Step 3 NBME questions with answers

1. A 64-year-old man is admitted to the intensive care
unit with pneumonia and septic shock. Over the past 4
days, he has had increasing shortness of breath and
fever. He has hypertension. Surgical history is
significant for a previous cholecystectomy. Medications
are amlodipine and hydrochlorothiazide.
On physical examination, temperature is 38.8 °C (98.8
°F), pulse rate is 110/min, respiratory rate is 22/min,
and blood pressure is 85/50 mm Hg. Cardiac examination
reveals a grade 2/6 systolic murmur. On pulmonary
examination, there are crackles over the entire right
lung field. There is trace pedal edema.
Laboratory studies on admission:
Laboratory StudiesGlucose 115 mg/dL (6.38 mmol/L)Blood
urea nitrogen 22 mg/dL (7.86 mmol/L)Creatinine 1.4 mg/dL
(123.79 μmol/L)Sodium 135 meq/L (135 mmol/L)Potassium
4.8 meq/L (4.8 mmol/L)Chloride 103 meq/L (103 mmol/L)Bicarbonate
10 meq/L (10 mmol/L)Albumin 3.8 g/dL (38 g/L)
Arterial blood gas studies (with the patient breathing
room air):
pH 6.94PCO2 48 mm HgPO2 51 mm Hg
Which of the following conditions is most likely present
in this patient?A Anion gap metabolic acidosisB Mixed
non–anion gap metabolic acidosis and respiratory
acidosisC Mixed anion gap metabolic acidosis and
respiratory alkalosisD Mixed anion gap metabolic
acidosis and respiratory acidosisE Mixed non–anion gap
metabolic acidosis and respiratory alkalosis
2.A 52-year-old woman with alcoholism comes to the
physician after a serum cholesterol level of 290 mg/dL
was found on a routine screening. She drinks a pint of
vodka daily. She takes captopril for hypertension and
glyburide for type 2 diabetes mellitus. She also has
intermittent episodes of gout.
Fasting serum studies show:
Total cholesterol 252 mg/dL HDL-cholesterol 80 mg/dL
Triglycerides 300 mg/dL Glucose 118 mg/dL
Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step
in management?
A) Alcohol cessation B) Better control of diabetes C)
Switch from captopril to calcium-channel blocking agent
therapy D) Gemfibrozil therapy E) Thyroid replacement
therapy

3. A 52-year-old woman with alcoholism comes to the
physician after a serum cholesterol level of 290 mg/dL
was found on a routine screening. She drinks a pint of
vodka daily. She takes captopril for hypertension and
glyburide for type 2 diabetes mellitus. She also has
intermittent episodes of gout.
Fasting serum studies show:
Total cholesterol 252 mg/dL HDL-cholesterol 80 mg/dL
Triglycerides 300 mg/dL Glucose 118 mg/dL
Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step
in management?
A) Alcohol cessation B) Better control of diabetes C)
Switch from captopril to calcium-channel blocking agent
therapy D) Gemfibrozil therapy E) Thyroid replacement
therapy

4.A 23-year-old man comes to the physician because of a
1-month history of intermittent right-sided abdominal
pain, nausea, and vomiting. He has sickle cell disease
and has been treated severaltimes for painful crises.
Examination of the abdomen shows tenderness to palpation
of the light upper quadrant on inspiration.
Laboratorystudies show:
Hematocrit 25%Leukocyte count 11,000/mm3Serum Bilirubin
Total 3.2 mg/dLDirect 0.3 mg/dLAlkaline phosphatase 56
U/L
Ultrasonography of the gallbladder shows a fillingdefect.
Which of the following is the most likely cause of this
patient's hyperbilirubinemia?
A) Aggregation of cholesterol in the gallbladder
B) Inhibition of glucuronosyltransferase
C) Lysis of erythrocytes
D) Malnutrition-induced cirrhosis
E) Neoplastic growth in the gallbladder

16. A 58-year-old white store manager comes to the
office for a periodic health evaluation. You have been
treating both the patient and his wife for the past 15
years. Today the patient is tearful and agitated. He
says that he is having difficulty with his son, who is
age 32 years and has schizophrenia. The son has been
living intermittently in a group home or on the streets.
The patient says that his son is noncompliant with his
antipsychotic medications. Recently, the son has been
calling the patient's house asking for money, which the
patient suspects his son uses to buy alcohol and illicit
drugs. It is most appropriate to advise the patient to
do which of the following?
A) Arrange an involuntary commitment to a psychiatric
hospital for his son
B) Ask his son's psychiatrist to adjust his medication
C) Change his phone number
D) Contact the local chapter of the National Alliance for
the Mentally Ill for support and advice
E) Obtain a restraining order against his son

17. A 20-year-old man comes to the health center because
of ankle pain. Two days ago he sustained an inversion
injury of his left ankle in a basketball game. He has
been able to walk unassisted since the injury. Today he
has pain and moderate swelling and discoloration over
the lateral malleolus. Physical examination shows
tenderness on palpation over the anterolateral corner of
the ankle joint. He has had two similar injuries in the
past. Which of the following is the most appropriate
initial management?
A) An ankle-strengthening exercise program
B) Application of a long-leg cast for 3 weeks
C) Application of a short-leg cast for 3 weeks
D) Protected weight bearing
E) Surgical repair of the ankle ligaments

18. A 52-year-old woman comes to the office because of a
4-day history of increasing pain of the right hip and
thigh. The pain is exacerbated by lying on her right
side while sleeping. She says the pain often awakens her
and is accompanied by a burning sensation along the
right side of her posterior thigh that radiates to her
knee. She usually has stiffness and pain in the hip
during the following morning that gradually diminishes
as she walks around her house and does house chores. She
says the pain is also triggered by sitting with her
right leg crossed over the left leg. The patient is
otherwise healthy and takes no medications. She is 168
cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23
kg/m2. Vital signs are normal. Physical examination
discloses tenderness on deep palpation of the right
trochanter. Which of the following is the most likely
diagnosis?
A) Arthritis of the hip
B) Aseptic necrosis of the femoral head
C) Bursitis
D) Gout
E) Osteosarcoma of the femoral head

8. An 18-year-old man comes to the health center because
he has had pain in his right leg for the past 5 days. He
says that he recently added jogging to his
weight-lifting workouts, and he started running 5 miles
per day 2 weeks ago. He is 180 cm (5 ft 11 in) tall and
weighs 83 kg (185 lb). On physical examination he has
moderate tenderness over the midtibia. X-ray of the leg
will most likely show which of the following?
A) A bone cyst
B) Displaced fracture
C) Metastatic disease
D) Soft-tissue calcification
E) Normal findings

9. A 47-year-old woman returns to the office because of
gastrointestinal symptoms. She says, "I still have
burning pain in my stomach that travels up my chest to
my neck after I eat." During the past 5 years she has
been treated with antacids, H2-blocking medications,
proton pump inhibitors and motility agents, with only
mild relief. She smokes one pack of cigarettes per day
and drinks one cup of coffee in the morning. There is no
family history of peptic ulcer disease. Previous
endoscopies, the last of which was 6 months ago, have
shown lower esophagitis secondary to reflux with healing
ulcers and scarring. Gastric and duodenal cultures for
Helicobacter pylori have been negative. Vital signs
today are normal. Physical examination, including rectal
examination, is normal. Which of the following is the
most appropriate next step?
A) Consider an alternative pharmacotherapeutic regimen
B) Continue current treatment
C) Do esophageal pH monitoring
D) Obtain surgical consultation
E) Repeat endoscopy
10.A 19-year-old college student
comes to the student health center because of
palpitations, shortness of breath and a runny nose. He
has asthma that he has treated with an over-the-counter
cold preparation and an epinephrine metered-dose inhaler
every 2 to 3 hours at night. He just used the
bronchodilator in the waiting room. Vital signs are:
temperature 38.2°C (100.8°F), pulse 82/min and
respirations 18/min. He appears to be somewhat anxious
and his breathing is labored. Auscultation discloses
mildly diminished breath sounds in all lung fields
accompanied by scattered wheezing. Which of the
following is the most appropriate management?
A) Add oral aminophylline therapy
B) Admit him to the hospital for respiratory therapy
C) Prescribe decongestant/antihistamine therapy
D) Prescribe antihistamine therapy
E) Substitute an albuterol nebulizer for the epinephrine

11. A 25-year-old man develops fever, muscle pain, and
headache 1 week after being bitten by several ticks
while camping near the Grand Canyon. The fever remits
and he feels better in 7 days. Two to four days later,
his symptoms recur. A Giemsa stain of a peripheral blood
stain shows intracellular bacterium. Which of the
following is the most likely explanation of the
reoccurrence of symptoms?
A) Expression of endotoxin-like structures on the
surface of the organism B) Migration of the organism
from a tissue site to the blood stream C) Production of
a toxin that had become suppressed during the infection
D) Secondary infection by a different organism of the
same species E) Variation of a major surface protein
antigen of the organism

12> A 4-year-old girl is brought to the emergency
department by her mother because of severe wrist pain.
The girl was playing with her friends in her backyard
and fell, breaking the fall with her outstretched hand.
On physical examination there is slight swelling over
the dorsal aspect of the wrist. X-ray films of the wrist
are shown.
The findings are most consistent with which of the
following?
A) Carpal navicular fracture
B) Cortical fracture of the radius
C) Fracture of the distal radius and ulnar growth plates
D) Fracture of the distal radius growth plate
E) Perilunate dislocation of the wrist

13> Which of the following is the most appropriate
management?
A) Apply an elastic bandage and apply ice packs to the
wrist
B) Do closed reduction of the fracture
C) Do closed reduction of the fracture and report the
case to child protective services
D) Immobilize the forearm and hand in situ in a cast
E) Prepare for open reduction and internal fixation

14.A 10-year-old boy is brought to the emergency
department because he developed hives and shortness of
breath 10 minutes after being stung by an insect. His
father tells you that he had a similar episode of
dyspnea and urticaria 2 years ago. Physical examination
now shows a frightened child who appears out of breath,
has generalized urticaria and asks for help in a hoarse
voice. Vital signs are: temperature 37.0°C (98.6°F),
pulse 120/min, respirations 36/min and blood pressure
70/40 mm Hg.
Which of the following is the most important first step
in managing this patient?
A) Administer diphenhydramine, orally
B) Administer epinephrine, subcutaneously
C) Administer oxygen via face mask
D) Establish intravenous access
E) Obtain arterial blood gas values

15> After 10 minutes there is no change in his
condition.
At this time, the most appropriate next step is to
administer which of the following?
A) Diphenhydramine, orally
B) Dopamine, intravenously
C) Epinephrine, subcutaneously
D) Prednisone, orally
E) Ranitidine, orally

16.> A 56-year-old white executive is admitted to the
hospital from the emergency department following a
severe nosebleed. One month ago he had a brief viral
illness after being exposed to an exanthem eruption of
one of his grandchildren. At that time the patient was
also referred to a urologist because of fatigue, low
back pain, and urinary frequency. He was diagnosed with
prostatitis, for which he has been taking
sulfamethoxazole-trimethoprim for the past 12 days. He
does not take any other medications. On arrival in the
emergency department vital signs were: temperature
36.8°C (98.2°F), pulse 100/min, respirations 16/min, and
blood pressure 120/66 mm Hg. The patient appeared pale
with scattered areas of bruising on his limbs and body
and a few petechiae. No lymphadenopathy or organomegaly
was found. Results of laboratory studies obtained in the
emergency department are shown:BloodUrineHematocrit
21%WBC 0/hpfHemoglobin 5.6 g/dLRBC 10–20/hpfWBC
2000/mm3MCV 102 ìm3Partial thromboplastin time 26
secPlatelet count 20,000/mm3Prothrombin time 12.8 secINR
1.3
Bone marrow biopsy shows marked hypocellularity.Which of
the following is the most appropriate management?
A) Administer granulocyte colony-stimulating factor
B) Administer high-dose short-term corticosteroids
C) Administer parenteral broad-spectrum antibiotics
D) Begin transfusion with whole blood
E) Discontinue sulfamethoxazole-trimethoprim

17> Supportive measures are provided for the patient.
Which of the following is the most appropriate treatment
recommendation for this patient at this time?
A) Chemotherapy
B) Follow-up evaluation in 1 week
C) Glucocorticoid therapy
D) Hematopoietic growth factor therapy
E) Stem cell transplant

18.Healthy 23 yr old comes to the office for health
maintenance exam. She has no complaints, does not smoke
or take alcohol. No signifincant family history. Vitals
are within normal limits, PE is also normal. PAP shows
ASCUS. What is the most appropriate next step?
1) Refer for colposcopy2) Set up repeat pap in 3
months3) Treat with Doxy and repeat pap in 3 weeks4)
Reassure and repeat Pap in one yr5) Obtain HPV testing
on sample

19.29 yr old F comes to your office for routine health
maintenance exam. She has H/O migriane headache, smokes
1 pk of cigarettes every 3 days, drinks alocohol on
weekends. Dad died of colon ca at 50, mom is diabetic.
She is taking no meds, Vitals are within normal limits
and physical exam is normal. PAP smear + for HSIL and
satisfactory colposcopy + for CIN-2. What is the next
step?
1) LEEP2) Cryosurgery3) Laser therapy4) Expectant
management5) Cold Knife conization
1.2.A3.D4.C5.e6.c7.c8.e9.d10.B11.E121314 B15 C16 D17 C
18.5 19.1.