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First Aid USMLE Step 3 Questions And Answers With Complete Solutions
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First Aid USMLE Step 3 Questions And AnswersWith Complete Solutions
A 42 year old woman presents with HA, nausea, vomiting, and a red eye that has progressively
worsened since this morning. She also notes vision changes. Exam reveals conjunctival injection: a
mid-range fixed, dilated pupil: and no focal weakness in the extremities. What should you do next?
correct answer: Use tonometry to check IOP. A pressure of over 30 mmHg confirms the diagnosis of
acute closed angle glaucome. Emergent referral to ophthamology and possible hospitalization to
reduce IOP. Treatment includes topical BB (timolol), IV acetazolamide, and topical steroids.
A 71 year old man with a history of well controlled asthma presents in November for his annual
checkup. He has no complaints, and his PE findings are unremarkable. He received the
pneumococcal vaccine 3 years ago. What should be given before the completion of his visit? correct
answer: Annual influenza vaccination is recommended for all patients over 6 months of age who lack
contraindications (severe allergy/ anaphylaxis to egg protein). The live attenuated vaccine should not
be used in populations who are pregnant, immunosuppressed, or have taken influenza antiviral
medication within 48 hours.
A 68 year old woman is brought to your office because her son is concerned that she is losing her
memory. He describes several instances in which she forgot what he has just told her, adding that
she was recently unaware that he was calling to her at a crowded park. She spends most of her time
at home watching television. What is the diagnosis? correct answer: Presbycusis, or age related
hearing loss. Hearing loss in elderly persons must be evaluated. Patients may have difficulty
distinguishing voices in a crowd, which is often misinterpreted as memory loss. Patients may become
socially isolated.
A 24 year old medical student develops a rash when he puts on a pair of latex examination gloves.
What is the mechanism leading to this rash? correct answer: Allergic contact dermatitis is a result of
delayed contact (type IV) hypersensitivity caused by allergen-primed memory T lymphocytes (vs
irritant contact dermatitis, which results from cytokines released following irritant contact).
A 26 year old man presents with targetoid papules that appeared on his palms 2 days ago. He states
that he was recently prescribed a new antiseizure medication for his epilepsy. He denies any other
symptoms, and exam reveals no other lesions. What is the diagnosis? correct answer: Erythema
multiforme secondary to the new antiseizure medication. EM differs from Steven-Johnson syndrome/
toxic epidermal necrolysis in that lesions are genrally localized to the extremities (vs spreading from
the face and trunk), and the disease course is usually less severe.
A 71 year old man complains of a lesion on his right flank that was preceeded by tingling in the same
area 1 day ago. Exam reveals a 4 inch band of painful vesicles with secondary crusting and a clear
midline border. What test do you send to confirm your clinical diagnosis? correct answer: Although a
clinical exam is typically sufficient for the diagnosis of herpes zoster, a PCR of fluid from the lesion
can be confirmatory. NSAIDs may be useful for pain control, and antiviral therapy may speed
resolution and decrease the likelihood of postherpetic neuralgia.
A patient presents for evaluation of a pigmented skin lesions. Biopsy reveals melanocytes with
marked atypia characteristic of melanoma. What feature is the most important prognostic factor?
correct answer: Depth of invasion of the melanoma
, A 74 year old man presents with inability to maintain an erection. Although the problem started
several years ago, he states that he ignored it because he thought it was a normal part of aging. How
should the patient be counseled? correct answer: Although erectile dysfunction is associated with
age, it is still considered abnormal, and patients with erection difficulties should be adequately
evaluated for all potential causes.
A 70 year old man is prescribed terazosin for his benign prostatic hyperplasia. How does the drug
treat his condition, and what other medical condition does its mechanism of action address? correct
answer: Alpha blockers such as terazosin act on smooth muscle in the prostate, bladder neck, and
urethra. They also act on vascular smooth muscle, causing vasodilation; therefore, they can work to
lower HTN as well.
A 41 year old woman with woman with no significant medical history comes to your clinic for her first
checkup. Her mother has type 2 DM. Her PE findings, including BMI, are normal. Which screening
tests might you recommend? correct answer: A Pap smear and HTN screening. A diabetes workup
(fasting glucose test, HbA1c) is not needed as the patient is under 45 years of age with a normal BMI.
Given the patient's age, a screening mammogram is controversial. It is important to discuss the risks,
benefits, and alternatives of screening before proceeding.
A 58 year old woman with long standing HTN is admitted to the hospital with dyspnea on exertion and
bibasilar crackles, and you suspect heart failure. Which imaging modality would confirm your
diagnosis? correct answer: Transthoracis echocardiography (TTE). TTE provides specific information,
such as left ventricular ejection factor (LVEF) and diastolic compliance and relaxation, which can
confirm the diagnosis of systolic and diastolic heart failure. It also yields information about specific
etiologies or precipitants such as valvular or wall motion abnormalities.
A 54 year old business executive develops chest pain while at work. His vital signs remain stable.
The chest pain is partially relieved by nitroglycerin but worsens with cough and deep inspiration. He is
brought to the ED, where his ECG reveals diffuse ST-T elevations. His cardiac biomarkers are
normal. What is the appropriate treatment? correct answer: NSAIDs. The patient most likely has
pericarditis, which is a clinical diagnosis.
A 64 year old woman suddenly develops hypotension and SOB 1 day after CABG surgery. Exam
reveals JVD and muffled heart sounds, and bedside pulsus paradoxus is present. Besides ordering
an urgent echocardiogram, what are your next therapeutic steps? correct answer: Administer IV fluids
pursue emergent therapeutic pericardiocentesis or pericardial window.
A 65 year old Caucasian man who has a history of diabetes and is currently on meformin has BP
readings of 150/90 and 140/95 on multiple office visits. You start him on an ACEI, but he returns for
follow-up complaining of a dry cough with a measured BP of 145/92. What is your BP goal for this
patient, and what are additional options for treating his hypertension? correct answer: Thiazide
diuretics, CCBs, ACEIs, and ARBs are all therapeutic options. The BP goal for this patient would be
under 130/80. In light of his cough (a potential adverse effect of ACEIs), you could switch the patient
to an ARB and add a second medication to achieve goal BP.
A 69 year old hospital administrator presents to the ED with severe, tearing chest pain that radiates to
his back. CXR is unrevealing. Given your concern for potential aortic dissection, what is the next
diagnostic step? correct answer: Chest CT with IV contrast. TEE is appropriate for patients with a
history of allergic reaction to IV contrast.
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