Master the board step 3

Master the Boards: USMLE Step 3
Restrictive Cardiomyopathy
Restrictive cardiomyopathy presents with a history of sarcoidosis, amyloidosis,
hemochromatosis, cancer, myocardial fibrosis, or glycogen storage
diseases. Shortness of breath is the main presenting complaint in all forms
of cardiomyopathy. Kussmaul’s sign is present: this is an increase in jugular
venous pressure on inhalation.
Amyloid
••
Low-voltage EKG
••
Speckled pattern on echo
Diagnostic Testing
Cardiac catheterization shows rapid x and y descent. The EKG shows low voltage.
Echocardiography is the mainstay of diagnosis. Endomyocardial biopsy
is the single most accurate diagnostic test of the etiology.
Treatment
Diuretics and correcting the underlying cause are the best treatments.
Pericardial Disease
Pericarditis
Chest pain that is pleuritic (changes with respiration) and positional (relieved
by sitting up and leaning forward) is the presentation that is most often given
on Step 3. The pain will be described as sharp and brief. Ischemic pain is dull
and sore, like being punched. The vast majority of pericarditis cases are viral.
Although any infectious agent, collagen-vascular disease, or trauma can be in
the history, remember that Step 3 most often hands you a clear diagnosis and
asks what you want to do about it, such as testing and treatment.
Physical Exam
The only pertinent positive finding is a friction rub, which can have 3 components.
The rub is only present in 30 percent of patients. There is no pulsus
paradoxus, tenderness, edema, or Kussmaul’s sign present. Blood pressure is
normal, and there is no jugular venous distention or organomegaly.
Diagnostic Testing
The best initial test is the EKG. ST segment elevation is present everywhere
(all leads). PR segment depression is pathognomonic in lead II, but is not
always present.
Treatment
The best initial therapy is an NSAID, such as indomethacin, naproxen, aspirin,
or ibuprofen. Advance the clock 1–2 days and have the patient visit the office.
If the pain persists, add prednisone orally to the treatment and advance the
clock 1–2 more days. Colchicine adds efficacy to steroids.
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