United States Medical Licensing Examination
Step Three: Advanced Clinical Decision-
Making, Patient Safety, Systems-Based
Practice, and Critical Care Management for
Independent Medical Practice – A
Comprehensive Question Bank V2.0 Question
Bank actual update
Question 1
A 72-year-old man with a history of hypertension and type 2 diabetes presents to the
emergency department with a 2-day history of progressive confusion, lethargy, and fever. His
family reports that he has been coughing for the past week. On examination, temperature is
38.8°C, heart rate 112 bpm, blood pressure 95/60 mm Hg, respiratory rate 28/min, and oxygen
saturation 88% on room air. Lung auscultation reveals crackles at the right lung base. Laboratory
studies show WBC 18,500/µL with 15% bands, creatinine 2.1 mg/dL (baseline 1.1 mg/dL), and
lactate 3.8 mmol/L. Chest radiograph shows a right lower lobe infiltrate. Which of the following
is the most appropriate next step in management?
A) Administer intravenous ceftriaxone and azithromycin in the emergency department
B) Administer intravenous vancomycin and piperacillin-tazobactam
C) Obtain blood cultures and administer intravenous levofloxacin
D) Transfer to the intensive care unit for continuous monitoring
E) Administer intravenous fluids and observe for 4 hours
,Correct Answer: B
Rationale: This patient has severe community-acquired pneumonia with sepsis (hypotension,
elevated lactate, acute kidney injury, hypoxemia). He meets criteria for ICU admission and
requires broad-spectrum empiric antibiotics covering both typical and atypical pathogens as
well as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin
plus piperacillin-tazobactam provides appropriate coverage for severe healthcare-associated or
community-acquired pneumonia with risk factors for drug-resistant organisms. Ceftriaxone and
azithromycin are appropriate for non-severe CAP. Levofloxacin alone may not provide adequate
MRSA coverage. Observation alone is inappropriate.
Question 2
A 58-year-old woman with a 25-year history of type 2 diabetes mellitus presents with a 3-month
history of progressively worsening bilateral lower extremity burning pain, numbness, and
tingling. She reports that the pain is worse at night and interferes with her sleep. She has tried
over-the-counter acetaminophen without relief. Her most recent HbA1c was 8.9%. On
examination, she has decreased sensation to pinprick and vibration in a stocking distribution
bilaterally, absent ankle reflexes, and intact motor strength. Which of the following is the most
appropriate initial pharmacologic therapy for her neuropathic pain?
A) Gabapentin
B) Duloxetine
C) Pregabalin
D) Amitriptyline
E) Tramadol
Correct Answer: B
Rationale: This patient has painful diabetic peripheral neuropathy. Duloxetine is a first-line
agent for diabetic neuropathy with the added benefit of improving glycemic control and
addressing associated depression. Gabapentin and pregabalin are also first-line options but are
less preferred in patients with renal impairment (this patient's renal function is not specified).
Amitriptyline is effective but has more side effects and is not preferred in elderly patients.
Tramadol is a second-line agent due to addiction potential and side effects.
Question 3
,A 34-year-old man presents to the emergency department with a 1-day history of severe,
colicky abdominal pain that started in the periumbilical region and migrated to the right lower
quadrant. He reports nausea and vomiting. On examination, temperature is 38.2°C, heart rate
105 bpm, and blood pressure 135/85 mm Hg. He has right lower quadrant tenderness with
rebound and guarding. Laboratory studies show WBC 16,000/µL with 85% neutrophils. CT scan
of the abdomen with contrast shows a dilated, thick-walled appendix with surrounding fat
stranding and a 2.5 cm periappendiceal abscess. Which of the following is the most appropriate
management?
A) Emergency appendectomy
B) Interval appendectomy after 6 weeks
C) CT-guided percutaneous drainage of the abscess and intravenous antibiotics, followed by
interval appendectomy
D) Intravenous antibiotics alone
E) Laparoscopic appendectomy with abscess drainage
Correct Answer: C
Rationale: This patient has complicated appendicitis with a periappendiceal abscess >2 cm. The
standard management is percutaneous drainage of the abscess with intravenous antibiotics,
followed by interval appendectomy in 6-8 weeks. Emergency appendectomy in the setting of a
large abscess is associated with higher morbidity. Antibiotics alone are insufficient. Interval
appendectomy without drainage would leave the abscess untreated.
Question 4
A 45-year-old woman with no significant medical history presents with a 2-week history of
progressive shortness of breath, nonproductive cough, and low-grade fever. She reports no sick
contacts and no recent travel. She is a lifelong nonsmoker. On examination, she has bilateral
crackles in the lung bases. Chest radiograph shows bilateral interstitial infiltrates. High-
resolution CT of the chest shows bilateral ground-glass opacities with a peripheral and lower
lobe predominance. Laboratory studies show negative antinuclear antibody and rheumatoid
factor. Which of the following is the most likely diagnosis?
A) Idiopathic pulmonary fibrosis
B) Sarcoidosis
C) Cryptogenic organizing pneumonia
D) Hypersensitivity pneumonitis
E) Connective tissue disease-associated interstitial lung disease
, Correct Answer: C
Rationale: This patient has cryptogenic organizing pneumonia (COP), characterized by subacute
onset of dyspnea, cough, fever, bilateral ground-glass opacities with peripheral and lower lobe
predominance, and absence of connective tissue disease. IPF typically shows honeycombing
and reticular opacities with basal predominance. Sarcoidosis typically presents with hilar
adenopathy. Hypersensitivity pneumonitis requires an exposure history. Connective tissue
disease would have positive autoantibodies.
Question 5
A 68-year-old man with a history of coronary artery disease, hypertension, and chronic kidney
disease stage 3 presents with a 1-week history of progressive dyspnea on exertion, orthopnea,
and paroxysmal nocturnal dyspnea. On examination, he has jugular venous distension, crackles
in both lung bases, and 2+ pitting edema in the lower extremities. His blood pressure is 160/95
mm Hg, and heart rate is 95 bpm. Echocardiography reveals a left ventricular ejection fraction of
35% with moderate mitral regurgitation. His medications include aspirin, atorvastatin, lisinopril
20 mg daily, and metoprolol succinate 50 mg twice daily. Which of the following is the most
appropriate addition to his medication regimen?
A) Furosemide 40 mg daily
B) Spironolactone 25 mg daily
C) Hydralazine and isosorbide dinitrate
D) Digoxin 0.125 mg daily
E) Sacubitril/valsartan
Correct Answer: E
Rationale: This patient has heart failure with reduced ejection fraction with persistent
symptoms on optimal medical therapy (ACE inhibitor and beta-blocker). Sacubitril/valsartan
(ARNI) has been shown to reduce mortality and hospitalizations compared to ACE inhibitors in
patients with HFrEF and should be used as first-line therapy in appropriate patients. Furosemide
is for symptom management but does not improve survival. Spironolactone is indicated for
NYHA class III-IV but is not the primary addition. Hydralazine/isosorbide dinitrate is for African
American patients. Digoxin improves symptoms but not survival.
Question 6
Step Three: Advanced Clinical Decision-
Making, Patient Safety, Systems-Based
Practice, and Critical Care Management for
Independent Medical Practice – A
Comprehensive Question Bank V2.0 Question
Bank actual update
Question 1
A 72-year-old man with a history of hypertension and type 2 diabetes presents to the
emergency department with a 2-day history of progressive confusion, lethargy, and fever. His
family reports that he has been coughing for the past week. On examination, temperature is
38.8°C, heart rate 112 bpm, blood pressure 95/60 mm Hg, respiratory rate 28/min, and oxygen
saturation 88% on room air. Lung auscultation reveals crackles at the right lung base. Laboratory
studies show WBC 18,500/µL with 15% bands, creatinine 2.1 mg/dL (baseline 1.1 mg/dL), and
lactate 3.8 mmol/L. Chest radiograph shows a right lower lobe infiltrate. Which of the following
is the most appropriate next step in management?
A) Administer intravenous ceftriaxone and azithromycin in the emergency department
B) Administer intravenous vancomycin and piperacillin-tazobactam
C) Obtain blood cultures and administer intravenous levofloxacin
D) Transfer to the intensive care unit for continuous monitoring
E) Administer intravenous fluids and observe for 4 hours
,Correct Answer: B
Rationale: This patient has severe community-acquired pneumonia with sepsis (hypotension,
elevated lactate, acute kidney injury, hypoxemia). He meets criteria for ICU admission and
requires broad-spectrum empiric antibiotics covering both typical and atypical pathogens as
well as methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin
plus piperacillin-tazobactam provides appropriate coverage for severe healthcare-associated or
community-acquired pneumonia with risk factors for drug-resistant organisms. Ceftriaxone and
azithromycin are appropriate for non-severe CAP. Levofloxacin alone may not provide adequate
MRSA coverage. Observation alone is inappropriate.
Question 2
A 58-year-old woman with a 25-year history of type 2 diabetes mellitus presents with a 3-month
history of progressively worsening bilateral lower extremity burning pain, numbness, and
tingling. She reports that the pain is worse at night and interferes with her sleep. She has tried
over-the-counter acetaminophen without relief. Her most recent HbA1c was 8.9%. On
examination, she has decreased sensation to pinprick and vibration in a stocking distribution
bilaterally, absent ankle reflexes, and intact motor strength. Which of the following is the most
appropriate initial pharmacologic therapy for her neuropathic pain?
A) Gabapentin
B) Duloxetine
C) Pregabalin
D) Amitriptyline
E) Tramadol
Correct Answer: B
Rationale: This patient has painful diabetic peripheral neuropathy. Duloxetine is a first-line
agent for diabetic neuropathy with the added benefit of improving glycemic control and
addressing associated depression. Gabapentin and pregabalin are also first-line options but are
less preferred in patients with renal impairment (this patient's renal function is not specified).
Amitriptyline is effective but has more side effects and is not preferred in elderly patients.
Tramadol is a second-line agent due to addiction potential and side effects.
Question 3
,A 34-year-old man presents to the emergency department with a 1-day history of severe,
colicky abdominal pain that started in the periumbilical region and migrated to the right lower
quadrant. He reports nausea and vomiting. On examination, temperature is 38.2°C, heart rate
105 bpm, and blood pressure 135/85 mm Hg. He has right lower quadrant tenderness with
rebound and guarding. Laboratory studies show WBC 16,000/µL with 85% neutrophils. CT scan
of the abdomen with contrast shows a dilated, thick-walled appendix with surrounding fat
stranding and a 2.5 cm periappendiceal abscess. Which of the following is the most appropriate
management?
A) Emergency appendectomy
B) Interval appendectomy after 6 weeks
C) CT-guided percutaneous drainage of the abscess and intravenous antibiotics, followed by
interval appendectomy
D) Intravenous antibiotics alone
E) Laparoscopic appendectomy with abscess drainage
Correct Answer: C
Rationale: This patient has complicated appendicitis with a periappendiceal abscess >2 cm. The
standard management is percutaneous drainage of the abscess with intravenous antibiotics,
followed by interval appendectomy in 6-8 weeks. Emergency appendectomy in the setting of a
large abscess is associated with higher morbidity. Antibiotics alone are insufficient. Interval
appendectomy without drainage would leave the abscess untreated.
Question 4
A 45-year-old woman with no significant medical history presents with a 2-week history of
progressive shortness of breath, nonproductive cough, and low-grade fever. She reports no sick
contacts and no recent travel. She is a lifelong nonsmoker. On examination, she has bilateral
crackles in the lung bases. Chest radiograph shows bilateral interstitial infiltrates. High-
resolution CT of the chest shows bilateral ground-glass opacities with a peripheral and lower
lobe predominance. Laboratory studies show negative antinuclear antibody and rheumatoid
factor. Which of the following is the most likely diagnosis?
A) Idiopathic pulmonary fibrosis
B) Sarcoidosis
C) Cryptogenic organizing pneumonia
D) Hypersensitivity pneumonitis
E) Connective tissue disease-associated interstitial lung disease
, Correct Answer: C
Rationale: This patient has cryptogenic organizing pneumonia (COP), characterized by subacute
onset of dyspnea, cough, fever, bilateral ground-glass opacities with peripheral and lower lobe
predominance, and absence of connective tissue disease. IPF typically shows honeycombing
and reticular opacities with basal predominance. Sarcoidosis typically presents with hilar
adenopathy. Hypersensitivity pneumonitis requires an exposure history. Connective tissue
disease would have positive autoantibodies.
Question 5
A 68-year-old man with a history of coronary artery disease, hypertension, and chronic kidney
disease stage 3 presents with a 1-week history of progressive dyspnea on exertion, orthopnea,
and paroxysmal nocturnal dyspnea. On examination, he has jugular venous distension, crackles
in both lung bases, and 2+ pitting edema in the lower extremities. His blood pressure is 160/95
mm Hg, and heart rate is 95 bpm. Echocardiography reveals a left ventricular ejection fraction of
35% with moderate mitral regurgitation. His medications include aspirin, atorvastatin, lisinopril
20 mg daily, and metoprolol succinate 50 mg twice daily. Which of the following is the most
appropriate addition to his medication regimen?
A) Furosemide 40 mg daily
B) Spironolactone 25 mg daily
C) Hydralazine and isosorbide dinitrate
D) Digoxin 0.125 mg daily
E) Sacubitril/valsartan
Correct Answer: E
Rationale: This patient has heart failure with reduced ejection fraction with persistent
symptoms on optimal medical therapy (ACE inhibitor and beta-blocker). Sacubitril/valsartan
(ARNI) has been shown to reduce mortality and hospitalizations compared to ACE inhibitors in
patients with HFrEF and should be used as first-line therapy in appropriate patients. Furosemide
is for symptom management but does not improve survival. Spironolactone is indicated for
NYHA class III-IV but is not the primary addition. Hydralazine/isosorbide dinitrate is for African
American patients. Digoxin improves symptoms but not survival.
Question 6
