Usmle Step 2 Secrets

Front 1

What's your job when the step 2 exam describes a pt with chest pain?

Back 1

Do what you have to do to rule out an MI

Front 2

What elements of the H & P steer you away from an MI Dx?

Back 2

Wrong age (any pt under 40 in the absence of known heart dz, strong FmHx, or multiple risk factors)
Lack of Risk Factors (if their only one is age, and otherwise healthy, probably not MI)
Physical char of pain; if reproducible by palpation, MI pain shouldn't be sharp or well localized

Front 3

What EKG findings should make you suspect an MI?

Back 3

Flipped or flattened T waves, ST segment elevation (depression means ischemia, elevation means injury), and/or Q waves in a segmental distribution

Front 4

Describe the classic pattern of chest pain in an MI?

Back 4

Classically crushing or pressure sensation, poorly localized substernal that may radiate to shoulder, arm, or jaw. Usually not reproducible on palpation, and often doesn't resolve with Nitro. Usually lasts at least half an hour

Front 5

What tests are used to Dx an MI?

Back 5

EKG, Serial CK-MB, Troponin, or myoglobin. Echo may show ventribular wall motion abnormalities

Front 6

Describe the classic physical exam findings in pts with MI?

Back 6

Diaphoretic, anxious, tachycardic, tachypneic, and pale, may have N/V. With larger heart attacks that cause heart failure, look for bilateral pulmonary rales in absence of other pneumonia like Sx, distended neck veins, S3 or S4, new murmurs, hypotension, and/or shock

Front 7

What historical points should steer you toward Dx of MI?

Back 7

Hx of angina, murmurs, arrhythmias, risk factors for CAD, HTN, or DM. May also be taking digoxin, furosemide, cholesterol, or other meds

Front 8

Describe Tx for an MI?

Back 8

Early thrombolysis (under 6 hrs from pain onset) or PTCA or CABG if not thrombolysis.
EKG monitoring, O2, Control pain with morphine, Nitro, Beta Blockers, ASA, consider an ACE and a statin acutely

Front 9

When is heparin indicated in the setting of chest pain and MI?

Back 9

Should be started if unstable angina is Dx, if pt has a cardiac thrombus, or if severe CHF is seen on echo.

Front 10

Clues that suggest Pericarditis instead of MI?

Back 10

Look for viral URI prodrome, EKG shows diffuse ST-segment elevation, sed rate is elevated, and a low-grade fever is present. Classically the pain is relieved by sitting forward.

Front 11

Most common cause of pericarditis infection?

Back 11

Coxsackievirus. Others include TB, uremia, malignancy, and SLE or other autoimmune dzs

Front 12

Describe Prinzmetal's angina?

Back 12

Rare angina char by pain at rest and ST elevation. Cardiac enzymes are normal, and the cause is coronary artery spasm. Usually it responds to Nitro, and is Tx over long term with Ca channel blockers

Front 13

Define silent MI, and how common it is?

Back 13

They don't devp chest pain, they present with CHF, shock, or confusion and delirium (esp in elderly). MIs are silent in up to 25% of cases

Front 14

PE findings with Mitral stenosis?

Back 14

Late diastolic blowing murmur (best heard at apex). Also opening snap, loud S1, AF, LAE, and PH

Front 15

PE findings with Mitral regurg?

Back 15

Holosystolic murmur (radiates to axilla). Also, soft S1, LAE, PH, LVH

Front 16

Aortic Stenosis Physical char?

Back 16

Harsh systolic ejection murmurs (best heard in aortic area, radiates to carotids). Also, slow pulse upstroke, S3/S4, ejection click, LVH, cardiomegaly, syncope, angina, heart failure

Front 17

Aortic Regurg Physical char?

Back 17

Early diastolic decrescendo murmur (best heard at apex). Also widened pulse pressure, LVH, LV dilatation, and S3

Front 18

Mitral Prolapse Physical char?

Back 18

Midsystolic click, late systolic murmur. Also panic disorder

Front 19

Who should receive endocarditis prophylaxis?

Back 19

People with known valvular heart dz, or prosthetic valves. In pts with MVP, use only if murmur is heard on PE, or if Hx of previous endocarditis

Front 20

What are the protocols for endocarditis prophylaxis?

Back 20

For oral surgery: amoxicillin before and after, clinda or azithro may be substituted for PCN allergy. For GI or GU procedures: Ampicillin + Gentamicin before and amoxicillin after, can sub vanco for PCN allergy

Front 21

What's Virchow's triad?

Back 21

Endothelial damage, venous stasis, and hypercoagulability, all assoc with DVT

Front 22

Common clinical scenarios for dev't of DVT?

Back 22

surgery, malignancy, trauma, immobilization, pregnancy, birth control pills, DIC, hematologic disorders

Front 23

S/Sx of DVT?

Back 23

Unilateral leg swelling, pain, tenderness, and/or + Homan's (in about 30%). Best Dx by dopplar US, gold standard is venography