A 57-year-old otherwise healthy male presents to his primary care physician for a check-up. He has no complaints. His blood pressure at the previous visit was 160/95. The patient did not wish to be on any medications and at the time attempted to manage his blood pressure with diet and exercise. On repeat measurement of blood pressure today, the reading is 163/92. His physician decides to prescribe a medication which the patient agrees to take. The patient calls his physician 6 days later complaining of a persistent cough, but otherwise states that his BP was measured as 145/85 at a local pharmacy. Which of the following is a contraindication to this medication?

Bilateral renal artery stenosis

Chronic obstructive pulmonary disease

A 56-year-old woman comes to the physician for follow-up after a measurement of elevated blood pressure at her last visit three months ago. She works as a high school teacher at a local school. She says that she mostly eats cafeteria food and take-out. She denies any regular physical activity. She does not smoke or use any recreational drugs. She drinks 2 to 3 glasses of wine per day. She has hypercholesterolemia for which she takes atorvastatin. Her height is 165 cm (5 ft 5 in), weight is 82 kg (181 lb), and BMI is 30.1 kg/m2. Her pulse is 67/min, respirations are 18/min, and blood pressure is 152/87 mm Hg on the right arm and 155/92 mm Hg on the left arm. She would like to try lifestyle modifications to improve her blood pressure before considering pharmacologic therapy. Which of the following lifestyle modifications is most likely to result in the greatest reduction of this patient's systolic blood pressure?

Losing 15 kg (33 lb) of body weight

Walking for 30 minutes, 5 days per week

Reducing sodium intake to less than 2.4 g per day

Decreasing alcohol consumption to maximum of one drink per day

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 62-year-old man with a past medical history of previous myocardial infarction, angina, hypertension, hyperlipidemia, diabetes mellitus, peripheral vascular disease, and below knee amputation has developed new chest pain. His medication includes insulin, hydrochlorothiazide, lisinopril, metoprolol, daily aspirin, atorvastatin, and nitroglycerin as needed. His vitals include: blood pressure 135/87 mm Hg, pulse 52/min, and respirations 17/min. Coronary arteriography shows a reduced ejection fraction, a 65% stenosis of the left anterior descending artery, and a 75% stenosis of the left circumflex artery. Which of the following is the recommended treatment for the patient?

Coronary artery bypass grafting (CABG)

Angioplasty with stent placement

Extended release nitrate therapy

An 80-year-old man presents to the emergency department because of gnawing substernal chest pain that started an hour ago and radiates to his neck and left jaw. A 12-lead ECG is obtained and shows ST-segment elevation with newly developing Q waves. He is admitted for treatment. 4 days after hospitalization he suddenly develops altered mental status, and his blood pressure falls from 115/75 mm Hg to 80/40 mm Hg. Physical examination shows jugular venous distention, pulsus paradoxus, and distant heart sounds. What is the most likely cause of this patient's condition?

Compression of heart chambers by blood in the pericardial space

Arrhythmia caused by ventricular fibrillation

Acute pulmonary edema from left heart failure

A 69-year-old man is scheduled to undergo radical retropubic prostatectomy for prostate cancer in 2 weeks. He had a myocardial infarction at the age of 54 years. He has a history of GERD, unstable angina, hyperlipidemia, and severe osteoarthritis in the left hip. He is unable to climb up stairs or walk fast because of pain in his left hip. He had smoked one pack of cigarettes daily for 30 years but quit 25 years ago. He drinks one glass of wine daily. Current medications include aspirin, metoprolol, lisinopril, rosuvastatin, omeprazole, and ibuprofen as needed. His temperature is 36.4°C (97.5°F), pulse is 90/min, and blood pressure is 136/88 mm Hg. Physical examination shows no abnormalities. A 12-lead ECG shows Q waves and inverted T waves in leads II, III, and aVF. His B-type natriuretic protein is 84 pg/mL (N < 125). Which of the following is the most appropriate next step in management to assess this patient's perioperative cardiac risk?

Radionuclide myocardial perfusion imaging

24-hour ambulatory ECG monitoring

A 57-year-old man presents to his primary care provider because of chest pain for the past 3 weeks. The chest pain occurs after climbing more than 2 flight of stairs or walking for more than 10 minutes and resolves with rest. He is obese, has a history of type 2 diabetes mellitus, and has smoked 15-20 cigarettes a day for the past 25 years. His father died from a myocardial infarction at 52 years of age. Vital signs reveal a temperature of 36.7 °C (98.06°F), a blood pressure of 145/93 mm Hg, and a heart rate of 85/min. The physical examination is unremarkable. Which of the following best represents the most likely etiology of the patient’s condition?

Fixed, atherosclerotic coronary stenosis (> 70%)

Hypertrophy of the interventricular septum

Multivessel atherosclerotic disease with or without a nonocclusive thrombus

Intermittent coronary vasospasm with or without coronary atherosclerosis

Sudden disruption of an atheromatous plaque, with a resulting occlusive thrombus

Cardiac rehabilitation for USMLE Step 3: High-Yield Internal Medicine Lessons

Cardiac Rehab - The Comeback Trail

Goal: Restore optimal physiological, psychological, and vocational functioning.
Core Components:
- Exercise: Supervised, progressive aerobic & resistance training. Goal: 30-60 mins, 3-5 days/wk.
- Education: On risk factors (lipids, BP, diabetes), nutrition (DASH/Med diet), and medication adherence.
- Counseling: Stress management, depression screening, and psychosocial support.
Indications: Post-MI, CABG, PCI, stable angina, stable systolic HF, valve repair/replacement.
Contraindications: Unstable angina, decompensated HF, uncontrolled arrhythmias, severe aortic stenosis.

⭐ Participation in cardiac rehab is associated with a ~25% reduction in mortality.

Cardiac Rehab Enrollment & Completion in Medicare

Phases of Rehab - The Rehab Roadmap

Cardiac rehab is a structured, multi-phase program designed to optimize cardiovascular health after a cardiac event. It progresses from inpatient care to long-term independent maintenance.

⭐ High-Yield Fact: Participation in cardiac rehabilitation is associated with a ~25% reduction in cardiovascular mortality and a significant decrease in rehospitalization rates.

Core Components - The Rehab Toolkit

Exercise Prescription (FITT Principle)
- Frequency: 3-5 days/week
- Intensity: 40-80% of max capacity; RPE 11-16
- Time: 20-60 mins per session
- Type: Aerobic (treadmill, cycle) + resistance training
Patient Education
- Cardiovascular risk factor management (lipids, HTN, DM)
- Nutritional counseling (DASH, Mediterranean diet)
- Medication adherence
Psychosocial Counseling
- Screening for depression & anxiety
- Stress management techniques
- Vocational guidance

⭐ Cardiac rehab is a Class 1A recommendation post-MI and is associated with a 20-25% reduction in cardiovascular mortality.

FITT Principle for Cardiac Rehab Exercise Prescription

Contraindications - Red Flags & Risks

Absolute Contraindications:
- Unstable angina
- Decompensated heart failure
- Uncontrolled life-threatening arrhythmias
- Severe symptomatic aortic stenosis
- Acute pulmonary embolism or DVT
Relative Contraindications (Proceed with caution):
- Resting SBP >180 or DBP >110 mmHg
- Significant electrolyte abnormalities
- Tachyarrhythmias with high ventricular rates

⭐ Warning: Stop exercise if SBP drops >10 mmHg with increasing workload, accompanied by other evidence of ischemia.

Cardiac rehab is a multidisciplinary program for patients post-MI, CABG, PCI, stable angina, and stable HF.

It combines supervised exercise, risk factor education, and psychosocial counseling to improve outcomes.

Significantly reduces all-cause mortality (~25%) and hospital readmissions while improving functional capacity and quality of life.

Focuses on secondary prevention through lifestyle modification and medication adherence.

Contraindicated in unstable angina, decompensated HF, and severe, symptomatic aortic stenosis.

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