United States Medical Licensing Examination Step Three:
Comprehensive Review of Foundations of Independent Practice and
Advanced Clinical Medicine for Final Physician Licensure – A High-Yield
Question Bank Covering Diagnosis, Management, Biostatistics, Ethics,
Patient Safety, and Computer-Based Case Simulation Principles
Question Bank actual update
graded A+
Question 1
A 72-year-old man with a 40-pack-year smoking history presents with progressive dyspnea on
exertion and a chronic cough productive of scant sputum for the past 6 months. Spirometry
shows an FEV₁/FVC ratio of 0.65 and an FEV₁ of 55% of predicted. He has no history of asthma or
atopy. Which of the following is the most appropriate initial pharmacologic therapy?
A) Inhaled corticosteroid monotherapy
B) Long-acting beta-agonist monotherapy
C) Tiotropium bromide
D) Combination inhaled corticosteroid and long-acting beta-agonist
E) Theophylline
Correct Answer: D
Rationale: This patient has moderate COPD (GOLD stage 2) based on FEV₁ 50-79% predicted and
FEV₁/FVC <0.70. For patients with moderate to severe COPD and exacerbation risk, guidelines
recommend combination therapy with an inhaled corticosteroid plus a long-acting beta-agonist
(LABA) as initial maintenance therapy. Inhaled corticosteroid monotherapy is not
recommended. Tiotropium (LAMA) can be used but combination LABA/ICS is preferred for this
severity with symptoms. Theophylline is a third-line agent.
Question 2
A 45-year-old woman with type 2 diabetes mellitus (HbA1c 8.2%) and hypertension (blood
pressure 148/92 mm Hg) is currently on metformin 1000 mg twice daily and lisinopril 20 mg
,daily. Her serum creatinine is 1.4 mg/dL, and estimated GFR is 45 mL/min/1.73 m². Urine
albumin-to-creatinine ratio is 300 mg/g. Which of the following is the most appropriate addition
to her regimen?
A) Glipizide
B) Pioglitazone
C) Empagliflozin
D) Sitagliptin
E) Insulin glargine
Correct Answer: C
Rationale: This patient has type 2 diabetes with chronic kidney disease (eGFR 45 mL/min) and
albuminuria. SGLT2 inhibitors such as empagliflozin have demonstrated renal protective effects
and cardiovascular benefits in patients with diabetic kidney disease, regardless of glycemic
control. They reduce progression of albuminuria and decline in eGFR. Glipizide is acceptable but
does not offer renal protection. Pioglitazone may cause fluid retention. Sitagliptin requires dose
adjustment but lacks the robust renal outcome data. Insulin would be considered if glycemic
targets are not met.
Question 3
A 28-year-old woman at 32 weeks gestation presents with headache, visual disturbances, and
epigastric pain. Blood pressure is 165/105 mm Hg. Urinalysis shows 3+ protein. Laboratory
studies reveal platelet count of 85,000/µL, AST 120 U/L, ALT 95 U/L, and creatinine 1.3 mg/dL.
Which of the following is the most appropriate next step?
A) Administer magnesium sulfate and initiate antihypertensive therapy
B) Administer dexamethasone and plan for delivery within 48 hours
C) Perform immediate cesarean delivery
D) Administer labetalol and observe for 24 hours
E) Transfer to intensive care unit for continuous monitoring
Correct Answer: A
Rationale: This patient has severe preeclampsia with features concerning for HELLP syndrome
(hemolysis, elevated liver enzymes, low platelets). The most appropriate immediate
management is seizure prophylaxis with magnesium sulfate and blood pressure control with
antihypertensive agents (labetalol or nifedipine). Delivery is indicated but should be planned
after stabilization, not necessarily emergent cesarean unless obstetrical indications exist.
,Dexamethasone is used for fetal lung maturity if delivery is anticipated within 48 hours but is
not the immediate first step.
Question 4
A 68-year-old man with a history of coronary artery disease presents with sudden onset of
severe, tearing chest pain radiating to the back. Blood pressure is 190/110 mm Hg in the right
arm and 150/90 mm Hg in the left arm. Heart rate is 110 bpm. Which of the following is the
most appropriate initial imaging study?
A) Chest radiography
B) Transthoracic echocardiography
C) CT angiography of the chest
D) Transesophageal echocardiography
E) Magnetic resonance angiography
Correct Answer: C
Rationale: This patient presents with classic findings of acute aortic dissection (tearing chest
pain, pulse differential, hypertension). CT angiography of the chest is the most rapid and widely
available imaging modality for diagnosis of aortic dissection, with excellent sensitivity and
specificity. Transesophageal echocardiography is also sensitive but is more operator-dependent
and invasive. Chest radiography is insensitive. MRI takes too long in an acute setting. The initial
management should include blood pressure control with beta-blockers while awaiting imaging.
Question 5
A 55-year-old man with cirrhosis due to hepatitis C presents with increasing abdominal girth
and lower extremity edema. Paracentesis reveals a serum-ascites albumin gradient of 2.0 g/dL
and a total protein of 1.5 g/dL. Cell count shows 250 neutrophils/µL. Which of the following is
the most appropriate next step?
A) Intravenous albumin infusion
B) Oral furosemide and spironolactone
C) Intravenous ceftriaxone
D) Therapeutic paracentesis
E) Transjugular intrahepatic portosystemic shunt
Correct Answer: C
, Rationale: This patient has spontaneous bacterial peritonitis (SBP) with ascitic fluid neutrophil
count >250 cells/µL. The most appropriate next step is empiric intravenous antibiotics such as
ceftriaxone. Serum-ascites albumin gradient >1.1 confirms portal hypertension as the cause of
ascites. While diuretics, albumin, and therapeutic paracentesis may be part of management,
antibiotic therapy is the priority in SBP. TIPS is reserved for refractory ascites.
Question 6
A 34-year-old woman presents with a 2-week history of progressive weakness in her lower
extremities, urinary retention, and a sensory level at T6. She reports a viral respiratory infection
2 weeks prior. MRI of the spine reveals a hyperintense T2-weighted signal in the thoracic spinal
cord. Which of the following is the most appropriate initial treatment?
A) Intravenous acyclovir
B) Intravenous methylprednisolone
C) Plasma exchange
D) Intravenous immunoglobulin
E) Oral prednisone taper
Correct Answer: B
Rationale: This patient presents with acute transverse myelitis, suggested by the subacute onset
of bilateral lower extremity weakness, sensory level, and urinary retention following a viral
prodrome. The most appropriate initial treatment is high-dose intravenous methylprednisolone.
Acyclovir would be indicated if herpes myelitis were suspected, but the clinical picture is more
consistent with post-infectious or idiopathic transverse myelitis. Plasma exchange or IVIG may
be used in severe or steroid-refractory cases. Oral prednisone is not appropriate for initial acute
management.
Question 7
A 62-year-old woman with a history of hypertension and hyperlipidemia presents with acute
onset of severe headache, nausea, and vomiting. On examination, she is hypertensive (blood
pressure 220/120 mm Hg) and has nuchal rigidity. CT scan of the head without contrast shows
diffuse subarachnoid hemorrhage. Which of the following is the most appropriate next step in
management?
A) Lumbar puncture
B) CT angiography of the head and neck
Comprehensive Review of Foundations of Independent Practice and
Advanced Clinical Medicine for Final Physician Licensure – A High-Yield
Question Bank Covering Diagnosis, Management, Biostatistics, Ethics,
Patient Safety, and Computer-Based Case Simulation Principles
Question Bank actual update
graded A+
Question 1
A 72-year-old man with a 40-pack-year smoking history presents with progressive dyspnea on
exertion and a chronic cough productive of scant sputum for the past 6 months. Spirometry
shows an FEV₁/FVC ratio of 0.65 and an FEV₁ of 55% of predicted. He has no history of asthma or
atopy. Which of the following is the most appropriate initial pharmacologic therapy?
A) Inhaled corticosteroid monotherapy
B) Long-acting beta-agonist monotherapy
C) Tiotropium bromide
D) Combination inhaled corticosteroid and long-acting beta-agonist
E) Theophylline
Correct Answer: D
Rationale: This patient has moderate COPD (GOLD stage 2) based on FEV₁ 50-79% predicted and
FEV₁/FVC <0.70. For patients with moderate to severe COPD and exacerbation risk, guidelines
recommend combination therapy with an inhaled corticosteroid plus a long-acting beta-agonist
(LABA) as initial maintenance therapy. Inhaled corticosteroid monotherapy is not
recommended. Tiotropium (LAMA) can be used but combination LABA/ICS is preferred for this
severity with symptoms. Theophylline is a third-line agent.
Question 2
A 45-year-old woman with type 2 diabetes mellitus (HbA1c 8.2%) and hypertension (blood
pressure 148/92 mm Hg) is currently on metformin 1000 mg twice daily and lisinopril 20 mg
,daily. Her serum creatinine is 1.4 mg/dL, and estimated GFR is 45 mL/min/1.73 m². Urine
albumin-to-creatinine ratio is 300 mg/g. Which of the following is the most appropriate addition
to her regimen?
A) Glipizide
B) Pioglitazone
C) Empagliflozin
D) Sitagliptin
E) Insulin glargine
Correct Answer: C
Rationale: This patient has type 2 diabetes with chronic kidney disease (eGFR 45 mL/min) and
albuminuria. SGLT2 inhibitors such as empagliflozin have demonstrated renal protective effects
and cardiovascular benefits in patients with diabetic kidney disease, regardless of glycemic
control. They reduce progression of albuminuria and decline in eGFR. Glipizide is acceptable but
does not offer renal protection. Pioglitazone may cause fluid retention. Sitagliptin requires dose
adjustment but lacks the robust renal outcome data. Insulin would be considered if glycemic
targets are not met.
Question 3
A 28-year-old woman at 32 weeks gestation presents with headache, visual disturbances, and
epigastric pain. Blood pressure is 165/105 mm Hg. Urinalysis shows 3+ protein. Laboratory
studies reveal platelet count of 85,000/µL, AST 120 U/L, ALT 95 U/L, and creatinine 1.3 mg/dL.
Which of the following is the most appropriate next step?
A) Administer magnesium sulfate and initiate antihypertensive therapy
B) Administer dexamethasone and plan for delivery within 48 hours
C) Perform immediate cesarean delivery
D) Administer labetalol and observe for 24 hours
E) Transfer to intensive care unit for continuous monitoring
Correct Answer: A
Rationale: This patient has severe preeclampsia with features concerning for HELLP syndrome
(hemolysis, elevated liver enzymes, low platelets). The most appropriate immediate
management is seizure prophylaxis with magnesium sulfate and blood pressure control with
antihypertensive agents (labetalol or nifedipine). Delivery is indicated but should be planned
after stabilization, not necessarily emergent cesarean unless obstetrical indications exist.
,Dexamethasone is used for fetal lung maturity if delivery is anticipated within 48 hours but is
not the immediate first step.
Question 4
A 68-year-old man with a history of coronary artery disease presents with sudden onset of
severe, tearing chest pain radiating to the back. Blood pressure is 190/110 mm Hg in the right
arm and 150/90 mm Hg in the left arm. Heart rate is 110 bpm. Which of the following is the
most appropriate initial imaging study?
A) Chest radiography
B) Transthoracic echocardiography
C) CT angiography of the chest
D) Transesophageal echocardiography
E) Magnetic resonance angiography
Correct Answer: C
Rationale: This patient presents with classic findings of acute aortic dissection (tearing chest
pain, pulse differential, hypertension). CT angiography of the chest is the most rapid and widely
available imaging modality for diagnosis of aortic dissection, with excellent sensitivity and
specificity. Transesophageal echocardiography is also sensitive but is more operator-dependent
and invasive. Chest radiography is insensitive. MRI takes too long in an acute setting. The initial
management should include blood pressure control with beta-blockers while awaiting imaging.
Question 5
A 55-year-old man with cirrhosis due to hepatitis C presents with increasing abdominal girth
and lower extremity edema. Paracentesis reveals a serum-ascites albumin gradient of 2.0 g/dL
and a total protein of 1.5 g/dL. Cell count shows 250 neutrophils/µL. Which of the following is
the most appropriate next step?
A) Intravenous albumin infusion
B) Oral furosemide and spironolactone
C) Intravenous ceftriaxone
D) Therapeutic paracentesis
E) Transjugular intrahepatic portosystemic shunt
Correct Answer: C
, Rationale: This patient has spontaneous bacterial peritonitis (SBP) with ascitic fluid neutrophil
count >250 cells/µL. The most appropriate next step is empiric intravenous antibiotics such as
ceftriaxone. Serum-ascites albumin gradient >1.1 confirms portal hypertension as the cause of
ascites. While diuretics, albumin, and therapeutic paracentesis may be part of management,
antibiotic therapy is the priority in SBP. TIPS is reserved for refractory ascites.
Question 6
A 34-year-old woman presents with a 2-week history of progressive weakness in her lower
extremities, urinary retention, and a sensory level at T6. She reports a viral respiratory infection
2 weeks prior. MRI of the spine reveals a hyperintense T2-weighted signal in the thoracic spinal
cord. Which of the following is the most appropriate initial treatment?
A) Intravenous acyclovir
B) Intravenous methylprednisolone
C) Plasma exchange
D) Intravenous immunoglobulin
E) Oral prednisone taper
Correct Answer: B
Rationale: This patient presents with acute transverse myelitis, suggested by the subacute onset
of bilateral lower extremity weakness, sensory level, and urinary retention following a viral
prodrome. The most appropriate initial treatment is high-dose intravenous methylprednisolone.
Acyclovir would be indicated if herpes myelitis were suspected, but the clinical picture is more
consistent with post-infectious or idiopathic transverse myelitis. Plasma exchange or IVIG may
be used in severe or steroid-refractory cases. Oral prednisone is not appropriate for initial acute
management.
Question 7
A 62-year-old woman with a history of hypertension and hyperlipidemia presents with acute
onset of severe headache, nausea, and vomiting. On examination, she is hypertensive (blood
pressure 220/120 mm Hg) and has nuchal rigidity. CT scan of the head without contrast shows
diffuse subarachnoid hemorrhage. Which of the following is the most appropriate next step in
management?
A) Lumbar puncture
B) CT angiography of the head and neck
