NBME 4 STEP 3 PRACTICE EXAM QUESTIONS
WITH CORRECT ANSWERS 2025/2026
65 yo F has a 3 month hx of *increasing low back pain*. Had low back pain for past 3 yrs that's
been treated w/NSAIDs and codeine. Now rated as 7/10 in severity. Pain radiates to both legs,
worsens when walking or standing & Relieved when sitting. 1 YEAR AGO: X ray lumbosacral
spine: mild osteoarthritis. Exam: 4/5 mm strength LE, hyporeflexia of knees&ankles b/, unsteady
gait b/c of pain. No other abnormalities. Most appropriate diagnostic study of lumbosacral spine
to order at this time? - CORRECT ANSWER -*MRI*
-prly b/c this pain is worse than the usual pain & neuro sx of hyporeflexia, decreased mm
strength, and unsteady gait
A couple comes to discuss the results of prenatal testing in current pregnancy. Screening test
showed increased risk for having a child w/Down syndrome. Amniocentesis is suggested for her.
Husband asks "When can we schedule the amniocentesis? I think that we should just get on
w/it." Wife responds angrily, "That's easy for u to say. U haven't been carrying this baby for 4
months & u haven't felt it move like I have. Appropriate response? - CORRECT ANSWER -"I know
this is difficult news for both of u. I would like to know what both of u are thinking now"
3 y.o. boy is at 50th %tile for height&weight. Exam: hemihypertrophy of left side of body when
compared to right. Palpable mass in LLQ. Labs: Hgb 12, Hct 36%, Urine: SG 1.020, WBC 0-1/hpf,
RBC 10-20/hpf. U/S: left kidney mass. Dx? - CORRECT ANSWER -*Wilms tumor*
-most common RENAL malignancy in kids
-age <5
-*Unilateral, PAINFUL, abdominal mass*
-HTN, hematuria
neuroblastoma - CORRECT ANSWER -most common extracranial solid tumors in kids
-painLESS abdominal mass
-may have HTN Due to mass compressing renal artery and activating renin-angiotensin system
,-FLUSHING &SWEATING due to catecholamine hypersecretion
-neural crest origin
-involves adrenal medulla, sympathetic chain
-median age <2
-*periorbital ecchymoses(orbital METASTASES)*
-spinal cord compression from epidural invasion("dumbbell tumor")
-opsoclonus-myoclonus syndrome
DX: elevated catecholamine metabolites, small&round blue cells on histology, N-myc gene
amplification
58 year old F has heavy substernal chest pain relieved by nitroglycerin & rest. Pain occurs
w/exertion&accompanied by some SOB&sweating. 6 months ago: CABG. VSS. ECG: NSR
w/*inverted T waves NEW in leads V4-V6.* next step in evaluation is to do which? - CORRECT
ANSWER -*Repeat coronary artery catheterization*->NOT order echo or MUGA scan
-maybe b/c of NEW inverted T waves?
70 yo has 1 wk hx left eyelid droop. PMG COPD&Quit smoking 5 yrs ago. Troublesome pain
radiating down left arm. Left ptosis w/small pupil on exam. Diagnostic study? - CORRECT
ANSWER -*CT scan thorax*
-prly pancoast tumor
65 yo F had 2 min generalized tonic-clonic seizure that occured when asleep. PMH: HTN, breast
cancer 2 yrs ago s/p lumpectomy, radiation therapy, adjuvant chemo 1 yr ago. Meds: lisinopril,
tamoxifen.Pt is drowsy, not oriented to person,place,time. BP 160/95. Pulse ox 95%.Exam: right
lower face drooping. Eyes conjugately deviated to left. Briskly withdraws LUE & both LE to
noxious stimuli; there's no movement of RUE. Fingerstick BG 70, serum sodium concentration
130. CAUSE of seizure? - CORRECT ANSWER -*Brain metastasis* prly from breast cancer
-looks like she got a stroke
, strongest predisposing factor for prostate cancer - CORRECT ANSWER -age (old)
32 yo F 6 day f/u for 12 cm lipoma removal from left lateral thigh. For past 2 days, she had
swelling &mild increase in tenderness on and around incision site. Exam of incision site: bubble-
like swelling underneath incision w/o erythema, drainage or lymphadenopathy. Area is
ballotable & fluid wave on palpation.DX? - CORRECT ANSWER -*Seroma*=pocket of clear serous
FLUID -common after surgery
-ballotable means significant effusion
28 yo F G1P1 at 33 wks gestation in active labor. RR 22. Exam: nontender abdomen. fundal
height 36 cm. pelvic ultrasound shows pocket of amniotic fluid 91.5 mm. Underlying cause? -
CORRECT ANSWER -*Fetal esophageal atresia* (not fetal polycystic kidneys)
66 yo Irish American man has SOB on exertion for past 6 months, but now present when
climbing 1 flight of stairs. +Dry cough. Retired 1 yr ago from job in *Stone* quarry. Exam: finger
*Clubbing," end-expiratory crackles. CXR: fibronodular infiltrate in UPPER LOBES. Dx? - CORRECT
ANSWER -*Silicosis*
asbestosis - CORRECT ANSWER --construction & shipyard workers
-20 yrs after initial exposure
-dyspnea on exertion, cough, chest tightness, wheezing
-chest CT: pulmonary fibrosis
mesothelioma - CORRECT ANSWER -linked to asbestos exposure
-dyspnea, chest pain
-CXR: nodule thickening of pleura and/or obscuring of diaphragm
10 month old girl has 12 hr hx of intermittent colicky pain&vomiting. Dx 1 wk ago w/otitis media
and 10 day course of amoxicillin started at that time. P 168, BP 82/46. Infant is fussy. Observed
WITH CORRECT ANSWERS 2025/2026
65 yo F has a 3 month hx of *increasing low back pain*. Had low back pain for past 3 yrs that's
been treated w/NSAIDs and codeine. Now rated as 7/10 in severity. Pain radiates to both legs,
worsens when walking or standing & Relieved when sitting. 1 YEAR AGO: X ray lumbosacral
spine: mild osteoarthritis. Exam: 4/5 mm strength LE, hyporeflexia of knees&ankles b/, unsteady
gait b/c of pain. No other abnormalities. Most appropriate diagnostic study of lumbosacral spine
to order at this time? - CORRECT ANSWER -*MRI*
-prly b/c this pain is worse than the usual pain & neuro sx of hyporeflexia, decreased mm
strength, and unsteady gait
A couple comes to discuss the results of prenatal testing in current pregnancy. Screening test
showed increased risk for having a child w/Down syndrome. Amniocentesis is suggested for her.
Husband asks "When can we schedule the amniocentesis? I think that we should just get on
w/it." Wife responds angrily, "That's easy for u to say. U haven't been carrying this baby for 4
months & u haven't felt it move like I have. Appropriate response? - CORRECT ANSWER -"I know
this is difficult news for both of u. I would like to know what both of u are thinking now"
3 y.o. boy is at 50th %tile for height&weight. Exam: hemihypertrophy of left side of body when
compared to right. Palpable mass in LLQ. Labs: Hgb 12, Hct 36%, Urine: SG 1.020, WBC 0-1/hpf,
RBC 10-20/hpf. U/S: left kidney mass. Dx? - CORRECT ANSWER -*Wilms tumor*
-most common RENAL malignancy in kids
-age <5
-*Unilateral, PAINFUL, abdominal mass*
-HTN, hematuria
neuroblastoma - CORRECT ANSWER -most common extracranial solid tumors in kids
-painLESS abdominal mass
-may have HTN Due to mass compressing renal artery and activating renin-angiotensin system
,-FLUSHING &SWEATING due to catecholamine hypersecretion
-neural crest origin
-involves adrenal medulla, sympathetic chain
-median age <2
-*periorbital ecchymoses(orbital METASTASES)*
-spinal cord compression from epidural invasion("dumbbell tumor")
-opsoclonus-myoclonus syndrome
DX: elevated catecholamine metabolites, small&round blue cells on histology, N-myc gene
amplification
58 year old F has heavy substernal chest pain relieved by nitroglycerin & rest. Pain occurs
w/exertion&accompanied by some SOB&sweating. 6 months ago: CABG. VSS. ECG: NSR
w/*inverted T waves NEW in leads V4-V6.* next step in evaluation is to do which? - CORRECT
ANSWER -*Repeat coronary artery catheterization*->NOT order echo or MUGA scan
-maybe b/c of NEW inverted T waves?
70 yo has 1 wk hx left eyelid droop. PMG COPD&Quit smoking 5 yrs ago. Troublesome pain
radiating down left arm. Left ptosis w/small pupil on exam. Diagnostic study? - CORRECT
ANSWER -*CT scan thorax*
-prly pancoast tumor
65 yo F had 2 min generalized tonic-clonic seizure that occured when asleep. PMH: HTN, breast
cancer 2 yrs ago s/p lumpectomy, radiation therapy, adjuvant chemo 1 yr ago. Meds: lisinopril,
tamoxifen.Pt is drowsy, not oriented to person,place,time. BP 160/95. Pulse ox 95%.Exam: right
lower face drooping. Eyes conjugately deviated to left. Briskly withdraws LUE & both LE to
noxious stimuli; there's no movement of RUE. Fingerstick BG 70, serum sodium concentration
130. CAUSE of seizure? - CORRECT ANSWER -*Brain metastasis* prly from breast cancer
-looks like she got a stroke
, strongest predisposing factor for prostate cancer - CORRECT ANSWER -age (old)
32 yo F 6 day f/u for 12 cm lipoma removal from left lateral thigh. For past 2 days, she had
swelling &mild increase in tenderness on and around incision site. Exam of incision site: bubble-
like swelling underneath incision w/o erythema, drainage or lymphadenopathy. Area is
ballotable & fluid wave on palpation.DX? - CORRECT ANSWER -*Seroma*=pocket of clear serous
FLUID -common after surgery
-ballotable means significant effusion
28 yo F G1P1 at 33 wks gestation in active labor. RR 22. Exam: nontender abdomen. fundal
height 36 cm. pelvic ultrasound shows pocket of amniotic fluid 91.5 mm. Underlying cause? -
CORRECT ANSWER -*Fetal esophageal atresia* (not fetal polycystic kidneys)
66 yo Irish American man has SOB on exertion for past 6 months, but now present when
climbing 1 flight of stairs. +Dry cough. Retired 1 yr ago from job in *Stone* quarry. Exam: finger
*Clubbing," end-expiratory crackles. CXR: fibronodular infiltrate in UPPER LOBES. Dx? - CORRECT
ANSWER -*Silicosis*
asbestosis - CORRECT ANSWER --construction & shipyard workers
-20 yrs after initial exposure
-dyspnea on exertion, cough, chest tightness, wheezing
-chest CT: pulmonary fibrosis
mesothelioma - CORRECT ANSWER -linked to asbestos exposure
-dyspnea, chest pain
-CXR: nodule thickening of pleura and/or obscuring of diaphragm
10 month old girl has 12 hr hx of intermittent colicky pain&vomiting. Dx 1 wk ago w/otitis media
and 10 day course of amoxicillin started at that time. P 168, BP 82/46. Infant is fussy. Observed
