USMLE Step 3: ACTUAL EXAM ALL
QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% VERIFIED SOLUTIONS |
UPDATED PER LATEST GUIDELINES |
GRADED A+
Section 1: Day 1 – Foundations of Independent Practice
Question 1
A 65-year-old woman with a history of hypertension and type 2 diabetes presents for a routine
follow-up. Her blood pressure today is 148/92 mmHg. She is adherent to her lisinopril 20 mg
daily. Which of the following is the most appropriate next step in management?
A) Add hydrochlorothiazide 12.5 mg daily
B) Increase lisinopril to 40 mg daily
C) Add amlodipine 5 mg daily
D) Order a 24-hour ambulatory blood pressure monitor
Answer: A) Add hydrochlorothiazide 12.5 mg daily
Rationale: This patient's blood pressure is above the target of <130/80 mmHg. The next step is
to add a low-dose thiazide diuretic to her ACE inhibitor (lisinopril) for better blood pressure
control. This is a common first-line combination. Increasing the ACE inhibitor dose may be
considered, but adding a diuretic is generally more effective for hypertension management in
this scenario. The question tests your ability to manage chronic conditions, which is a Day 1
focus .
Question 2
A 55-year-old man is undergoing a routine health maintenance examination. He has a 20-pack-
,year smoking history and quit smoking 5 years ago. Which of the following screening tests is
most appropriate for this patient?
A) Annual low-dose CT chest
B) Annual PSA screening
C) Colonoscopy every 10 years
D) Fasting lipid panel
Answer: C) Colonoscopy every 10 years
Rationale: The USPSTF recommends screening for colorectal cancer starting at age 45. The
patient is in the recommended age range, so a colonoscopy is the appropriate screening test.
Annual low-dose CT is for lung cancer screening, which would be indicated for patients aged 50-
80 with a 20 pack-year history who currently smoke or quit within the past 15 years. This patient
quit 5 years ago, so he is eligible for lung cancer screening, but the question is asking
about routine health maintenance, and colonoscopy is the most routine, evidence-based
screening for his age. The test most appropriate is the one that screens for colorectal cancer.
The question tests your knowledge of screening guidelines.
Question 3
A study is published showing a new drug reduces the risk of stroke by 25% compared to
placebo. The absolute risk of stroke in the placebo group is 8%, and in the treatment group is
6%. What is the number needed to treat (NNT)?
A) 25
B) 50
C) 100
D) 200
Answer: B) 50
Rationale: The NNT is calculated as 1 / Absolute Risk Reduction (ARR). The ARR is the difference
in event rates between the control group (8%) and the treatment group (6%), which is 2% or
0.02. NNT = .02 = 50. This is a high-yield biostatistics calculation tested on Day 1 .
Question 4
A 72-year-old man with a history of hypertension and BPH presents with fever, chills, and weight
loss over the past 3 months. He reports recent episodes of painless hematuria. Physical exam
reveals a pale, cachectic man with tenderness over the pelvis. CT shows a 5-cm complex cystic
,mass in the right kidney. His hematocrit is 55% and platelet count is 625,000/mm³. Which of the
following is the most appropriate next step?
A) Percutaneous needle biopsy of the mass
B) Radical nephrectomy
C) Chest X-ray and bone scan
D) Ultrasonography of the kidney
Answer: C) Chest X-ray and bone scan
Rationale: This patient has classic signs of renal cell carcinoma (RCC), including hematuria, flank
pain, weight loss, fever, and erythrocytosis from inappropriate erythropoietin production .
Before proceeding with definitive treatment like a radical nephrectomy, it is essential to rule out
metastasis. Therefore, a chest X-ray and bone scan are the most appropriate next steps to stage
the disease . A percutaneous biopsy is not typically needed for a mass with classic imaging
features. Ultrasonography is not the best next step as CT has already provided a clear diagnosis.
Question 5
A 4-year-old girl is brought to the ED after a sudden episode of choking and drooling while
playing in the kitchen. She is in mild respiratory distress with stridor. Chest X-ray is normal.
Twenty minutes later, the patient's condition is improving, with an SpO2 of 97%. Which of the
following is the best next step?
A) Administer racemic epinephrine and dexamethasone
B) Begin intravenous levofloxacin
C) Order a lateral X-ray of the neck
D) Perform endotracheal intubation
Answer: C) Order a lateral X-ray of the neck
Rationale: The sudden onset of drooling and coughing in a young child is highly concerning for
foreign-body aspiration . Although the chest X-ray is normal, a radiopaque foreign body may be
lodged in the esophagus or pharynx. A lateral neck X-ray can visualize coins or other objects in
the posterior oropharynx. Racemic epinephrine and dexamethasone are for croup, which is
unlikely given the sudden onset. Levofloxacin is not indicated for this presentation. Intubation is
not necessary as the patient is improving and maintaining oxygenation .
Section 2: Day 2 – Advanced Clinical Medicine & CCS
, Question 6
You are managing a 23-year-old female in the emergency department with acute right lower
quadrant pain that started 3 hours ago. The pain began periumbilically and migrated to the RLQ.
She has nausea, vomiting, and chills. Which of the following is an appropriate management
action in the CCS software?
A) Order a complete blood count and urinalysis
B) Order an abdominal CT with contrast
C) Make the patient NPO
D) All of the above
Answer: D) All of the above
Rationale: This is a classic presentation for acute appendicitis. To maximize your CCS score, you
should order the appropriate tests (CBC, UA, pregnancy test, and CT) and ensure the patient is
NPO in case surgery is needed . The CCS software rewards you for completing all steps in the
patient care process .
Question 7
In the same case from Question 6, the CT confirms appendicitis. The surgeon is consulted and
recommends appendectomy. What is the most appropriate next step in your CCS management?
A) Order IV fluids and antibiotics
B) Transfer the patient to the operating room
C) Order perioperative labs
D) All of the above
Answer: D) All of the above
Rationale: To maximize your score, you should complete the full patient care workflow. This
includes ordering IV fluids and antibiotics, ordering routine preoperative labs, and transferring
the patient to the appropriate location for surgery . The CCS software rewards you for thinking
about all aspects of patient management, not just diagnosis.
Question 8
A 79-year-old man presents with acute onset of severe right leg pain below the knee that
started 4 hours ago. He has a history of colon cancer. Physical exam reveals absent dorsalis pedis
and posterior tibial pulses in the right lower extremity. Which of the following is the most
appropriate immediate management?
QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% VERIFIED SOLUTIONS |
UPDATED PER LATEST GUIDELINES |
GRADED A+
Section 1: Day 1 – Foundations of Independent Practice
Question 1
A 65-year-old woman with a history of hypertension and type 2 diabetes presents for a routine
follow-up. Her blood pressure today is 148/92 mmHg. She is adherent to her lisinopril 20 mg
daily. Which of the following is the most appropriate next step in management?
A) Add hydrochlorothiazide 12.5 mg daily
B) Increase lisinopril to 40 mg daily
C) Add amlodipine 5 mg daily
D) Order a 24-hour ambulatory blood pressure monitor
Answer: A) Add hydrochlorothiazide 12.5 mg daily
Rationale: This patient's blood pressure is above the target of <130/80 mmHg. The next step is
to add a low-dose thiazide diuretic to her ACE inhibitor (lisinopril) for better blood pressure
control. This is a common first-line combination. Increasing the ACE inhibitor dose may be
considered, but adding a diuretic is generally more effective for hypertension management in
this scenario. The question tests your ability to manage chronic conditions, which is a Day 1
focus .
Question 2
A 55-year-old man is undergoing a routine health maintenance examination. He has a 20-pack-
,year smoking history and quit smoking 5 years ago. Which of the following screening tests is
most appropriate for this patient?
A) Annual low-dose CT chest
B) Annual PSA screening
C) Colonoscopy every 10 years
D) Fasting lipid panel
Answer: C) Colonoscopy every 10 years
Rationale: The USPSTF recommends screening for colorectal cancer starting at age 45. The
patient is in the recommended age range, so a colonoscopy is the appropriate screening test.
Annual low-dose CT is for lung cancer screening, which would be indicated for patients aged 50-
80 with a 20 pack-year history who currently smoke or quit within the past 15 years. This patient
quit 5 years ago, so he is eligible for lung cancer screening, but the question is asking
about routine health maintenance, and colonoscopy is the most routine, evidence-based
screening for his age. The test most appropriate is the one that screens for colorectal cancer.
The question tests your knowledge of screening guidelines.
Question 3
A study is published showing a new drug reduces the risk of stroke by 25% compared to
placebo. The absolute risk of stroke in the placebo group is 8%, and in the treatment group is
6%. What is the number needed to treat (NNT)?
A) 25
B) 50
C) 100
D) 200
Answer: B) 50
Rationale: The NNT is calculated as 1 / Absolute Risk Reduction (ARR). The ARR is the difference
in event rates between the control group (8%) and the treatment group (6%), which is 2% or
0.02. NNT = .02 = 50. This is a high-yield biostatistics calculation tested on Day 1 .
Question 4
A 72-year-old man with a history of hypertension and BPH presents with fever, chills, and weight
loss over the past 3 months. He reports recent episodes of painless hematuria. Physical exam
reveals a pale, cachectic man with tenderness over the pelvis. CT shows a 5-cm complex cystic
,mass in the right kidney. His hematocrit is 55% and platelet count is 625,000/mm³. Which of the
following is the most appropriate next step?
A) Percutaneous needle biopsy of the mass
B) Radical nephrectomy
C) Chest X-ray and bone scan
D) Ultrasonography of the kidney
Answer: C) Chest X-ray and bone scan
Rationale: This patient has classic signs of renal cell carcinoma (RCC), including hematuria, flank
pain, weight loss, fever, and erythrocytosis from inappropriate erythropoietin production .
Before proceeding with definitive treatment like a radical nephrectomy, it is essential to rule out
metastasis. Therefore, a chest X-ray and bone scan are the most appropriate next steps to stage
the disease . A percutaneous biopsy is not typically needed for a mass with classic imaging
features. Ultrasonography is not the best next step as CT has already provided a clear diagnosis.
Question 5
A 4-year-old girl is brought to the ED after a sudden episode of choking and drooling while
playing in the kitchen. She is in mild respiratory distress with stridor. Chest X-ray is normal.
Twenty minutes later, the patient's condition is improving, with an SpO2 of 97%. Which of the
following is the best next step?
A) Administer racemic epinephrine and dexamethasone
B) Begin intravenous levofloxacin
C) Order a lateral X-ray of the neck
D) Perform endotracheal intubation
Answer: C) Order a lateral X-ray of the neck
Rationale: The sudden onset of drooling and coughing in a young child is highly concerning for
foreign-body aspiration . Although the chest X-ray is normal, a radiopaque foreign body may be
lodged in the esophagus or pharynx. A lateral neck X-ray can visualize coins or other objects in
the posterior oropharynx. Racemic epinephrine and dexamethasone are for croup, which is
unlikely given the sudden onset. Levofloxacin is not indicated for this presentation. Intubation is
not necessary as the patient is improving and maintaining oxygenation .
Section 2: Day 2 – Advanced Clinical Medicine & CCS
, Question 6
You are managing a 23-year-old female in the emergency department with acute right lower
quadrant pain that started 3 hours ago. The pain began periumbilically and migrated to the RLQ.
She has nausea, vomiting, and chills. Which of the following is an appropriate management
action in the CCS software?
A) Order a complete blood count and urinalysis
B) Order an abdominal CT with contrast
C) Make the patient NPO
D) All of the above
Answer: D) All of the above
Rationale: This is a classic presentation for acute appendicitis. To maximize your CCS score, you
should order the appropriate tests (CBC, UA, pregnancy test, and CT) and ensure the patient is
NPO in case surgery is needed . The CCS software rewards you for completing all steps in the
patient care process .
Question 7
In the same case from Question 6, the CT confirms appendicitis. The surgeon is consulted and
recommends appendectomy. What is the most appropriate next step in your CCS management?
A) Order IV fluids and antibiotics
B) Transfer the patient to the operating room
C) Order perioperative labs
D) All of the above
Answer: D) All of the above
Rationale: To maximize your score, you should complete the full patient care workflow. This
includes ordering IV fluids and antibiotics, ordering routine preoperative labs, and transferring
the patient to the appropriate location for surgery . The CCS software rewards you for thinking
about all aspects of patient management, not just diagnosis.
Question 8
A 79-year-old man presents with acute onset of severe right leg pain below the knee that
started 4 hours ago. He has a history of colon cancer. Physical exam reveals absent dorsalis pedis
and posterior tibial pulses in the right lower extremity. Which of the following is the most
appropriate immediate management?
