieved by rest or nitroglycerin.

Front 2

If patients have a positive exercise stress test what is the next appropriate step?

Back 2

Cardiac catheterization

Front 3

What drugs are used to perform a pharmacological stress test?

Back 3

IV adenosine, dobutamine, dipyramidole.

Front 4

What drug is indicated in all patients with a coronary artery disease?

Back 4

Aspirin

Front 5

when is a CABG indicated over PTCA?

Back 5

Indicated in patients with left main artery disease, three-vessel disease w/ reduced left ventricular function, 2-vessel disease with proximal LAD stenosis, or severe ischemia for palliation of symptoms

Front 6

What are the clinical features of unstable angina?

Back 6

1. Angina at rest
2. Chronic angina that is getting progressively worse.
3. New onset angina that is severe and worsening.

Front 7

What enzymes must be ordered in a patient with unstable angina and why?

Back 7

Troponins to rule out the possibility of an NSTEMI. These 2 present very similar clinically but are managed differently and therefore must be distinguished.

Front 8

T/F: calcium channel blockers have not been proven to be beneficial in unstable angina

Back 8

True. They are only helpful as a second line treatment for stable angina.

Front 9

Along with aspirin what other classes of drugs are considered first line therapy for treatment of unstable angina?

Back 9

1. Beta-blockers
2. LMWH - enoxaparin is the DOC.
3. Nitrates.

Front 10

What are the 7 risk factors used to calculate the TIMI score?

Back 10

1. Age > 65
2. More than 3 risk factors for CAD.
3. Known CAD
4. At least 2 episodes of severe angina in the last 24 hrs.
5. Aspirin use in the last 7 days.
6. Elevated cardiac enzymes
7. ST changes > .5mm

Front 11

What are the hallmark clinical symptoms of a myocardial infarction?

Back 11

Severe crushing substernal chest pain, greater than 30 min not relieved by rest + diaphoresis.

Front 12

What is seen very early on EKG in an MI patient?

Back 12

Hyperacute T-wave changes

Front 13

How soon after an MI do troponins increase in blood and how long do they stay in blood?

Back 13

They increase 3-5 hours after onset and return to normal in a week.

Front 14

T/F: Troponins have less sensitivity/specificity than CK-MB for myocardial injury

Back 14

False. Troponins have a greater sensitivity and specificity than CK-MB and are the gold standard for diagnosing MI.

Front 15

ST segment elevations in which leads suggest an anteroseptal MI?

Back 15

V1-V4

Front 16

ST segmenet elevations in leads II, III, and aVF suggest an MI in which portion of the heart

Back 16

Inferior

Front 17

What ST segment changes suggest a posterior wall MI?

Back 17

ST depression in V1-V2 with a large R and large T wave in V1-V2.

Front 18

Which classes of drugs are the only ones show to decrease mortality in patients with MI?

Back 18

Aspirin, Beta-blockers, and ACE inhibitors.

Front 19

If there are no contraindications what treatment should be administered ASAP for patients with acute MI?

Back 19

thrombolytic therapy

Front 20

What are the contraindications for thrombolytic therapy?

Back 20

1. Uncontrolled HTN
2. Trauma
3. Previous stroke
4. Recent invasive procedure or surgery
5. Dissecting aortic aneurysm
6. Active peptic ulcer disease
7. Patient who is having a NSTEMI.

Front 21

What therapy is indicated in patients with MI who are contraindicated for thrombolytic therapy?

Back 21

PTCA

Front 22

What is the most common cause of death in MI patients?

Back 22

Vfib

Front 23

What does a repeat ST elevation on EKG 24 hours after a recent MI indicate

Back 23

recurrent infarction.

Front 24

what is the treatment for a free wall rupture of the heart post-MI

Back 24

hemodynamic stabilization, pericardiocentesis, and surgical repair.

Front 25

Papillary muscle rupture in an MI patient can lead to what valvular abnormality?

Back 25

Mitral regurgitation.

Front 26

What drugs are contraindicated in patients with acute pericarditis post-MI

Back 26

NSAIDS and corticosteroids.

Front 27

What is the treatment for Dressler's syndrome?

Back 27

Aspirin

Front 28

What is the most common cause of systolic congestive heart failure?

Back 28

Myocardial Infarction

Front 29

What is the most common cause of diastolic heart failure?

Back 29

Myocardial hypertrophy 2dary to HTN.

Front 30

What are the characteristic clinical symptoms of CHF?

Back 30

dsypnea
orthopnea
PND

Front 31

What is the most common cause of right sided heart failure?

Back 31

Left sided heart failure

Front 32

Fill in the blank:

____ are short horizontal lines seen near the periphery of the lung near the costophrenic angle on a CXR. They indicate pulmonary congestion

Back 32

Kerley B lines

Front 33

What is the initial test of choice for evaluating someone with suspected CHF?

Back 33

Echocardiogram

Front 34

Patients with systolic heart failure typically have an ejection fraction less than what %

Back 34

40-45%

Front 35

The initial treatment in all patients with symptomatic CHF includes what classes of drugs?

Back 35

Diuretics (preferably a loop diuretic) and an ACE inhibitor

Front 36

What class of drug is indicated in all patients with CHF

Back 36

ACE inhibitor

Front 37

which class of drug has been shown to reduce mortality and is therefore indicated in patients with post-MI CHF?

Back 37

Beta-Blockers

Front 38

What is the INR goal range for someone on anticoagulation and what is the one exception to this?

Back 38

2-3. However, if the patient is on anticoagulation s/p heart valve replacement then the goal range is 2.5-3.5

Front 39

If a patient with Afib is hemodynamically unstable what is the next step?

Back 39

Immediate electrical cardioversion

Front 40

If a patient with Afib is hemodynamically stable and has a ventricular rate of 150 what is the next step.

Back 40

Rate control with CCB or beta-blockers.

Front 41

what is the INR goal range in a patient who you are treating for Afib with anticoagulation?

Back 41

2-3

Front 42

What are the indications for electrical cardioversion in a patient with a dysrhythmia?

Back 42

Afib, Atrial flutter, VTach (w/ pulse), SVT

Front 43

What are the indications for defribillation in a patient with a dysrhythmia?

Back 43

Vfib, VTach (w/o pulse)

Front 44

What are the indications for autonomic implantable defribrillator in a patient with an arrhythmia?

Back 44

VFib and/or VTach unresponsive to medical therapy

Front 45

What are the indications for anticoagulation in a patient with acute Afib

Back 45

Afib longer than 48 hours or for an unknown amount of time.
Afib with a thrombus present on TEE.

Front 46

What test is required for a definitive diagnosis of hepatocellular carcinoma?

Back 46

-Liver biopsy

Front 47

Which tumor marker is elevated in hepatocellular carcinoma?

Back 47

-AFP

Front 48

Which enzyme shows decreased activity in patients with Gilbert's Syndrome?

Back 48

-UDPGT

Front 49

What is the only elevated marker in Gilbert's Syndrome?

Back 49

-Unconjugated bilirubin

Front 50

Is the serum-ascites albumin gradient above or below 1.1 g/dL in a patient with Budd-Chiari?

Back 50

-Above

Front 51

What is the best diagnostic test for a patient with Budd-Chiari syndrome?

Back 51

-Hepatic venogram

Front 52

What is the treatment for a patient with Budd-Chiari syndrome?

Back 52

-Surgery with placement of a stent in IVC.

Front 53

Which type of bilirubin is more toxic, conjugated or unconjugated? Why?

Back 53

-Unconjugated because it can cross the BBB and cause neurological damage and also cannot be excreted in the urine.

Front 54

T/F: conjugated bilirubin can be excreted in the urine.

Back 54

-True. Unconjugated bilirubin cannot.

Front 55

If ALT & AST are elevated in the low hundreds what are the most likely causes?

Back 55

chronic viral hepatitis, or acute alcoholic hepatitis

Front 56

If ALT & AST are moderately elevated in the hundreds to thousands what are the most likely causes?

Back 56

Acute viral hepatitis

Front 57

If ALT & AST are elevated above 10,000 what are the most likely causes?

Back 57

hepatic necrosis either from:
1. ischemic liver disease
2. Acetaminophen toxicity
3. Severe viral hepatitis

Front 58

Alkaline phosphatase is an enzyme not specific to the liver. where else can it be found?

Back 58

Bone, gut, and placenta

Front 59

What other lab value should be measured to confirm whether an elevation of alkaline phosphatase is biliary in origin?

Back 59

GGT

Front 60

A positive Boa's sign is suggestive of what disease?

Back 60

cholelithiasis

Front 61

What is the best diagnostic test for cholelithiasis?

Back 61

Ultrasound

Front 62

how is the pain of cholelithiasis different from the pain of acute cholecystitis?

Back 62

Cholelithiasis: pain is colicky and precipitated by meals or at night and the pain resolves after some time.

Acute cholecystitis: the pain is constant and not related to food and also can radiate to the right scapula/shoulder.

Front 63

What is Murphy's sign? What does it indicate?

Back 63

Murphy's sign is arrest of inspiraition during palpation of the RUQ. This sign is pathognomonic for acute cholecystitis.

Front 64

What is the gold standard test for choledocolithiasis?

Back 64

ERCP