USMLE STEP 3 EXAM QUESTIONS AND
ANSWERS 100% PASS.
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
2026 STUDY MATERIAL @COPYRIGHT RESERVED 1
,2. treat first
3. ASA
4. CK-MB, troponins, stress test, echo, angiography
5. CK-MB
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:
1. first line treatment
2026 STUDY MATERIAL @COPYRIGHT RESERVED 2
,2. best benefit - ANS 1. LMWH
2. 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:
1. what tests do you order?
2. what meds do you order?
3. most likley dx:
4. if still symptomatic: - ANS 1.EKG, CXR, echo, oximetry, monitoring unit, ABG, BMP
2. O2, morphine, nitrates, furosemide
3. CHF exacerbation
** transfer to ICU in CCS!**
4. 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.......... - ...........-
2026 STUDY MATERIAL @COPYRIGHT RESERVED 3
, MR .................^ ..........dec .........^.......... dec
VSD.................^ ..........dec .........^.......... dec
HOCM ...........dec ........^ ...........dec......... ^
MVP ..............dec ........^ ...........dec......... ^
what is the optimal treatment for:
1. murmurs that improve on valsalva (and which murmurs are these?)
2. murmurs that improves with amyl nitrate (and which murmurs are these?)
3. best therapy for regurgitant lesions
4. best therapy for stenotic lesions - ANS 1. Valsalva = diuretics (AS, AR, MS, MR, VSD)= L
heart murmurs
2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
3. diuretics
4. 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
2026 STUDY MATERIAL @COPYRIGHT RESERVED 4
ANSWERS 100% PASS.
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
2026 STUDY MATERIAL @COPYRIGHT RESERVED 1
,2. treat first
3. ASA
4. CK-MB, troponins, stress test, echo, angiography
5. CK-MB
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:
1. first line treatment
2026 STUDY MATERIAL @COPYRIGHT RESERVED 2
,2. best benefit - ANS 1. LMWH
2. 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:
1. what tests do you order?
2. what meds do you order?
3. most likley dx:
4. if still symptomatic: - ANS 1.EKG, CXR, echo, oximetry, monitoring unit, ABG, BMP
2. O2, morphine, nitrates, furosemide
3. CHF exacerbation
** transfer to ICU in CCS!**
4. 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.......... - ...........-
2026 STUDY MATERIAL @COPYRIGHT RESERVED 3
, MR .................^ ..........dec .........^.......... dec
VSD.................^ ..........dec .........^.......... dec
HOCM ...........dec ........^ ...........dec......... ^
MVP ..............dec ........^ ...........dec......... ^
what is the optimal treatment for:
1. murmurs that improve on valsalva (and which murmurs are these?)
2. murmurs that improves with amyl nitrate (and which murmurs are these?)
3. best therapy for regurgitant lesions
4. best therapy for stenotic lesions - ANS 1. Valsalva = diuretics (AS, AR, MS, MR, VSD)= L
heart murmurs
2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
3. diuretics
4. 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
2026 STUDY MATERIAL @COPYRIGHT RESERVED 4
