Assessment Exam for

USMLE Step 3: *

Internal Medicine
Answers and Explanations

*USMLE is a joint program of the Federation of State Medical Boards of the United States, Inc. and the National Board of
Medical Examiners.
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 Internal Medicine Assessment Exam

1. A 65-year-old man with a history of diabetes mellitus 2. A 52-year-old alcoholic man comes to the emergency
type 2 comes to the clinic for a routine followup appoint- department (ED) with two episodes of hematemesis
ment. Over the past year he has noticed that he has had following a drinking binge. While in the ED, the patient
numerous episodes of weakness, lightheadedness, and has two more episodes of grossly bloody emesis. At this
sweatiness. Twice he has lost consciousness. At these times time the patient’s vital signs are remarkable for a blood
he has been found to have a low blood glucose level, and pressure of 92/60 mm Hg and a pulse of 120/min. The
his symptoms quickly improve with the administration of patient is disoriented and combative and unable to give
oral glucose gel or a sugary snack or piece of candy. The a coherent history, though he is well known to many of
man denies being ill, changing his diet or eating habits, or the emergency department staff. Physical examination
increasing his insulin dose. Indeed, he has been on the is remarkable for multiple spider angiomata, palmar
same dose of twice-daily NPH insulin for the last 3 years.
erythema, and hepatomegaly by percussion. Laboratory
Further, before this last year or two, the patient had found
studies show:
it extremely difficult to control blood glucose levels.
Long-standing diabetes has resulted in diabetic retinopa-
thy, a silent myocardial infarction 1 year ago, erectile dys- Hemoglobin 8 g/dL
function, and peripheral neuropathy. Today, vital signs Hematocrit 29%
and physical examination are unremarkable. Recent labo- Platelets 123
ratory studies show:
PT/INR 28 s/1.8
Blood, Plasma, Serum aPTT 103 s
Bicarbonate 24 mEq/L WBC 4500/mm3
Chloride 105 mEq/L
Two 16-gauge peripheral intravenous lines are placed,
Creatinine 2.7 mg/dL and a transfusion of fresh frozen plasma and blood is
Potassium 5.2 mEq/L begun. An infusion of a somatostatin analogue is begun
Sodium 131 mEq/L simultaneously, and the patient is transferred to the
Urea nitrogen 28 mg/dL intensive care unit. An emergent upper endoscopy
reveals bleeding esophageal varices that are treated suc-
Hematologic cessfully with rubber band ligation. Over the next couple
Hemoglobin A1c 4.9% of days the patient recovers and is prepared for discharge.
In addition to recommending abstinence from alcohol,
Of note, the patient’s hemoglobin A1c 1 year ago was 8% an appropriate medical treatment likely to reduce this
and 2 years ago was 9.5%. A urinalysis is remarkable for patient’s risk for recurrent bleeding is
2+ proteinuria. A chest radiograph is unrevealing,
whereas an electrocardiogram reveals Q waves in leads II, (A) famotidine
III, and aVF. Given this patient’s presentation, the most (B) misoprostol
likely cause of his repeated episodes of hypoglycemia is (C) octreotide
(A) development of insulinoma (D) omeprazole
(B) heart failure (E) propranolol
(C) noncompliance
(D) renal failure
(E) resolution of underlying diabetes

1
USMLE Step 3 Assessment Exam
3. A 70-year-old man comes to the office complaining of
knee and ankle pain. For the last couple of years he has
suffered from pain and swelling in his right knee and
ankle and has recently developed similar pain in his left
elbow. This winter the pain has been particularly severe,
prompting the man to seek help. The pain does bother
the man in the morning, when he feels stiff, but is usu-
ally worse at the end of the day. He denies any associat-
ed fevers, rash, or back pain. Past medical history is sig-
nificant for coronary artery disease, high blood pres-
sure, and a gastric ulcer. Current medications include a
daily baby aspirin, a beta-blocker, and an H2 receptor
blocker. Vital signs are normal, but examination of the
patient’s hands reveals mild swelling and nodularity of
multiple distal interphalangeal joints of the right hand.
Crepitation is present in the affected elbow and knee.
Although the joints are mildly swollen, they are not ten-
der or erythematous. Reviewing the patient’s past labo-
ratory studies reveals that he recently has had a normal
erythrocyte sedimentation rate and, aside from a slight
normocytic anemia, has had unremarkable routine lab-
oratory studies. Given this patient’s presentation, the
most appropriate treatment for control of his pain is to
(A) add acetaminophen
(B) begin capsaicin cream
(C) increase aspirin dose
(D) start an analgesic dose of ibuprofen (1200 mg/d)
(E) start an anti-inflammatory dose of ibuprofen
(2400 mg/d)
2
4. A 35-year-old man is rushed to the emergency depart-
ment after crashing his car into a tree late one Saturday
night. He sustains a femur fracture requiring an open
reduction and internal fixation. The operation goes well
and the patient is sent to the surgical step-down unit for
recovery. Over the next 2 postoperative days, he becomes
increasingly agitated and confused. He often does not
know where he is and suffers hallucinations and delu-
sions, seeing insects crawling up the walls and mistaking
shadows for devils. Laboratory studies are remarkable
for a mild transaminitis, including an elevated GGT, a
mild macrocytic anemia with a hematocrit of 36%, and
a mild hypokalemia and hypomagnesemia. Near the end
of postoperative Day 2, the patient suffers a short gener-
alized seizure that resolves before the house officer on
call arrives at the scene. Given this patient’s presenta-
tion, the most appropriate next step in this patient’s
management is to
(A) begin treatment with broad-spectrum antibiotics
(B) begin treatment with lorazepam
(C) provide daily beta-blocker and clonidine
(D) return to operating room for repair/replacement
of hardware
(E) start prophylactic phenytoin

5. A 66-year-old man comes to the emergency department
complaining of chest pressure. He is visibly sweaty and,
between breaths, explains that for the last 40 minutes he
has suffered band-like pressure across his left chest,
with some associated pain in his neck and shoulder. The
patient has never had pain like this before, but he has a
history of high blood pressure and diabetes and his
father died of a heart attack at age 58 years. The patient
receives oxygen and aspirin and is placed on a moni-
tored bed. Vital signs are temperature of 37.4 C (99.3
F), blood pressure of 144/88 mm Hg, pulse of 110/min,
and respirations of 28/min. Physical examination
reveals some mild chest wall tenderness, but is other-
wise unremarkable. The pain improves with some
nitroglycerin, and stat laboratory studies are sent. An
electrocardiogram is performed, and a concerned nurse
points out several abnormalities. An electrocardio-
graphic finding that would justify thrombolytic therapy
in this patient is
(A) diffuse T-wave flattening or inversions in all leads
(B) new-onset left bundle branch block seen in pre-
cordial leads
(C) new Q waves in lead 2, lead 3, and lead aVF
(D) new R-R′ pattern in precordial leads
(E) ST segment depression of >1 mm in the inferior/
lateral leads
Internal Medicine
6. A 24-year-old Mormon comes to the clinic complaining
of fatigue. He recently returned from a mission abroad,
where he had spread the gospel through central Africa.
Since returning from abroad, he has suffered progressive
fatigue to the point that he is no longer able to ride his
bicycle for more than a block without needing to rest.
Additionally, friends have remarked that, despite
months in the tropical sun, he appears quite pale. Over
the last 2 weeks the man also has noticed numerous
bruises on both of his legs. The young man denies any
recent fevers, chills, headaches, weight loss, night sweats,
or other systemic symptoms. The patient has not had
any recent respiratory infections, though he did have a
severe case of conjunctivitis in Africa, which was treated
with chloramphenicol eye drops. The conjunctivitis has
since resolved, and he has not taken any medications,
topical or otherwise, in months. A careful review of
social and sexual habits reveals no drug use or high-risk
sexual behavior. Family history is remarkable for an
uncle with prostate cancer and a grandfather who died
of colon cancer. Physical examination, aside from
marked pallor and some lower extremity ecchymosis, is
within normal limits. A complete blood count shows:
Hematologic
Hemoglobin 6.9 g/dL
Leukocyte count 2000/mm3
Platelets 38,000/mm3
Reticulocytes 0.2%
A chest radiograph and urinalysis are normal. The
peripheral smear, aside from a marked pancytopenia,
shows no abnormal cells or immature forms. Red cells
appear normocytic, there are no platelet clumps, and
few reticulocytes are seen. A bone marrow biopsy is
performed that shows marked hypocellularity with dif-
fuse fatty infiltration. Given this patient’s presentation,
the most appropriate management is
(A) evaluation for allogenic bone marrow transplan-
tation
(B) initiation of antithymocyte globulin and/or
cyclosporine
(C) treatment with granulocyte colony-stimulating
(GCSF) factor
(D) treatment with weekly injections of erythropoietin
(E) watchful waiting and blood product transfusions
as necessary
3
USMLE Step 3 Assessment Exam

7. Family members bring a 38-year-old woman to the 8. A 22-year-old homeless man arrives in the emergency
emergency department. The family members state that department complaining of fever, fatigue, a 2-week his-
the woman suddenly became confused, nonresponsive, tory of a cough, and occasional hemoptysis. A quick
and developed a right-sided facial droop. Furthermore, physical examination is remarkable for a temperature
approximately a month ago she was diagnosed with of 38.0 C (100.4 F), a faint diastolic murmur that
leukemia after a history of unexplained fevers and increases with inspiration, and obvious needle marks
weight loss. At that time she was started on all-trans- on the patient’s arms and legs. Without much resis-
retinoic acid. A quick evaluation in the emergency tance, the patient admits to prolonged drug and alcohol
department reveals a confused woman oriented only to use, including inhaled crack cocaine and intravenous
self, with left-sided hemiparesis and a left-sided heroine. Subsequent workup includes a chest radio-
Babinski sign. A stat head CT scan confirms the fears of graph, a transthoracic echocardiogram, three sets of
the emergency department attending physician; the blood cultures before antibiotics, and an electrocardio-
woman has suffered a right intraparenchymal hemor- gram. Results are as follows:
rhage. Laboratory studies show:
Chest radiograph Multiple cavitating
Hematologic nodular lesions
Hemoglobin 8.0 g/dL Echocardiogram Tricuspid vegetation
Leukocytes 2200/mm3 and regurgitation,
Platelets 52,000/mm3 normal ventricular
function
Prothrombin time 22 seconds
Partial thromboplastin time 55 seconds Blood cultures Highly resistant
methicillin-resistant
Additional laboratory studies reveal an elevated D- Staphylococcus aureus
dimer and reduced fibrinogen level. A peripheral smear (MRSA)
shows expected atypical cells with the presence of Auer Electrocardiogram Prolonged PR-interval,
rods and occasional schistocytes and helmet cells. Given otherwise within normal
this patient’s presentation, the form of leukemia she is limits
suffering from is
(A) M0undifferentiated Based on this patient’s presentation, the most com-
pelling reason to request a surgical consultation is
(B) M3promyelocytic
(C) M5monocytic (A) cultures indicating highly resistant organism
(D) M6erythroleukemic (B) no surgical treatment indicated at this time
(E) M7megakaryoblastic (C) presence of electrocardiogram abnormalities
(D) radiographic evidence of embolic events
(E) right-sided lesion associated with regurgitation

4
 Internal Medicine

9. A 58-year-old man comes to the clinic complaining of
weakness and leg pain. Approximately 10 days ago he
was started on ampicillin/sulbactam for treatment of
cellulitis, believed to be caused in part by a small ulcer-
ation between his toes. Since then his cellulitis has
resolved and he has completed the antibiotics this
morning as prescribed. For the past 2 days he has felt
slightly confused, has suffered generalized malaise and
weakness, and has had crampy pain in his legs. He
denies any fevers, rigors, cough, dysuria, or constitu-
tional symptoms. Vital signs are: temperature 37.0 C
(98.6 F), blood pressure 178/98 mm Hg (at previous
visit, 138/88 mm Hg), pulse 105/min, and respirations
20/min. Cardiac examination reveals a jugular venous
pressure of 10 cm/H2O, a regular tachycardia without
murmurs, and the presence of a rub. Auscultation of
the chest reveals faint bibasilar crackles, and there is 1+
pitting edema bilaterally. A maculopapular rash is pre-
sent across the patient’s back. The rest of the examina-
tion is unremarkable. Laboratory studies show:
Blood, Plasma, Serum
Creatinine, serum 6.9 mg/dL
Electrolytes
Sodium 135 mEq/L
Potassium 6.2 mEq/L
Chloride 108 mEq/L
Bicarbonate 14 mEq/L
Urea nitrogen, serum 88 mg/dL
10. A 34-year-old man comes to the office for follow-up for
an asthma attack. He presented to a local emergency
department wheezing and responded to beta-agonists
and steroids. Pulmonary function tests at that time indi-
cated an obstructive ventilatory defect and a low peak
flow consistent with acute bronchospasm. He has not
had asthma before, but over the past few years he has
developed severe episodes of nasal congestion and rhin-
orrhea, which he had assumed were caused by “hay
fever.” The only thing this man can think of that may
have triggered these past attacks and his recent episode is
the occasional use of ibuprofen or aspirin. Head and
neck examination is remarkable for some mild rhinor-
rhea, boggy turbinates, and the presence of two small
nasal polyps. Chest auscultation is unremarkable; there
are no wheezes or crackles. The rest of the examination is
normal. Given this patient’s presentation, an appropriate
treatment for his symptoms, in addition to a beta-agonist
rescue inhaler and the avoidance of aspirin, is
(A) aminophylline or theophylline
(B) epi-pen (SQ emergency epinephrine)
(C) nedocromil meter dose inhaler
(D) salmeterol meter dose inhaler
(E) zafirlukast or montelukast

Past laboratory studies indicate that the patient has

chronic renal insufficiency with a baseline creatinine of
2.8 mg/dL. A chest radiograph shows bilateral small
effusions and a normal appearing cardiac silhouette.
Additional workup is ordered that includes a urinalysis,
complete blood count, and a Wright stain for
eosinophils. The complete blood count is remarkable for
a high percentage (14%) of eosinophils. The urinalysis
reveals 2+ proteinuria, and the Wright stain is positive
for eosinophils. Based on this patient’s presentation, the
most appropriate treatment for his condition is to
(A) administer a fluid bolus to improve perfusion
(B) restart broad-spectrum antibiotics
(C) send him for immediate hemodialysis
(D) send him for percutaneous renal biopsy
(E) start a furosemide drip

5
USMLE Step 3 Assessment Exam

11. A concerned wife and son accompany a 71-year-old 12. A 44-year-old man comes to the walk-in clinic com-
man to the clinic. They state that the man has “not been plaining of fever, fatigue, and anorexia. For the past few
acting himself ” over the past 6 months and seems to months, the patient has been homeless and has basical-
have begun his decline a year ago. They are concerned ly been on one long, occasionally interrupted alcoholic
that the patient often seems to have difficulty finding binge. Over the last week, he has noticed that his skin
words, is frequently confused, and now gets lost walk- has a yellow tint. Vital signs are temperature of 38.3 C
ing home from the grocery store. The man in response (101.0 F), blood pressure of 107/60 mm Hg, pulse of
to these claims states that he is fine, though he does 105/min, and respirations of 14/min. Physical examina-
admit that his memory is not what it used to be. He tion reveals a disheveled, cachectic-appearing man who
denies any symptoms of depression and states he would smells intoxicated. He has mild scleral icterus and is
be fine if his family would quit imagining things. Before noticeably jaundiced. Lungs are clear to auscultation
this past year, the patient has been healthy most of his and his heart has a regular rate and rhythm. His
life and has had no major illnesses, head trauma or falls, abdomen is nondistended but is mildly tender in the
dietary deficiencies, or history of high blood pressure, right upper quadrant. The liver tip is 7 cm below the
diabetes, or strokes. Vital signs and general physical costal margin by percussion. There is no splenomegaly.
examination are within normal limits. A mini-mental Shifting dullness is not present. There is no palmar ery-
status examination, however, reveals dramatic deficits thema, spider angiomata, asterixis, or other stigmata of
in concentration and recent memory. A review of the chronic liver disease. Laboratory studies show:
patient’s medical records reveals a recent normal TSH
Blood, Plasma, Serum Hematologic Serology/Toxicology
level and normal routine laboratory studies. Based on
ALT 89 U/L PT 68 sec Acetaminophen Negative
this patient’s presentation, the most appropriate next
Alk phos 172 U/L INR 4.6 HBsAg Negative
test to diagnose his current condition is
AST 298 U/L PTT 70 sec HBcAg Negative
(A) brain biopsy of temporal lobe Bili (total) 10.0 mg/dL Anti-HBC Negative
(B) central nervous system acetylcholine level
A urinalysis and a chest radiograph are within normal
(C) magnetic resonance imaging of the brain limits. An ultrasound of the abdomen reveals an
(D) no additional testing necessary enlarged liver but no evidence of ascites. In addition to
(E) referral to neurology for neurodiagnostic studies abstinence from alcohol, the most appropriate interven-
tion that will likely improve this patient’s prognosis is
(A) albumin
(B) ceftriaxone
(C) octreotide
(D) prednisolone
(E) propranolol

6
 Internal Medicine

13. A 34-year-old man arrives at the office seeking help for 14.
a 4-month history of joint pain and a strange rash that
has developed over a similar period of time. The patient
reports pain in his right ankle and left knee that is par-
tially relieved with ibuprofen. Additionally, a strange
rash that he originally treated with an over-the-counter
antifungal cream is present on the soles of his feet. He
denies any previous history of joint pain or trauma and
has had no fevers, chills, weight loss, or other constitu-
tional symptoms. Vital signs are normal. Examination
reveals a mild redness of both eyes and a mild photo-
phobia. Cardiac and chest examinations are normal.
Palpation of the joints, particularly of the lower extrem-
ities, reveals some mild pain at the enthesis (site of
insertion of the ligaments, tendons, joint capsule, or
fascia to bone), but no marked erythema or crepitation.
The soles of the patient’s feet reveal thick scaly lesions
and macules and papules. The toenails are markedly
thickened, whereas the fingernails seem normal. Given
this patient’s presentation, the most important further
aspect of his history to obtain is
(A) family history of malignancy
(B) family history of skin disease
(C) occupational history and exposures
(D) previous dermatologic complaints
(E) recent sexually transmitted diseases (STDs) or
gastrointestinal illnesses
A 62-year-old woman comes to the clinic for a routine
physical examination. She has no significant complaints
and reports that she feels she is in excellent health. Her
past medical history is significant for diabetes mellitus
type 2 diagnosed 3 years ago. Since then she has
achieved good glycemic control with diet, exercise, and
a low dose of metformin. She has had no complications
related to her diabetes; she has no history of cere-
brovascular or coronary events, has an undetectable
microalbuminuria, and has had unremarkable ophthal-
mologic and podiatric examinations. Vital signs and
physical examination are within normal limits.
Laboratory studies show:
Blood, Plasma, Serum
Cholesterol
Low-density lipoprotein 131 mg/dL
High-density lipoprotein 43 mg/dL
Triglycerides 120 mg/dL
Fasting glucose 129 mg/dL
Hematologic
Hemoglobin A1c 6.8%
Given this patient’s presentation, the most appropriate
course of action regarding her lipid profile is to
(A) begin therapy with simvastatin, recheck lipid panel
in 3 to 6 months
(B) encourage exercise and dietary changes, recheck in
3 to 6 months
(C) increase metformin, recheck hemoglobin A1c and
lipids in 3 to 6 months
(D) no further action at this time, recheck lipid panel
in 1 year
(E) start therapy with gemfibrozil, recheck lipid panel
in 3 to 6 months

7
USMLE Step 3 Assessment Exam
15. A concerned nurse calls you at 2 AM to come see a
patient complaining of shortness of breath. The patient
is a 77-year-old man recovering from pneumonia on
the medicine floor. He reports the sudden onset of
shortness of breath and that he has some mild pain and
a funny feeling in his chest. He also reports feeling
incredibly weak and apparently became dizzy and fell
when trying to get out of bed to use the bathroom. Vital
signs at this time are temperature of 38.0 C (100.4 F),
blood pressure of 82/45 mm Hg, pulse of 170/min, and
respirations of 22/min. Examination reveals an irregu-
lar heartbeat without rubs, gallops, or jugular venous
distention. Lung fields are clear and there is no periph-
eral edema or cyanosis. The rest of the examination is
within normal limits. An electrocardiogram reveals an
irregularly irregular heart beat with p-waves with dif-
fering morphologies. The most appropriate treatment
for this patient’s condition is
(A) amiodarone bolus and continuous infusion
(B) either intravenous diltiazem or metoprolol
(C) emergent cardioversion at the bedside
(D) placement of a transvenous pacemaker, followed
by a permanent pacemaker
(E) urgent transesophageal echocardiogram, anticoag-
ulation, and cardioversion
8
16. A 74-year-old woman is sent to the emergency depart-
ment after being found in a confused state at her long-
term care facility. For the past 2 weeks she has been act-
ing “not quite herself.” According to nursing staff at the
facility, she has had a cough that seems worse during
meals, and occasional low-grade fevers, though no rig-
ors. Before this episode the patient had been fairly func-
tional but required physical therapy and nursing for a
recent stroke and resulting left-sided hemiparesis. Vital
signs on time of arrival are temperature of 38.0 C
(100.4 F), blood pressure of 108/68 mm Hg, pulse of
108/min, and respirations of 24/min. An oxygen satura-
tion obtained with the patient’s vital signs is 85%. The
woman is confused and oriented only to self. She has a
cough and produces some foul-smelling green sputum.
Physical examination is remarkable for inspiratory
crackles heard over the right mid lung zone and right
lung base. Tactile fremitus is increased in this area and
bronchial breath sounds are also present. Laboratory
studies show:
Hematologic
Leukocyte count 20,000/mm3
Neutrophils, segmented 70%
Neutrophils, band 18%
Hematocrit 35%
Platelet count 368,000/mm3
A urinalysis and routine set of chemistries are un-
remarkable. A chest radiograph reveals a patchy,
ill-defined opacity in the superior segment of the right
lower lobe, with a small area of central cavitation. Given
this patient’s presentation, the most appropriate treat-
ment is to
(A) begin trimethoprim/sulfamethoxazole and pred-
nisone
(B) obtain high-resolution CT scan of the lung
(C) order bronchoscopy with biopsy
(D) prescribe empiric ceftriaxone and azithromycin
(E) start empiric clindamycin

17. An 18-year-old woman comes to the office complaining
of recent bruising, severe nosebleeds, and heavy men-
strual periods over the last few weeks. Before this visit,
she has been healthy and, aside from a “bad case of the
flu” a month ago, cannot recall any recent illnesses or
symptoms. She specifically denies any fatigue, fevers,
chills, nausea, abdominal pain, or weight changes. The
woman does not take any medications and knows of no
illnesses that run in her family. Vital signs are tempera-
ture of 37.0 C (98.6 F), blood pressure of 118/78 mm
Hg, pulse of 96/min, and respirations of 14/min.
Physical examination is remarkable for a small amount
of dried blood on her nasal turbinates and multiple
petechiae on her buccal mucosa and on both lower
extremities. There is no hepatosplenomegaly and the
examination is otherwise within normal limits.
Preliminary laboratory studies show:
Hematologic
Hematocrit 37%
Leukocyte count 10,000/mm3
Neutrophils 60%
Lymphocytes 30%
Platelets 18,000/mm3
Prothrombin time 10 seconds
Partial thromboplastin time 25 seconds
A manual review of the blood smear by the laboratory
technician reveals some large platelets and rare platelet
clumps, but no abnormal cells or schistocytes. Given
this patient’s likely illness, the most appropriate first
line treatment is
(A) DDAVP or factor VIII replacement
(B) immediate platelet transfusion
(C) intravenous gamma-globulin (IVIg)
(D) 1 month of prednisone with taper
(E) transfusion of fresh frozen plasma
Internal Medicine
18. An 82-year-old nursing home patient comes to the clin-
ic for a routine healthcare visit. Although he has been
relatively healthy over the past year, he has had some
mild weight loss over the course of the year. The physi-
cian who makes weekly rounds at the nursing home
noticed that the patient appeared somewhat gaunt and,
on physical examination, noticed some “lumps and
bumps” in the patient’s neck. Labs were drawn and the
patient was advised to follow up with his primary care
physician. The patient denies any fevers, chills, night
sweats, abdominal pain, recurrent infections, change in
bowel habits, or history of bleeding. Physical examina-
tion is remarkable for bilateral cervical and supraclavic-
ular adenopathy. The nodes are firm, mobile, and non-
tender, with the largest node being approximately 2.5
cm. Cardiopulmonary examination is normal, but pal-
pation of the abdomen reveals some mild splenomegaly.
Laboratory study includes normal chemistries, liver
function tests remarkable only for a mild hypogamma-
globulinemia, and normal thyroid function tests. A
complete blood count, however, shows:
Hematologic
Hemoglobin 12.5 g/dL
Leukocytes 48,200/mm3
Neutrophils 10%
Lymphocytes 84%
Monocytes 5%
Platelets 152,000/mm3
A review of the blood smear reveals a predominance of
mature lymphocytes. The other cell lines seem to have a
normal morphology. Based on this abnormal smear, the
patient undergoes a bone marrow biopsy and has blood
sent for flow cytometry (cell marker studies). The bone
marrow smear shows a diffuse infiltration with mature-
appearing lymphocytes and an increased number of
megakaryocytes. Myeloid and erythroid cell lines seem
normal. Flow cytometry reveals a predominance of
CD20 and CD5 positive cells. Based on this presentation,
the most appropriate treatment plan for this patient is to
(A) begin treatment with high-dose chlorambucil
(B) begin treatment with low-dose chlorambucil
(C) follow up as needed or in 1 year, no treatment
(D) repeat CBC and examination in 3 months, no
treatment
(E) start pulse prednisone with prolonged taper
9
USMLE Step 3 Assessment Exam
19. A 55-year-old man comes to the office complaining of a
swollen left leg. The condition started approximately 2
days ago and seems to be getting worse. He denies any
recent immobilization, shortness of breath, fever, chills,
or pleuritic pain. The man does, however, report a past
history of coronary artery disease, high blood pressure,
and atrial fibrillation. Current medications include war-
farin and metoprolol. Inspection of the leg reveals an old
scar that the patient states is from a previous vein graft
for a coronary artery bypass 2 years ago and a distinct
area of erythema. The patient’s foot to mid-calf is warm,
erythematous, and tender to touch. The patient’s feet
show evidence of tinea, but the lower extremities are oth-
erwise unremarkable. Given this patient’s presentation,
the most appropriate next step in his management is
(A) complete blood count, set of chemistries, and
blood cultures
(B) duplex ultrasonography of the leg
(C) empiric antibiotics for gram-positive and gram-
negative organisms
(D) skin biopsy and culture of the edge of the erythe-
matous lesion
(E) venography of lower extremity
10
20. A 53-year-old, obese man undergoes spinal surgery for
multilevel spinal stenosis. The operation goes well but is
technically challenging, requiring a prolonged operat-
ing room course of more than 12 hours. During this
time, the patient is kept in the prone position to facili-
tate laminectomy. Postoperatively, the patient is moni-
tored in the ICU, where he is noted to have dark, rusty
urine and unexpectedly low urine output. Vital signs
are: temperature 36.8 C (98.2 F), blood pressure 120/77
mm Hg, pulse 100/min, and respirations 20/min. The
patient is intubated, but when sedation is weaned, he is
alert and oriented, follows commands, and does not
seem to be in any pain. Aside from diffuse muscu-
loskeletal tenderness over pressure points from the
operating room, the examination is unremarkable. A
quick urine dipstick reveals 3+ blood. Concerned about
rhabdomyolysis, the intern taking care of the patient
sends off a full panel of chemistries, a microscopic uri-
nalysis, an arterial blood gas, and a creatine phosphok-
inase level. An expected result of these tests would be a
(A) high arterial blood pH
(B) high urine red blood cell count
(C) low serum calcium
(D) low serum phosphate
(E) low serum potassium

21. A 22-year-old man comes to the office seeking treatment
for a cough and wheeze. His symptoms occur only inter-
mittently and usually are not too severe. However, he
recently went skiing, and had a severe episode requiring
nebulized treatments at an urgent care center. The man
sheepishly admits to smoking half a pack a day and real-
izes it may worsen his symptoms. His recent episode has
convinced him to quit, but he is worried that his symp-
toms will recur. The young man is otherwise quite
healthy. Physical examination reveals a well-appearing
man in no apparent distress. Vital signs are: temperature
36.7 C (98.0 F), blood pressure 124/88 mm Hg, pulse
68/min, and respirations 16/min. Auscultation of the
chest reveals no crackles, wheeze, or bronchial breath
sounds, and tactile fremitus is normal. The rest of the
examination is unremarkable. A chest radiograph
reveals clear lung fields and crisp, well rounded
diaphragms. The patient also receives evaluation with
spirometry and carbon monoxide diffusion testing.
Given this patient’s presentation, the most likely finding
on pulmonary function tests (PFT) is
(A) an abnormal elevation of flow rates using a peak
expiratory flow meter
(B) an FEV1/FVC ratio of less than 60 to 70% of pre-
dicted values
(C) an increase in the diffusing capacity for carbon
monoxide (DLCO)
(D) normal, with obstructive pattern following metha-
choline challenge
(E) a reduction in the total lung capacity, with pre-
served FEV1/FVC ratio
FEV = forced expiratory volume
FEV1 = forced expiratory volume in 1 second
Internal Medicine
22. A 25-year-old man is brought to the emergency depart-
ment in respiratory distress. He is brought in on a
stretcher, as he has been unable to get out of bed for the
last 5 days. A quick look at the man reveals that he is
having difficulty breathing. While speaking, he often
gets winded and has to stop and catch his breath. He
relates a recent history of weakness that started in both
of his ankles and, over the course of the week, extended
to include his legs, then hips, and finally his torso.
Today he has had extreme difficulty breathing and
states that the process is “exhausting.” Aside from a
recent episode of gastroenteritis characterized by gross-
ly bloody diarrhea, the man has been healthy. He denies
any systemic illnesses, intravenous drug use, or HIV
risk factors, though he does smoke marijuana and occa-
sionally binge drinks. Physical examination is remark-
able for flaccid paralysis of the lower extremities with
no deep tendon reflexes. Sensation is mildly reduced in
the lower extremities and torso, but cranial nerve exam-
ination is within normal limits. In addition to respira-
tory and other supportive care, an appropriate treat-
ment for this patient’s condition is
(A) antibiotics
(B) antitoxin
(C) interferon
(D) plasmapheresis
(E) steroids
11
USMLE Step 3 Assessment Exam
23. A 59-year-old woman comes to the clinic complaining of
pain in her hands. She states that her fingers are often
numb and tingling, particularly along her thumb and first
three fingers. The pain sometimes wakes her from her
sleep and requires her to shake her hands until normal
sensation returns. The pain, described as sharp tingling
preceded by numbness, is often worse after knitting, a
hobby she pursues with great vigor. Aside from this pain,
she complains only of mild fatigue and being overweight.
She denies any fevers, chills, visual changes, polyphagia/
polydipsia/polyuria, or other systemic symptoms. Past
medical history is remarkable only for depression, irrita-
ble bowel syndrome (constipation dominant), and high
blood pressure treated with a thiazide diuretic. Physical
examination shows mild wasting of the bilateral thenar
eminences of her palms. Tapping on her wrist increases
the pain, as does prolonged flexion of her wrists. Given
this patient’s presentation, an appropriate test to order
when working up the primary cause of her hand pain is
(A) antinuclear antibody titer
(B) hemoglobin A1c level
(C) no additional testing necessary
(D) thyroid-stimulating hormone
(E) urine pregnancy test
12
24. A 29-year-old man comes to the clinic complaining of a
burning in his chest. For the past year the patient has
had substernal, burning pain in his chest that is usually
present when going to bed. The pain is rated a 5 out of
10 on a pain scale and does not radiate, nor is it associ-
ated with any shortness of breath, nausea, or arm and
neck pain. The pain is exacerbated by large meals and
alcohol and is sometimes associated with burping and a
foul taste in the back of his mouth. Aside from these
symptoms, the man is healthy without any underlying
diseases. A review of symptoms does not reveal any
fevers, chills, weight loss, anorexia, dysphagia, or
odynophagia. Vital signs are temperature of 37.0 C
(98.6 F), blood pressure of 128/88 mm Hg, pulse of
72/min, and respirations of 16/min. Physical examina-
tion is unremarkable, as are a routine complete blood
count and set of chemistries. An electrocardiogram and
a chest radiograph are within normal limits. Given this
patient’s presentation, the most appropriate next step in
his management is to
(A) obtain a breath urease test for H. pylori
(B) recommend an empiric trial of omeprazole
(C) recommend that he avoid spicy foods
(D) schedule an elective upper endoscopy
(E) start a course of omeprazole/amoxicillin/
clarithromycin

25. A 37-year-old woman comes to the clinic complaining
of diarrhea. Over the past couple of months she has had
4 to 5 loose, brown bowel movements per day. Noticing
her fidgety nature, you ask some pointed questions. The
patient admits to having an unintentional, though
appreciated, 12-pound weight loss over the last 2
months. She also has significant heat intolerance; she
often feels hot and sweaty when other people feel that
the temperature is normal. Further, many of her friends
have noticed that she is irritable, though she attributes
this to her recent inability to get a good night’s sleep.
The woman’s vital signs are temperature of 38.0 C
(100.4 F), blood pressure of 152/92 mm Hg, pulse of
118/min, and respirations of 16/min. She is restless and
fidgety, has thin, fine hair, and displays a slight tremor
when she extends her hands. Ophthalmic examination
is remarkable for a stare and lid-lag and exophthalmos.
Her thyroid is diffusely enlarged and nontender, with-
out any palpable nodules. Cardiac examination is
remarkable only for tachycardia. The rest of her exami-
nation, with the exception of hyperactive reflexes, is
unremarkable. Laboratory studies are remarkable for
an elevated free T4, an undetectable thyroid-stimulating
hormone, and the presence of thyrotropin receptor
antibodies. The aspect of this patient’s presentation
most specific for her diagnosis is
(A) diarrhea
(B) exophthalmos
(C) goiter
(D) hyperreflexia
(E) lid lag and stare
Internal Medicine
26. A 66-year-old man is rushed to the emergency depart-
ment with massive rectal bleeding that began abruptly
and painlessly approximately 1 hour ago with a grossly
bloody, loose bowel movement. A nasogastric lavage is
performed, which is negative, and stat laboratory stud-
ies are sent. A complete blood count at this time reveals:
Hematologic
Leukocyte count 9000/mm3
Hemoglobin 7.8 g/dL
Platelet count 200,000/mm3
A transfusion of packed red blood cells is begun, and
the gastroenterologist on call is notified of the case. It
takes 3 hours to finally get the gastroenterologist and
endoscopy nurse ready for a colonoscopy. During this
time, the patient continues to bleed and requires addi-
tional blood. A colonoscopy is performed, but because
of massive, brisk bleeding, the exact source is uniden-
tifiable, though numerous diverticular outpouchings
are seen in the colon. Surgery then is contacted. After
an additional hour wait, surgical recommendations
are to contact interventional radiology. During this
time the patient continues to bleed and requires more
transfusions of packed red blood cells and continued
fluid boluses to maintain adequate blood pressure.
Interventional radiology agrees to perform an angiog-
raphy with embolization but does not have the neces-
sary staff until the morning. Over the next 5 hours the
patient continues to bleed briskly and continues to
require blood transfusions. In the morning the patient
is brought to the interventional radiology suite, where
he has a 2-minute tonic-clonic seizure. In addition to
embolization, an appropriate treatment for this
patient is
(A) calcium
(B) fresh frozen plasma
(C) lorazepam
(D) phenytoin
(E) potassium
13
USMLE Step 3 Assessment Exam
27. A 60-year-old man is being evaluated in the emergency
department for chest pain. While at the triage desk, he
suddenly clutches his chest and falls to the ground. He
is rushed to the emergency department, where you are
seeing patients. You immediately order that his airway
be maintained and that one of the nurses start provid-
ing positive pressure ventilation with a bag face mask.
The patient is hooked up to a cardiac monitor, and
intravenous access is obtained. Based on the monitor
readings and the patient’s lack of a palpable pulse, you
call for the defibrillator. After a series of shocks, the
patient is still in the same pulseless rhythm, and CPR is
resumed. At this point, the pharmacist providing ACLS
medications suggests that magnesium may be particu-
larly useful for this patient’s rhythm. This patient’s
rhythm, and the rhythm that is most likely to respond
to magnesium, is
(A) junctional tachycardia
(B) monomorphic ventricular tachycardia
(C) polymorphic ventricular tachycardia
(D) pulseless electrical activity
(E) ventricular fibrillation
14
28. A 19-year-old African American man is brought to the
emergency department in extreme pain. He states that
he has a history of sickle cell anemia and is now having
extreme chest pain that is worse when he takes a deep
breath. He also is having pain in his back and left ankle.
The pain began suddenly over the course of the day and
has been associated with a low-grade fever. The man
states that he has had pain like this before, and that it
usually requires hydromorphone for adequate pain con-
trol. He denies any recent fever, chills, diarrhea, dysuria,
fatigue, or other symptoms. His only outpatient medica-
tions are a combination of oxycodone/acetaminophen
and a daily multivitamin. Physical examination reveals a
young man in acute distress. Vital signs are temperature
of 38.0 C (100.4 F), blood pressure of 168/90 mm Hg,
pulse of 118/min, and respirations of 26/min. Physical
examination is remarkable for pallor, a systolic flow
murmur, and mild chest wall tenderness. The rest of the
examination is unremarkable. Laboratory studies fail to
reveal any evidence of infection, and the patient
improves with hydration, oxygen, and aggressive pain
management. When planning this patient’s discharge, a
treatment likely to reduce recurrences of the events pre-
cipitating this hospital admission is
(A) exchange transfusion
(B) folate supplementation
(C) home oxygen
(D) hydroxyurea
(E) transdermal fentanyl

29. A 52-year-old man comes to the emergency department
complaining of exquisite back pain that started earlier
in the morning. On further questioning, it seems that
the pain is actually along the left side of his abdomen
and flank, and radiates toward his groin. The pain is
described as sharp and occurring in waves and can last
for bursts of up to half an hour. He denies ever having
pain like this in the past. The only associated symptom
the man reports is some dark-colored urine. Past med-
ical history is significant for diabetes mellitus type 2,
complicated by diabetic nephropathy (baseline creati-
nine of 1.9 mg/dL), morbid obesity, and high blood
pressure, controlled with an ACE inhibitor. Vital signs
are: temperature 38.0 C (100.4 F), blood pressure
150/88 mm Hg, pulse 110/min, and respirations
22/min. Physical examination reveals an obviously
uncomfortable man who cannot seem to find a com-
fortable position on the examination table. Cardiac and
pulmonary examinations are normal, and his abdomen
is nontender. Although he states that his flank does
indeed hurt, the pain is not worse with palpation. A
dipstick urinalysis reveals a large amount of blood with
no white blood cells, leukocyte esterase, or nitrates pre-
sent. Given this patient’s likely condition, the most
appropriate and sensitive confirmatory diagnostic test
to order is a/an
(A) abdominal and renal ultrasound
(B) contrast enhanced CT scan of the abdomen/pelvis
(C) intravenous pyelogram (IVP)
(D) KUB (kidney/ureters/bladder) radiograph
(E) noncontrast spiral CT scan of abdomen/pelvis
Internal Medicine
30. A 66-year-old woman comes to the clinic complaining
of fatigue and back pain that have become progressively
worse over the past year. A quick review of her chart
reveals that she suffered a fracture of her left tibia 2
months ago when stepping off a curb. Her laboratory
studies are remarkable for a mildly elevated calcium and
a borderline elevated creatinine level, apparently missed
by the surgeons who treated her fracture. Suspicious of
a serious underlying condition, you order serum and
urine protein electrophoresis and a beta-microglobulin
level, and arrange for a bone marrow biopsy. Serum
electrophoresis is normal, but urine electrophoresis
reveals the presence of Bence-Jones protein. A beta-
microglobulin level is elevated, and the bone marrow
smear shows a marrow composed of 20% plasma cells.
The patient is understandably distraught when you tell
her the diagnosis. Her major concern in the short term
is preventing repeat fractures. The most appropriate
next test to look for potential pathologic lesions is
(A) computed tomography (CT) scan
(B) full body roentgenography (x-ray)
(C) magnetic resonance imaging (MRI)
(D) positron emission tomography (PET) scan
(E) technetium-99m uptake-scan (bone scan)
15
USMLE Step 3 Assessment Exam
31. A 48-year-old woman arrives in the emergency depart-
ment at 3 AM complaining of moderate to severe right
upper quadrant abdominal pain, fevers, sweats, and
chills. She has had intermittent right upper quadrant
pain over the last 2 months, but that pain has been brief
and intermittent and is described as dull and crampy and
often exacerbated by meals. Over the past day, however,
the pain has become more intense and unremitting and
feels as if it radiates through toward her upper back.
Directed questioning reveals a history of dark-colored
urine and light-colored stools. Physical examination
reveals a moderately overweight woman in obvious dis-
comfort. Her temperature is 38.4 C (101.1 F), blood
pressure is 100/70 mm Hg, pulse is 105/min, and respi-
rations are 16/min. Examination is remarkable for mild-
ly icteric sclera and a positive Murphy’s sign. Laboratory
studies are remarkable for a leukocytosis and a liver func-
tion panel revealing a cholestatic pattern. A right upper
quadrant ultrasound is ordered and is pending. Given
this patient’s presentation, the most important next step
in her management is to
(A) admit to medicine service and begin ticarcillin/
clavulanic acid
(B) arrange for emergent endoscopic ultrasound
(C) call GI fellow for endoscopic retrograde cholan-
giopancreatography
(D) call surgery to place T-tube for biliary decompres-
sion
(E) send patient to the operating room for exploratory
laparotomy
16
32. A 68-year-old man is brought to the emergency depart-
ment in respiratory distress. The man has a long history
of tobacco use and was recently diagnosed with chronic
bronchitis following pulmonary function tests that
revealed an obstructive ventilatory defect. Between pres-
sured breaths, the man reports having a recent increase
in the production of sputum, which now appears thick
and green, and some low-grade fevers over the past few
days. He is tachypneic and cyanotic and requires emer-
gency intubation. Once stabilized and transferred to the
intensive care unit, the patient is treated with intravenous
steroids, antibiotics, and nebulized albuterol and iprat-
ropium. The patient slowly improves and is eventually
extubated. Once stable, an arterial blood gas reveals:
pH 7.35
PCO2 60 mm Hg
PO2 52 mm Hg
This arterial blood gas is similar to one drawn in the
clinic approximately 2 weeks before his exacerbation.
Laboratory studies are also remarkable for an elevated
bicarbonate level and a normocytic anemia. In addition
to smoking cessation, the outpatient treatment most
likely to prolong this patient’s life is
(A) albuterol metered dose inhaler
(B) continuous home oxygen
(C) ipratropium metered dose inhaler
(D) pulmonary rehabilitation
(E) steroid metered dose inhaler

33. A 72-year-old woman comes to the clinic complaining
of a severe unilateral right-sided headache. The pain,
which she currently states is a throbbing 7/10, has built
up over the last 2 weeks, during which she has had near-
daily headaches. The headaches have been partially
relieved with acetaminophen, but given that they seem
to be intensifying, she finally decided to seek help. In
addition to her headaches, she has had blurred vision
out of her right eye for the past day and has been run-
ning a low-grade fever. She has never had symptoms
such as these before, but does have a past medical his-
tory that includes hypertension, hypercholesterolemia,
and polymyalgia rheumatica that recently has become
worse. Vital signs are temperature 38.0 C (100.4 F),
blood pressure 170/90 mm Hg, pulse 90/min, and res-
pirations 18/min. Examination is remarkable for signif-
icant tenderness anterior to the patient’s right tragus
and a visual acuity of 20/30 OS and 20/200 OD without
any photophobia. She has an erythrocyte sedimentation
rate of 100 mm/h and a normocytic anemia. Given this
patient’s therapy, the most appropriate next step in the
management of her condition is
(A) broad-spectrum antibiotics
(B) high-dose steroids
(C) lumbar puncture with CSF analysis
(D) MRI of the brain
(E) refer for a temporal artery biopsy
Internal Medicine
34. A 65-year-old man comes to the emergency department
after vomiting bright red blood twice at home approxi-
mately 4 hours ago. He has also had stomach pain for
the last 2 weeks. He denies any other symptoms and
specifically denies feeling dizzy, having any palpitations
or confusion, or having any chest pain. He also denies
weight loss, fatigue, anorexia, or persistent nausea. The
patient reports having severe osteoarthritis, for which
he has been taking high-dose indomethacin. He also
sheepishly admits to drinking “a fair bit” over the last
weeks, as there have been numerous holiday parties.
Vital signs are: temperature 37.0 C (98.6 F), blood pres-
sure 140/90 mm Hg, pulse 90/min, and respirations
20/min. Examination reveals some mild epigastric pain
on palpation, but is generally unremarkable. Stat blood
work reveals a hematocrit of 35%, compared with the
patient’s baseline hematocrit of 41%. A nasogastric
lavage is performed that reveals a large amount of dark,
coffee-ground material but no active bleeding. The
patient receives an intravenous H2-blocker and, the
next morning, an upper endoscopy. Endoscopy without
biopsy given the risk for bleeding shows a large gastric
ulcer and some diffuse gastritis. The ulcer seems to have
a clean base and distinct margins. Helicobacter pylori
testing is negative. In addition to acid suppression ther-
apy, an appropriate followup test for this patient is
(A) barium swallow study
(B) CT scan of chest, abdomen, and pelvis
(C) no further testing, follow patient clinically
(D) repeat H. pylori testing in 6 months
(E) repeat upper endoscopy and biopsy
17
USMLE Step 3 Assessment Exam
35. A 63-year-old man comes to the emergency department
complaining of shortness of breath and chest pain. The
symptoms began abruptly, just as he was pulling some
baggage off a Greyhound bus. He had just returned
from visiting his son, a good 2-day bus ride away. His
pain is worse with inspiration, and he has had two
episodes of coughing spells, resulting in blood-streaked
sputum. Further, over the course of the day the patient
has felt his heart racing, and he has developed a low-
grade fever. He has a history of lung disease, having
been diagnosed with silicosis 2 years ago after a workup
for pulmonary nodules and a chronic bronchitis.
However, he has never suffered symptoms similar to the
ones he currently has. Vital signs are temperature of
38.3 C (101.0 F), blood pressure of 158/98 mm Hg,
pulse of 110/min, and respirations of 28/min. Cardiac
and lung auscultations are unremarkable. An EKG
reveals sinus tachycardia with a right axis deviation.
The patient has no lower extremity edema, palpable
chords, and displays a negative Homans sign. The most
appropriate test to diagnose this patient’s acute condi-
tion is
(A) chest radiograph
(B) CT angiography
(C) D-dimer level
(D) pulmonary angiography
(E) ventilation/perfusion scan
18
36. A 28-year-old woman comes to the clinic complaining
of “tightness” in her hands. She states that the skin of
her hands feels taut, and that over the last 6 to 8 months
she has developed small, slowly healing ulcerations on
her fingertips. Before this she had suffered severe
Raynaud phenomena, but has never had ulcerations. A
careful review of systems reveals that the patient also
suffers from severe GERD symptoms, has a history of
recently diagnosed hypertension, and recently has
noticed severe shortness of breath with exertion. Vital
signs reveal a temperature of 37.0 C (98.6 C), blood
pressure of 155/95 mm Hg, pulse of 73/min, and respi-
rations of 18/min. Physical examination confirms the
presence of taut, sclerotic skin, occasional facial telang-
iectasias, and two small ulcerations at the tips of the
second and third digits of the right hand. Her fingers
are thin and spider-like. Chest examination reveals
good airflow. Cardiac auscultation reveals a widely split
S2, but is otherwise unremarkable. An autoimmune
antibody panel reveals the following:
Serologies
Rheumatoid factor Positive
Antinuclear antibodies Positive
Anticentromere antibodies Negative
Anti-SCL-70 (topoisomerase I) Positive
A complete blood count is remarkable for a normocytic
anemia with a hematocrit of 29%, and a set of
chemistries reveals a serum creatinine of 1.6 mg/dL.
Urinalysis reveals 2+ proteinuria. Given this patient’s
presentation, the most appropriate medication to start is
(A) hydrochlorothiazide
(B) ibuprofen
(C) lisinopril
(D) methotrexate
(E) prednisone

37. A 42-year-old man comes to the clinic complaining of a
lump in his neck. He noticed the neck swelling maybe a
month ago, but has not thought much of it, as he has
been too busy to come see a doctor. Because the lump
seems slightly larger, however, he is worried. The man
reports having Hodgkin lymphoma as a child, which
required radiation therapy to his chest and neck, and he
is worried that it may have recurred. He denies any dys-
phagia, odynophagia, hoarseness, or signs and symptoms
of hyperthyroidism. Family history is unremarkable for
any thyroid, head and neck, or other malignancies. Vital
signs are within normal limits. Palpation of the thyroid
reveals an enlarged, nontender gland with a large, firm
nodule in the lower pole of the right lobe. There is no
associated lymphadenopathy, and the rest of the exami-
nation is unremarkable. A chest radiograph obtained in
the office reveals calcification of the thyroid gland.
Thyroid studies are pending, and a fine needle aspiration
is scheduled for later in the week. If this patient’s nodule
is malignant, the most likely diagnosis is
(A) anaplastic carcinoma
(B) follicular carcinoma
(C) medullary carcinoma
(D) papillary carcinoma
(E) thyroid lymphoma
Internal Medicine
38. A 70-year-old man comes to the emergency department
complaining of substernal chest pain radiating to his left
arm. The pain occurred earlier in the day while he was
mowing his lawn and has since resolved. It was not asso-
ciated with nausea, shortness of breath, or diaphoresis,
and resolved with rest. The patient has had pain like this
before and states that it usually resolves with rest or a
sublingual nitroglycerin. Unfortunately, he recently ran
out of his medications and his concerned neighbor
insisted that he come to the emergency department. His
current medications include a beta-blocker, an ACE
inhibitor, an over-the-counter acetaminophen for pain,
a daily long-acting nitroglycerin pill, and sublingual
nitroglycerin as needed. Vital signs are: temperature 37.0
C (98.6 F), blood pressure 132/80 mm Hg, pulse 68/min,
and respirations 16/min. Cardiac examination reveals a
displaced, prominent point of maximal impulse and a
fourth heart sound. There is no jugular venous disten-
tion, peripheral edema, or murmurs, rubs, or gallops.
The rest of the examination is normal. An electrocardio-
gram shows large voltages in the precordial QRS com-
plexes, but no ST or T wave changes. The most appro-
priate course of management is to
(A) admit to cardiology for urgent cardiac catheteriza-
tion
(B) discharge with refills for 1 month and recommend
daily aspirin
(C) draw a set of cardiac enzymes, admit for monitor-
ing of serial enzymes
(D) order a stress echocardiogram or nuclear perfu-
sion study
(E) order a stress electrocardiogram as an outpatient
19
USMLE Step 3 Assessment Exam

39. An 84-year-old man is brought to the emergency
department after having an episode of hematemesis at a
skilled nursing facility. According to the nursing home
staff, the patient has not been feeling well for the past
week and, although he has taken his medications as pre-
scribed, he has not been eating or drinking much food
or fluids. The patient had some diarrhea that has
tapered off over the past few days, though some other
members of the nursing home have had similar prob-
lems. The patient’s past medical history is significant
for osteoarthritis, hypertension, and atrial fibrillation.
Current medications, some prescribed by the nursing
home physician and some by the patient’s previous
primary care provider, include acetaminophen, ibupro-
fen, hydrochlorothiazide, warfarin, and a recent course
of ciprofloxacin for gastroenteritis. Vital signs are tem-
perature of 37.0 C (98.6 F), blood pressure of 130/80
mm Hg, pulse of 110/min, and respirations of 16/min.
Physical examination is remarkable for multiple ecchy-
motic patches and some mild abdominal tenderness,
but is otherwise normal. Laboratory studies show:
Hematologic
Hematocrit 36%
Leukocyte count 9000/mm3
Neutrophils 64%
Lymphocytes 32%
Platelets 110,000/mm3
Prothrombin time/INR 120 s/10
Partial thromboplastin time 29 s
40. A 60-year-old man comes to the clinic complaining of
itchiness. After a warm bath or shower or after vigorous
rubbing of his skin, he suffers from severe pruritus, which
is relieved only partially with antihistamines (topical and
systemic), but seems to respond well to aspirin. An exten-
sive review of symptoms reveals vague complaints of
intermittent headaches and rare dizziness, but is other-
wise unremarkable. Past medical history is significant for
tobacco use, stage one hypertension, and obstructive sleep
apnea, treated 1 year ago with a surgical procedure to
reduce upper airway occlusion. At the time of the opera-
tion, the patient was told he had “high red blood” and to
follow up with his primary care physician, which he did
not do. The man denies any fevers, chills, night sweats,
changes in weight or appetite, fatigue, recent infections, or
other symptoms. Examination is remarkable for facial
plethora and a palpable spleen 2 cm below the left costal
margin. Reviewing the patient’s medical records, you find
a preoperative hematocrit level of 60% and suspect poly-
cythemia vera. If this is indeed the correct diagnosis, an
associated expected laboratory finding is
(A) low blood viscosity and red cell mass
(B) low leukocyte alkaline phosphatase level
(C) low serum cyanocobalamin level
(D) low serum erythropoietin level
(E) low white blood cell and platelet counts

Given this patient’s presentation, the most appropriate

initial treatment for his bleeding disorder is
(A) cryoprecipitate transfusion
(B) DDAVP
(C) platelet transfusion
(D) protamine
(E) vitamin K

20
 Internal Medicine

41. A 70-year-old woman is brought from a nursing home 42.
after having a witnessed grand mal seizure at her
daughter’s home, where the patient currently resides.
Apparently, she has had increased confusion over the
past day and has developed a low-grade fever over the
past few hours. She is now acutely disoriented and con-
fused. Past medical history is remarkable only for
hypertension and polymyalgia rheumatica, and current
medications include aspirin, a beta-blocker, and a pred-
nisone taper. Her temperature is 38.0 C (100.4 F), blood
pressure is 110/80 mm Hg, pulse is 78/min, and respi-
rations are 20/min. Ophthalmoscopic examination is
normal, without any papilledema, though mild photo-
phobia is present. Head and neck examination reveals
mild nuchal rigidity. The patient knows her own name,
but is uncertain where she is or what the date is. There
are no focal motor or sensory deficits, and toes are
downgoing bilaterally. Empiric ceftriaxone is started in
the emergency department, and the patient receives a
stat CT scan of the head, which is read as normal, with-
out evidence of increased intracerebral pressure. A lum-
bar puncture then is performed, and the patient is sent
to the medicine floor. Results of the Gram stain reveal a
predominantly neutrophilic leukocytosis, an extremely
low glucose relative to serum glucose, and an elevated
protein. Gram stain shows small gram-positive rods
and coccobacilli. The patient is continued on empiric
ceftriaxone. Twenty-four hours after admission to the
floor, she has another seizure that, despite appropriate
emergent treatment, results in a compromised airway
and subsequent respiratory arrest. An additional appro-
priate treatment that may have prevented this patient’s
condition is the empiric addition of
(A) acyclovir
(B) ampicillin
(C) dexamethasone
(D) piperacillin/tazobactam
(E) vancomycin
A 72-year-old man is brought to the emergency
department after being found to have an altered state
of consciousness. Over the past week he had become
increasingly confused at his nursing home, though the
nurse on duty reported that he has had normal vital
signs and has been afebrile. Aside from a chronic
cough, he had apparently been in good health over the
last few months. Physical examination reveals a mildly
disoriented man with some crackles and bronchial
breath sounds over his right middle lobe, but an other-
wise unremarkable examination. Initial chemistries are
remarkable for a sodium level of 121 mEq/L. A chest
radiograph reveals a large right-sided mass with indis-
tinct borders concerning for malignancy. Additional
studies are ordered to evaluate the patient’s hypona-
tremia, and are as follows:
Urine sodium 70 mmol/L
Urine osmolality 500 mOsmol/kg H2O
Serum osmolality 250 mOsmol/kg H2O
The patient is admitted to the medicine floor for fur-
ther evaluation and treatment. Given this presentation,
the most appropriate initial treatment for his hypona-
tremia is
(A) demeclocycline
(B) fluid restriction
(C) hydrochlorothiazide
(D) hypertonic saline
(E) normal saline

21
USMLE Step 3 Assessment Exam
43. A 30-year-old African American woman comes to the
clinic complaining of a chronic cough. Additional com-
plaints include aching joints and a strange rash on her
right tibia. These symptoms have bothered her for
approximately 2 months and seem to be getting worse.
Furthermore, over the last week she has suffered from
red eyes and occasional blurred vision. The cough is
worse with exertion, and she frequently needs to stop to
catch her breath. She denies any tobacco history, asth-
ma, recent travel, or relevant occupational exposures
and has not had similar symptoms in the past. The
woman has not suffered any recent fevers, chills, recur-
rent infections, weight loss, night sweats, or other con-
stitutional symptoms. Past laboratory studies have con-
firmed that the patient is HIV-negative and, 1 month
earlier, PPD-negative. Physical examination is remark-
able for some faint bilobar inspiratory crackles. Her leg
has multiple, tender, violaceous, subcutaneous nodules.
Further laboratory workup reveals an elevated calcium
level, an elevated erythrocyte sedimentation level, and
an elevated serum angiotensin level. Bilateral hilar
adenopathy is seen on a chest radiograph, together with
some basilar consolidation. Pulmonary function testing
with spirometry and carbon monoxide diffusion capac-
ity (DLCO) testing shows a mild restrictive defect with
reduction in the DLCO. Based on this patient’s presen-
tation, an expected finding with further workup is
(A) acid-fast bacillus seen on induced sputum smear
(B) elevated serum levels of 1,25-dihydroxy cholecal-
ciferol
(C) lymph node biopsy showing granulomas with cen-
tral necrosis
(D) prominent and severe reduction in CD4 cell count
(E) skin biopsy of rash that reveals noncaseating gran-
ulomas
22
44. A 70-year-old woman is being evaluated for a new-
onset dementia. Over the past year she has suffered
from increasingly severe cognitive deficits and has sig-
nificant difficulty with forming new memories, remem-
bering the names of children and grandchildren, and
can barely concentrate on simple tasks. Additionally,
her family reports that she now requires adult diapers
and has developed a clumsy walk and often falls.
Physical examination reveals a distracted, distant
woman in no apparent distress. She has a bradykinetic,
wide-based, shuffling gait, but does not have true trun-
cal ataxia or weakness. She speaks in few words, but is
alert and oriented to her surroundings and agrees that
she is not as sprightly as she once was. The mini-men-
tal status examination confirms deficits in near-term
memory, concentration, and executive functioning. The
rest of her examination is normal. Recent laboratory
studies have included normal thyroid studies, a normal
vitamin B12 level, a negative syphilis screening test, and
a normal complete blood count. A hyponatremia of 132
mEq/L was noted on a set of chemistries, but laborato-
ry studies have been otherwise unrevealing. A CT scan
reveals massive ventricular enlargement without signif-
icant sulcal atrophy. Based on this patient’s presenta-
tion, the most appropriate management is to
(A) begin treatment with carbidopa/levodopa
(B) begin treatment with vitamin E and donepezil
(C) explain that no further treatment is available
(D) refer for CSF shunt procedure
(E) slowly replete sodium to normal

45. A 48-year-old man is brought to the emergency depart-
ment after being found confused and incoherent in the
park. Apparently, the patient has a long history of
admissions for altered mental status and a history of
end-stage alcoholic cirrhosis. In the hospital he is som-
nolent but arousable. He is disoriented and does not
know the date or his current location. Vital signs are:
temperature 37.0 C (98.6 F), blood pressure 104/88 mm
Hg, pulse of 74/min, and respirations18/min. Chest is
clear to auscultation, and cardiac examination reveals
normal heart sounds without any murmurs, rubs, or
gallops. Percussion and palpation of the abdomen
reveal splenomegaly, though no hepatomegaly. Shifting
dullness is present, as is a visible fluid wave.
Examination of the skin shows multiple telangiectasias,
rhinophyma, and palmar erythema. Laboratory studies
show an elevated PT/INR, a decreased protein and
albumin, and a normal white blood cell count. A serum
venous ammonia level is elevated, and a urinalysis and
a chest radiograph are normal. The patient is given lac-
tulose by way of a nasogastric tube, and shortly after
having two large bowel movements seems more awake
and oriented. The most sensitive finding that would
support this patient’s likely diagnosis is
(A) asterixis
(B) fetor hepaticus
(C) flaccidity
(D) hyporeflexia
(E) nystagmus
46. A 49-year-old woman comes to the clinic complaining
of fatigue and weight gain. Over the past 6 months she
has felt as if she has no energy and has little interest in
doing much of anything. She does not feel that her
mood is down, but rather she seems to lack the energy
and volition to do much. Further, she has gained 10
pounds without any change in her diet. She feels cold
almost all the time and suffers from significant consti-
pation. Physical examination is remarkable for a visible
nontender goiter, dry, doughy skin, and deep tendon
reflexes with a delayed relaxation phase. The most
appropriate and first laboratory study to order to diag-
nose and follow this patient’s condition is
(A) free thyroxine (T4) index
(B) thyroid-stimulating hormone (TSH)
(C) thyroxine (T4), free
(D) thyroxine (T4), total
(E) triiodothyronine (T3), free
Internal Medicine
47. A 24-year-old woman comes to the clinic complaining
of joint pain. For the last couple of months, she has had
intermittent, diffuse joint pain, mainly in her hands and
wrists. Over the last month, she also has noticed some
swelling in her knuckles. Although her pain is con-
trolled with over-the-counter acetaminophen and
aspirin, she is worried that something more serious
may be occurring, as she has lost 20 pounds over the
past month, has had intermittent fevers, and feels tired
all the time. Past medical history is significant for a
“nervous breakdown” approximately 6 months ago
requiring a short hospital stay. Physical examination is
remarkable for a scaly, circular rash with a raised rim
and some central necrotic areas that spread over the
scalp and ears. Additionally, two small, shallow, pin-
point ulcers with clean bases are seen on the inside of
her lower lip. Examination of her digits reveals mild
warmth and erythema of the proximal interphalangeal
(PIP) and metacarpal (MC) joints. Laboratory studies
are remarkable for a positive ANA, a normocytic ane-
mia, positive anti-Smith and dsDNA antibodies, posi-
tive anti-RNP antibodies, and low complement levels.
The most specific finding characteristic of this patient’s
condition is
(A) her rash
(B) low complement levels
(C) positive ANA
(D) positive anti-RNP antibodies
(E) positive anti-Smith antibodies
23
USMLE Step 3 Assessment Exam
48. A 40-year-old woman comes to the emergency depart-
ment complaining of palpitations. Further questioning
reveals that these palpitations, which began last night,
also are associated with significant shortness of breath,
mild pleuritic pain, and a cough. She is a chain smoker,
though she knows she has to quit, but has no chronic
illnesses or history of cardiopulmonary disease. Her
only medication is an oral contraceptive pill. Vital signs
are temperature of 38.0 C (100.4 F), blood pressure of
134/88 mm Hg, pulse of 120/min, and respirations of
26/min. Chest auscultation reveals some mild inspira-
tory crackles and obvious splinting. The rest of the
examination is unremarkable. An electrocardiogram
reveals sinus tachycardia, with the presence of a large S-
wave in lead I, a small Q wave in lead III, and a flipped
T-wave in lead III. The patient is sent for a ventila-
tion/perfusion scan that reveals a large area of ventila-
tion without perfusion in her right lung. The patient is
started on a heparin drip and is admitted to the
medicine service. Based on this, the most appropriate
anticoagulation for this patient is
(A) daily aspirin or clopidogrel
(B) placement of a Greenfield filter
(C) 6 months of heparin
(D) 3 to 6 months of enoxaparin
(E) 3 to 6 months of warfarin
24
49. A 68-year-old man comes to the clinic complaining of
shortness of breath and difficulty sleeping. Apparently,
when he lies down he often feels as if he is drowning and
will sometimes wake at night gasping for air. He also
often wakes at night needing to use the bathroom, a
problem he did not suffer from until recently. When
walking or even climbing stairs, he is quickly winded
and needs to rest to catch his breath. Further question-
ing reveals a chronic cough, occasionally productive of
pink, frothy sputum, lower extremity swelling, and a 15-
pound weight gain over the past few months. His past
medical history is significant for two myocardial infarc-
tions, a history of hypertension, and borderline elevated
fasting blood glucose levels. The patient currently takes
a beta-blocker and a daily aspirin. Vital signs are: tem-
perature of 37.0 C (98.6 F), blood pressure 105/70 mm
Hg, pulse 110/min, and respirations 22/min. Physical
examination reveals bibasilar rales in his chest, a 2/6 sys-
tolic murmur heard over the apex, and a third heart
sound. Jugular venous pressure is approximately 10 cm
H2O, and the lower extremities display 2+ pitting
edema. The rest of the examination is normal. As part of
the patient’s workup, he receives an echocardiogram
that reveals anterior wall motion abnormalities consis-
tent with his previous myocardial infarction. The esti-
mated left ventricular ejection fraction is 20 to 25%.
Given this patient’s condition, he is started on treatment
for congestive heart failure. Among the agents available
to treat this patient’s condition, the drug most likely to
improve his chances of survival is
(A) digoxin
(B) furosemide
(C) hydrochlorothiazide
(D) spironolactone
(E) terazosin

50. A 68-year-old woman is referred to the clinic for a
preoperative evaluation before a left breast lumpectomy.
On a routine presurgical evaluation, she was found to
have an isolated prolonged partial thromboplastin time,
and the surgeon wishes to make sure that, if intraopera-
tive frozen sections warrant a more expansive operation,
the patient is not at risk for major hemorrhage. The
woman reports feeling well and, aside from a distant his-
tory of syphilis that she says was picked up by a labora-
tory study that was part of a military employment exam-
ination, she has been healthy. She has no major illnesses,
takes no medications, and can think of no illnesses that
affect herself, her parents, or her four healthy daughters.
Factor mixing studies are performed, but the patient’s
coagulation parameters do not improve. Although an
ANA and an FTA-ABS are negative, a Russell viper
venom test is positive. Based on this presentation, the
most appropriate treatment for this patient is
(A) daily vitamin K supplementation
(B) fresh frozen plasma before surgery
(C) no further treatment
(D) warfarin, goal INR of 2 to 3 seconds
(E) warfarin, goal INR of 2.5 to 3.5 seconds
51. A 56-year-old African American man comes to the office
for an annual health care checkup. As part of routine
healthcare maintenance, you offer the patient prostate
cancer screening, as his ethnicity and family history (an
uncle with prostate cancer) place him at risk for the dis-
ease. The man denies any current problems and has had
no weight loss, bony pain, change in appetite or weight,
or any other systemic symptoms. He denies any urinary
frequency, dysuria, nocturia, incomplete voiding, or
weak urinary stream. Digital rectal examination, howev-
er, reveals a firm, asymmetric prostate with a small, left-
sided nodule. A prostate-specific antigen (PSA) test is
ordered, the results of which should be available some-
time next week. In addition to a PSA test, an additional
appropriate test to order at this time is
(A) CT scan of abdomen and pelvis
(B) no additional tests at this time
(C) radionucleotide bone scan
(D) surgical biopsy
(E) transrectal ultrasound
Internal Medicine
52. A 48-year-old man comes to the emergency department
complaining of abdominal distention. He has a history
of hepatitis C-related cirrhosis and is currently on the
liver transplant waiting list. His cirrhosis has resulted in
edema and mild ascites, which have been controlled
with spironolactone and a low-sodium diet. Over the
past week, however, the man has noticed increasing
abdominal girth, despite continued use of his medica-
tions. His wife, who has accompanied the patient, also
notes that he has seemed more confused and has had
occasional low-grade fevers. The patient denies any
chills, headaches, nausea, severe abdominal pain,
change in stool color or consistency, cough, or dysuria.
Vital signs are: temperature 38.0 C (100.4 F), blood
pressure 108/80 mm Hg, pulse 90/min, and respirations
20/min. Physical examination is remarkable for scat-
tered telangiectasias, palmar erythema, and mild
splenomegaly. The patient’s abdomen displays bulging
flanks, shifting dullness, and a positive fluid wave. The
abdomen is tender but soft, and there is no guarding or
rebound tenderness. Abdominal sounds are normal.
Laboratory studies show:
Hematologic
Leukocytes 9000/mm3
Hematocrit 31%
Platelets 78,000/mm3
PT 20 seconds
PTT 28 seconds
A chest radiograph reveals a small, right-sided effusion,
but no infiltrates, and a KUB film is essentially normal.
A therapeutic paracentesis 1 month ago was normal.
Based on this patient’s presentation, the most appropri-
ate next step in the management of his condition is to
(A) add furosemide to medication regimen
(B) begin empiric cefotaxime immediately
(C) order abdominal CT scan and/or ultrasound
(D) perform diagnostic paracentesis
(E) perform diagnostic thoracentesis
25
USMLE Step 3 Assessment Exam

53. A 45-year-old woman comes to the urgent care clinic
complaining of abdominal pain. For the last 2 days she
has had pain in her lower abdomen and right flank,
and has felt weak and feverish. She reports diffuse
severe nausea and vomiting, fatigue, and increased uri-
nary frequency. The woman denies any recent sexual
contacts, but notes that she has had chlamydia in the
past, which was treated successfully 2 years ago. Vital
signs are: temperature 39.2 C (102.5 F), blood pressure
138/90 mm Hg, pulse 108/min, and respirations
18/min. Examination is remarkable for suprapubic
tenderness and right costovertebral angle tenderness.
The rest of the examination, including bimanual pelvic
examination, is unrevealing. Laboratory studies show:
Urinalysis
3+ leukocyte esterase; 3+ nitrate; many WBCs
and bacteria; trace protein
Gram stain
Many gram-negative bacilli (urine)
Urine culture
Results pending
CBC and differential
Results pending
On the basis of these results, the woman is admitted to
the medicine service for intravenous antibiotics. An
additional appropriate confirmatory test to order at this
time is a(n)
(A) abdominal and renal ultrasound
(B) CT scan of abdomen and pelvis
(C) intravenous pyelogram (IVP)
(D) KUB radiograph
(E) no additional tests
54. As an upcoming intern, your hospital requires you to
take a host of employment-related examinations. In
addition to hours of standardized testing, you need to
prove prior immunization status, have a general physi-
cal examination, and have a PPD test for tuberculosis.
Your immunizations are up to date, and you pass your
physical examination with flying colors. The test for
tuberculosis exposure, however, makes you anxious.
Although you are not immunocompromised and do
not have any chronic diseases, travel exposures, or
known TB contacts, you have heard of unsuspecting
interns being subjected to a prolonged course of INH
therapy. The PPD is placed, and you are told to come
back in 2 days. Given this scenario, a positive PPD
would be
(A) an area of erythema greater than 5 mm
(B) an area of erythema greater than 10 mm
(C) an area of induration greater than 5 mm
(D) an area of induration greater than 10 mm
(E) both erythema and induration greater than 15 mm
55. A 62-year-old man is brought to the clinic by his
concerned spouse. Over the past 6 months, the woman
tells you that her husband has not quite been himself.
He often stares into space, barely speaks, and often
seems slow to respond to questions. She has noticed
that he tries not to walk, because when he does he often
seems to fall. As a result, she tells you, he walks slowly
and with a slow, shuffling gait. Physical examination
reveals a well appearing but distracted elderly gentle-
man. He has little facial expression and takes a long
time to answer questions, though he is appropriate
when he finally does speak. His movements are
markedly bradykinetic and he has an obvious tremor
that improves with focused movement. Recent labora-
tory studies are unremarkable. Based on this presenta-
tion, the treatment most likely to delay the progression
of this patient’s condition is
(A) amantadine
(B) carbidopa/levodopa
(C) donepezil
(D) sertraline
(E) vitamin B12 and folate

26

56. A 56-year-old man awaiting a liver transplant comes to
the clinic complaining of increased abdominal girth.
He suffers from hepatitis C cirrhosis complicated by a
variceal bleed, portal gastropathy, and mild to moderate
ascites. This ascites has gotten worse over the last 1-2
weeks. The man’s pants can no longer be buttoned and
he has gained 12 pounds. He denies any fevers, chills, or
abdominal pain and has not been more confused than
usual. He has not changed his diet and is meticulous
about taking his medications regularly, which include
furosemide and spironolactone. Vital signs are unre-
markable, and physical examination, aside from an
obvious fluid wave and pronounced shifting dullness, is
unchanged from previous examinations. A diagnostic
paracentesis reveals the presence of a small number of
leukocytes (100/mm) and no organisms on Gram stain.
An ultrasound is then performed that, because of the
man’s girth, is technically difficult. The liver is visual-
ized and seems to have no clot in the hepatic veins or
visualized portion of the inferior vena cava. The liver
appears nodular and small and seems to have a 3-cm
mass in the right lobe. The most appropriate addition-
al laboratory study to order to determine if this mass
represents a hepatoma is
(A) alpha-fetoprotein (AFP)
(B) beta-human chorionic gonadotropin (β-hCG)
(C) cancer antigen 125 (CA-125)
(D) carcinoembryonic antigen (CEA)
(E) prostate-specific antigen (PSA)
Internal Medicine
57. A 48-year-old woman with long-standing diabetes mel-
litus comes to the office for a routine checkup. She is
extremely compliant and has a good understanding of
the disease. Her regimen includes a mix of NPH insulin
taken twice a day and regular insulin taken before
meals. She is concerned, as she has noticed that her
blood sugar levels recently have been less controlled
than normal. Although she admits that her diet has
changed somewhat since she started taking Thai
cooking classes, she feels she has adjusted her insulin
appropriately. Her only other complaints, aside from
morning hyperglycemia, are fatigue and poor sleep.
Over the past few weeks she has had numerous episodes
in which she wakes early in the morning or late at night
with shakes, chills, and occasional sweats. The symp-
toms resolve with drinking some orange juice or taking
a small snack, and she feels better in the morning,
though her blood sugar often is then elevated at 200 to
300 mg/dL. Given this patient’s presentation, the most
effective strategy for controlling her blood glucose lev-
els and nocturnal symptoms is to
(A) decrease the dose of evening NPH insulin
(B) decrease the dose of regular insulin before dinner
(C) encourage the patient not to have nocturnal snacks
(D) increase the dose of morning NPH insulin
(E) increase the dose of regular insulin before breakfast
27
USMLE Step 3 Assessment Exam
58. A 54-year-old woman comes to the emergency depart-
ment complaining of severe substernal chest pain and
difficulty breathing for the last 45 minutes. The woman
has a long list of cardiac risk factors, including tobacco
use, hypertension, dyslipidemia, and a family history of
coronary heart disease. In addition, she suffers from
severe rheumatoid arthritis, for which she has been tak-
ing prednisone, and obstructive sleep apnea. An elec-
trocardiogram reveals large ST segment elevations in
leads V1 through V6, and, because a cardiac catheteri-
zation laboratory is not available in the hospital or sur-
rounding area, the patient receives intravenous tissue
plasminogen activator (tPA). Despite early reperfusion,
she develops cardiogenic shock from a massive anterior
myocardial infarction, requiring intubation and treat-
ment with intravenous dobutamine. Over the next 4
days, the patient is weaned slowly from the dobutamine
as her cardiac function improves. When the sedation is
lowered and the patient is planned to be extubated,
however, she is unable to move her arms or legs and is
unable to create a high negative inspiratory force dur-
ing ventilator weaning trials. She can, however, open
and close her eyes on command and seems to under-
stand what is said to her. The most likely cause of this
patient’s current symptoms is
(A) atlantoaxial subluxation
(B) cervical epidural hematoma
(C) hypoxic brain damage
(D) intracerebral hemorrhage
(E) long-term prednisone use
28
59. A 57-year-old homeless man comes to the emergency
department complaining of vomiting bright red blood
after drinking his usual fifth of vodka. The patient is
hemodynamically stable, has a stable hematocrit of
38%, and has no bright red blood from nasogastric
lavage, though copious amounts of coffee grounds are
present. Hearing this over the phone, the gastroenterol-
ogy fellow on call decides to delay upper endoscopy
until the morning. The patient is made NPO and is
placed on intravenous maintenance fluids, specifically
D51/2NS at 100 mL/h. Early in the morning the patient
has three large, maroon, foul-smelling bowel move-
ments and begins to vomit bright red blood. Over the
next 6 hours, the patient receives 5 L of crystalloid
(D5NS) and 6 U of colloid (4 U of packed red blood
cells and 2 U of fresh frozen plasma). He requires intu-
bation to control his airway and receives a bedside
upper endoscopy in the intensive care unit. Diffuse gas-
tritis and a large bleeding peptic ulcer are seen. The
ulcer is clipped and injected with epinephrine and the
bleeding stops. Over the next 2 days, the patient is
weaned from ventilatory support. When the patient is
finally extubated, however, he is found to be confused
and inattentive to examination. He has bilateral lateral
rectus palsies and significant nystagmus. When physical
therapy attempts to walk the patient, he is unable to
maintain a steady stance and immediately falls over.
The treatment most likely to have prevented this
patient’s current condition is
(A) calcium
(B) folate
(C) magnesium
(D) vitamin B1
(E) vitamin B12
 Internal Medicine

60. A 72-year-old man comes to the office complaining of 61. A 44-year-old African American man comes to the clin-
leg pain. The man is well known to you, as he has a long ic for a routine checkup. Over the past year the man has
history of vascular disease, including two previous suffered from mild arthralgias, intermittent abdominal
myocardial infarctions and a carotid endarterectomy pain, and worsening fatigue. Additionally, he has devel-
following a stroke 2 years ago. Since his stroke the man oped erectile dysfunction, stating simply that he has lost
has regained his ability to walk, after completing a long the volition and ability to have sex. He has no idea why
rehabilitation program. Now when he walks even half a he is suffering from these problems and denies any
block, however, he suffers dull, crampy pain in his left depressive symptoms. Before this, he has been healthy
calf. The pain improves with rest and has never woken and does not smoke, drink, or use any illicit substances.
him from sleep, but it is making it nearly impossible for Aside from a father who died of diabetes, there are no
him to complete his regular daily activities or to com- family medical problems. Examination is remarkable
plete his “heart healthy” exercise routine. Current med- for hepatomegaly and a faint bronze hue to the skin. A
ications include baby aspirin, clopidogrel, metoprolol, review of recent laboratory studies reveals that the
simvastatin, and lisinopril. Physical examination reveals patient has a moderate transaminitis and an elevated
diminished left-sided posterior tibialis and dorsalis fasting blood glucose level. An iron panel shows:
pedis pulses. Further, the left foot appears shiny and
hairless and, when elevated, displays an increase in pal- Blood, plasma, serum
lor. An ankle-brachial index reveals: Iron, serum 420 µg/dL
Ferritin, serum 1580 ng/mL
Left lower extremity 0.5
Iron-binding capacity Low
Right lower extremity 0.9
Based on these results, the most appropriate treatment
The man is not interested in surgery and mainly wishes to
for this patient is
be able to walk further than he currently can. The medi-
cal treatment most likely to improve his symptoms is (A) deferoxamine
(A) adding cilostazol (B) ferrous sulfate
(B) adding pentoxifylline (C) liver transplant
(C) increasing the dose of aspirin (D) penicillamine
(D) stopping clopidogrel (E) phlebotomy
(E) stopping metoprolol

29
USMLE Step 3 Assessment Exam
62. A 59-year-old man comes to the clinic for a routine
health care checkup. He denies any recent change in his
health, though his chronic bronchitis is, as always, both-
ering him. He coughs throughout the winter, often pro-
ducing a thick, white sputum, and has done so for years.
Despite this, he continues to smoke at least one pack of
cigarettes per day, though he has cut down. In addition
to chronic bronchitis, the patient suffers from hyperten-
sion controlled with a thiazide diuretic, dyslipidemia
well treated with a statin, and benign prostatic hyper-
plasia. The man wishes to discuss cancer screening. He
has had a colonoscopy, prostate examination, and, at his
request, has had a prostate specific antigen level checked,
all of which were normal. He is concerned about his
lungs, however. The man realizes he is at risk for lung
cancer and wants to know if he should “get some x-rays
or something.” Physical examination and laboratory
studies are essentially unchanged from 6 months earlier.
The patient’s last chest radiograph was 4 years ago when
he was diagnosed with bronchitis, and he has never had
a CT scan or a sputum cytologic examination. Based on
this patient’s presentation, the most appropriate lung
cancer screening strategy is
(A) annual chest radiograph
(B) annual radiograph and sputum cytology
(C) annual sputum cytology
(D) CT scan of the thorax every 5 years
(E) no additional screening examination necessary
30
63. A 32-year-old man comes to the clinic for a routine visit.
He has recently immigrated from China and wishes to
be treated for his liver disease. In China, he was told that
he has had hepatitis since birth, but has never been
treated. Aside from occasional right upper quadrant
pain and fatigue, he reports otherwise being in good
health. He has a normal appetite and denies any fevers,
chills, nausea, vomiting, bleeding, weight gain or loss, or
change in abdominal girth. Past medical history is sig-
nificant for depression, currently treated with sertraline,
and, according to the patient, finally under reasonable
control. Vital signs and physical examination are unre-
markable. Laboratory studies reveal a mild transamini-
tis with an AST of 58 U/L and an ALT of 62 U/L, an
undetectable alfa-fetoprotein level, and a normal CBC
and set of chemistries. A hepatitis panel shows:
Hepatitis A antibody (IgG) Positive
Hepatitis B surface antibody Negative
Hepatitis B surface antigen Positive
Hepatitis B E antigen Positive
Hepatitis C antibody Negative
An ultrasound of the liver reveals a mildly enlarged liver
with normal consistency and ductal architecture. Based
on this patient’s presentation, the most appropriate ini-
tial therapy is
(A) interferon monotherapy
(B) interferon (pegylated) and ribavirin
(C) lamivudine (3TC) monotherapy
(D) no additional treatment necessary
(E) ribavirin monotherapy
 Internal Medicine

64. A 52-year-old woman comes to the clinic complaining 65. A 60-year-old man with a history of ischemic car-
of flank pain. The pain comes in waves and radiates to diomyopathy comes to the emergency department
her groin. She describes it as unbearable and being an short of breath. Over the last week he has suffered sig-
11 on a pain scale of 1 to 10. The pain started earlier in nificant lower extremity edema and has had to sleep on
the day and has occurred intermittently, lasting for two pillows to minimize a feeling of suffocation. He
upwards of an hour. There has been no associated nau- admits to running out of his usual medications approx-
sea, vomiting, fever, or chills. She has never had pain imately a week earlier and has been too busy to get his
like this before, but does have a past medical history sig- prescriptions refilled. Examination reveals a man in
nificant for poorly controlled diabetes and recurrent moderate discomfort who has difficulty completing his
urinary tract infections. Vital signs are: temperature 38 sentences when speaking. Vital signs are: temperature
C (100.4 F), blood pressure 149/90 mm Hg, pulse 37 C (98.6 F), blood pressure 108/70 mm Hg, pulse
105/min, and respirations 20/min. The woman appears 105/min, and respirations 22/min. Auscultation of the
uncomfortable and seems unable to find a comfortable lungs reveals bilateral basilar crackles, reduced breath
spot on the examination table. There is no costoverte- sounds in both bases, and dullness to percussion over
bral angle tenderness, though she has mild suprapubic the lower thorax. An S3 gallop is heard and 2+ clubbing
tenderness. She states her right flank hurts, but the pain edema is present in both lower extremities. An electro-
changes only minimally with palpation. A dipstick uri- cardiogram is unchanged from a previous one 4
nalysis shows: months earlier, and a set of cardiac enzymes is negative.
A chest radiograph shows an enlarged cardiac silhou-
Urine ette, interstitial fluid extending to pleural surface,
pH 9.0 cephalization of the blood vessels, and mild to moder-
ate bilateral effusions. The intern working the emergen-
Glucose 1+
cy department performs a thoracentesis and sends the
Protein 3+ pleural fluid to the laboratory for analysis. The most
Nitrite 1+ likely finding is
Leukocyte esterase 3+ (A) hemorrhagic-appearing pleural fluid with many
Blood 3+ RBCs
(B) pale yellow, almost clear-appearing pleural fluid
An abdominal radiograph reveals what seems to be a
(C) pleural fluid with a low glucose and low pH
small stone just superior to the pelvic rim. Given this
patient’s presentation, the most likely cause of her stone is (D) a significantly elevated pleural fluid LDH level
(E) a total protein level similar to serum protein level
(A) Escherichia coli infection
(B) nephritic syndrome
(C) nephrotic syndrome
(D) proteus infection
(E) staphylococcal infection

31
USMLE Step 3 Assessment Exam
66. A 32-year-old woman is referred to your office because
of hypertension that is difficult to control with the
usual medications. When the patient is examined and
basic laboratory studies are performed, it is discovered
that she also has mild diabetes mellitus, irregular
menses, easy bruisability, and osteoporosis. The family
also remarks that she has developed wide mood swings,
seeming to be euphoric at times, but having episodes of
unexplained sadness at other times. Relevant negative
findings include the fact that her serum potassium is
normal, she has no scalloping of her ribs on chest x-ray,
and there is no hint of any flank or upper abdominal
bruits. A reasonable way to continue her workup at this
point would be to do
(A) aldosterone and renin measurements
(B) duplex scanning of her renal arteries
(C) low-dose overnight dexamethasone suppression test
(D) spiral CT scanning of the thoracic aorta
(E) urinary collection for catecholamines
32
67. A 62-year-old man comes to the clinic for a routine
health checkup. One month earlier, he was scheduled to
have a cholesterol screening panel drawn. The laborato-
ry switched the requisition form with another patient’s,
however, and instead tested the sample for thyroid
stimulating hormone (TSH) levels and free thyroxine
(T4) levels. The patient was notified of the mistake and
the cholesterol panel was redrawn. It was noted, however,
that the TSH level was elevated at 20 mU/L, whereas the
T4 level was within normal limits, though nearing the
low side of normal. The test was repeated today, con-
firming the elevated TSH and normal T4 levels. The
patient, although he says he feels in his usual state of
health, is concerned about these abnormal laboratory
values. A full review of systems fails to reveal any symp-
toms that can be related specifically to thyroid disease,
though he reports vague symptoms of malaise and
arthralgias. His past medical history is significant for
coronary artery disease, with a myocardial infarction 5
years ago and a distant history of depression, but no
autoimmune or thyroid disease. Vital signs and physical
examination are within normal limits. The most appro-
priate next step in the management of this patient’s
condition us to
(A) begin supplemental thyroxine (T4) treatment with
a goal of normal TSH levels
(B) check antithyroid peroxidase antibody levels, start
T4 treatment if elevated
(C) no further treatment is necessary; recheck TSH
and T4 levels in 1 year
(D) order a T3 level; if reduced, start treatment with
supplemental T3 immediately
(E) schedule followup appointment in 3 months,
recheck TSH levels at that time
 Internal Medicine

68. A 48-year-old woman comes to the emergency depart- 70. A 29-year-old man comes to the emergency depart-
ment complaining of shortness of breath that was acute ment at 4 AM complaining of a terrible headache that
in onset, and also complains of lightheadedness. She began abruptly 2 hours earlier and awoke the patient
reports that she has a history of chronic obstructive from sleep. Acetaminophen and ibuprofen have barely
pulmonary disease and hypertension. Her medications affected the headache, and now his neck is beginning
include albuterol inhalers and hydrochlorothiazide. On to hurt. The headache, a 10/10, is located mainly on
examination, her pulse is 190/min and irregularly irreg- the right side of his head. The man is worried, as his
ular. Jugular venous distension is 18 cm of water. Blood father died from “some kind of stroke,” and he does not
pressure is 85/50 mm Hg. Chest examination reveals want the same to happen to him. Over the last week he
bilateral crackles. Cardiac examination reveals irregular has had a few severe headaches from which he does not
rhythm, systolic ejection murmur (3/6), and a loud left normally suffer, but none as severe as this. While you
ventricular S3. Chest radiograph is consistent with pul- are asking for more history, the man’s eyes suddenly
monary edema. Electrocardiogram reveals atrial fibril- roll backwards and he begins to convulse. Before you
lation with rapid ventricular response at 185/min. Prior can administer a milligram of lorazepam, he stops seiz-
electrocardiograms were in normal sinus rhythm. The ing and seems mildly confused as to where he is and
most appropriate management at this time is what all the fuss is about. A stat noncontrast CT scan is
obtained that reveals no evidence of bleeding. Given
(A) immediate direct current cardioversion
this patient’s presentation, the most appropriate next
(B) intravenous metoprolol test to diagnose this patient’s most likely condition is
(C) intravenous digoxin
(A) cerebral angiography
(D) intravenous diltiazem
(B) CT scan of brain with contrast
(E) intravenous adenosine
(C) lumbar puncture
(D) magnetic resonance imaging
69. A previously healthy 20-year-old college student comes (E) radiograph of head
to the clinic because of penile discharge, dysuria, and
urinary frequency. He had unprotected sexual inter-
course at a party 4 days before the onset of symptoms.
His temperature is 37.0 C (98.6 F), blood pressure is
110/60 mm Hg, pulse is 70/min, and respirations are
12/min. No penile lesions are noted. The remainder of
his physical examination is normal. Cultures from the
urethra are taken. Gram stain reveals gram-negative
diplococci in pairs. The most appropriate intervention
at this time is to
(A) treat empirically for gonorrhea
(B) treat empirically for gonorrhea and chlamydia
(C) treat empirically for gonorrhea and chlamydia and
give HIV prophylaxis
(D) treat empirically for gonorrhea, chlamydia, and
syphilis
(E) withhold treatment until cultures are obtained

33
USMLE Step 3 Assessment Exam

71. A 26-year-old man is involved in a serious motorcycle 72. A 57-year-old man comes to the clinic complaining of
accident and is thrown more than 50 feet, finally collid- constipation. For the past 6 months he has had signifi-
ing with a nearby parked car. Emergency medical ser- cant constipation, with an average of one bowel move-
vices bring him immediately to the hospital, where he is ment a week. His stools seem smaller in size, though he
found to be conscious but disoriented and in a great denies melena, mucus, or gross blood. A review of his
deal of pain. Skeletal survey reveals fractures of multi- diet reveals that he generally has a low-fiber, low-fluid
ple ribs, the vertebral body at T11, his right femur, and diet, at least part of which is due to a recent fad diet he
multiple pelvic fractures. He is stabilized and trans- has started. He reports a fairly sedentary lifestyle, hasn’t
ferred to the intensive care unit (ICU), where he devel- seen a physician in years, and does not take any pre-
ops hypoxemic respiratory failure and requires scription or over-the-counter medications. Review of
mechanical ventilation. On the second day of being in symptoms is unremarkable. Physical examination,
the ICU, his serum creatinine increases to 5.8 mg/dL including a rectal examination, is unrevealing. A com-
from its initial level of 0.9 mg/dL. Continuous plete blood count shows:
hemodialysis is begun and the patient remains stable.
One day later the nurse notes that the patient has begun Hematocrit 34%
to bleed from around intravenous lines and from trau-
Hemoglobin 11.1 g/dL
matic wounds that were previously sutured.
Nasogastric lavage yields frank blood. The study that is Leukocyte count 5500/mm3
most likely to be normal in this patient is
Mean corpuscle hemoglobin 21 pg/cell
(A) activated partial thromboplastin time
Mean corpuscle volume 74 µm3
(B) antithrombin III levels
Platelet count 483,000/mm3
(C) fibrinogen levels
(D) platelet count The most appropriate next step in management of this
(E) prothrombin time patient’s constipation is to
(A) order fecal occult blood testing
(B) perform a flexible sigmoidoscopy
(C) refer for a full colonoscopy
(D) start daily senna laxative treatment
(E) start a trial of fiber, fluids, and stool softener

34
 Internal Medicine

73. A 70-year-old man with a history of myelodysplasia
and chronic anemia comes to the clinic complaining of
severe fatigue. He is pale, easily winded, and has a
hyperdynamic systolic heart murmur. Over the past 6
months his myelodysplastic syndrome has become
worse, requiring him to have multiple transfusions to
maintain a safe hematocrit. Today he is found to have a
hematocrit of 21%. The patient is sent to the transfu-
sion center to receive a 2-unit transfusion of packed red
blood cells. However, once the patient is typed and
screened, the blood bank calls to inform you that they
do not have any appropriate blood available and will
have to search the Tri-County area for a suitable speci-
men. The patient has never had compatibility issues in
the past. The most likely reason for the difficulty in
finding appropriate blood for this patient is the
(A) development of alloantibodies
(B) development of autoantibodies
(C) need for special filtering of blood
(D) presence of anti-HLA antibodies
(E) progression of myelodysplasia
75. A 65-year-old woman comes to the emergency depart-
ment with a chief complaint of acute onset of substernal
chest pain for the past 2 hours. She complains of increas-
ing diaphoresis. She has a medical history that includes
high blood pressure and diabetes. She currently is taking
lisinopril, 10 mg daily, and glyburide, 5 mg daily. She has
no known medical allergies. Her blood pressure is 100/80
mm Hg and pulse is 60/min. Lungs sound clear. Heart is
regular. Electrocardiogram reveals 0.5 mm ST elevation
in the inferior leads. She is admitted to the intensive care
unit for an acute inferior myocardial infarction. In the
ICU, a pulmonary artery catheter is placed. Her wedge
pressure is 2 mm Hg, and right atrial pressure is
10 mm Hg. The most appropriate management is to
(A) administer digoxin
(B) administer dobutamine
(C) administer fluid boluses
(D) administer isosorbide mononitrate
(E) place an intraaortic balloon pump

74. A 42-year-old man comes to the clinic complaining of

severe abdominal pain that has developed over the past
week. The pain is alternating between dull and sharp
and is difficult to localize. Additionally, over the last
month the patient reports feeling weak, having inter-
mittent low-grade fevers, and having an unexplained
20-lb weight loss. When asked about his past medical
history, the patient states that he has been diagnosed
with “some type of hepatitis.” Review of systems reveals
significant arthralgias and myalgias but is otherwise
unremarkable. Physical examination reveals an uncom-
fortable, ill-appearing man with a blood pressure of
182/105 mm Hg. He has diffuse abdominal tenderness,
though no hepatosplenomegaly is appreciated.
Neurologic examination is remarkable for extremely
tender legs and a left foot drop and absent left lower
extremity reflexes. A mottled, flat purple rash is seen on
the patient’s left ankle. Routine laboratory studies are
remarkable for an elevated creatinine and a normocyt-
ic anemia. Given this patient’s presentation, the most
likely underlying condition is
(A) Hepatitis A
(B) Hepatitis B
(C) Hepatitis C
(D) Hepatitis D
(E) Hepatitis E

35
 Internal Medicine Assessment Exam
Answers and Explanations

ANSWER KEY
1. D 26. A 51. D
2. E 27. C 52. D
3. A 28. D 53. E
4. B 29. E 54. D
5. B 30. B 55. B
6. A 31. A 56. A
7. B 32. B 57. A
8. C 33. B 58. A
9. C 34. E 59. D
10. E 35. B 60. A
11. D 36. C 61. E
12. D 37. D 62. E
13. E 38. B 63. C
14. A 39. E 64. D
15. C 40. D 65. B
16. E 41. B 66. C
17. D 42. B 67. A
18. D 43. B 68. A
19. C 44. D 69. B
20. C 45. A 70. C
21. D 46. B 71. C
22. D 47. E 72. C
23. D 48. E 73. A
24. B 49. D 74. B
25. B 50. C 75. C

37
USMLE Step 3 Assessment Exam
1. The correct answer is D. This patient has numerous
complications of diabetes and now seems to have devel-
oped diabetic nephropathy (and a possible type IV RTA,
hinted at by the mild hyponatremia/hyperkalemia).
Insulin is cleared renally. As patients develop renal fail-
ure, the insulin’s effective half-life increases, resulting in
a reduced need for exogenous insulin. Patients may find
their diabetes seemingly “cured” by their renal failure or,
if their insulin dose is not adjusted accordingly, may
have episodes of hypoglycemia.
Insulinomas (choice A) are incredibly rare, on the order
of an annual four cases per 1 million people, and thus
this is unlikely to explain this patient’s symptoms.
Given that this patient has had long-standing diabetes
and now has proteinuria and an elevated creatinine
level, renal failure, resulting in a prolonged insulin
effect, seems a more likely scenario.
There is no evidence that this patient has heart failure
(choice B). The lack of any physical findings argues
against heart failure, and the Q-waves on EKG simply
reflect the presence of the patient’s previous myocardial
infarction. Heart failure, if associated with significant
edema, can reduce or delay insulin absorption, and
usually results in hyperglycemia, not hypoglycemia.
Noncompliance (choice C) is common, but usually
results in hyperglycemia. Prolonged hyperglycemia
results in glycosylated hemoglobin (nonenzymatic
attachment of glucose moieties to red blood cell mem-
branes). As such, one would expect an elevated
hemoglobin A1c, not a level that has declined over time.
Remember, hemoglobin A1c levels reflect glucose levels
over the last 8 to 12 weeks.
Resolution of underlying diabetes (choice E) is unlikely.
The natural history of diabetes is an increasing medica-
tion requirement. Patients first need oral hypoglycemics
and, as the disease progresses, require insulin. Given
the progression of this patient’s disease, it is unlikely that
the condition has reversed itself spontaneously.
2. The correct answer is E. This patient has had an
episode of esophageal variceal bleeding, likely caused by
underlying alcoholic cirrhosis. Cessation of alcohol
intake can result in some reversal of esophageal and
gastric varices. In addition, a nonselective beta-blocker
(commonly propranolol) can reduce portal pressure
and hence the risk for recurrent rupture of friable, dis-
tended esophageal veins. For patients who re-bleed
despite prophylactic therapy, other treatment options
include variceal sclerotherapy (which can be used as an
acute treatment or prophylactically), the addition of
nitrites and alpha-blockers, or interventional and surgi-
cal treatments. These treatments include transjugular
38
intrahepatic portosystemic shunts (TIPS procedure) or
definitive treatment with liver transplantation.
Famotidine (choice A) and omeprazole (choice D)
increase the pH of the stomach, reducing the likelihood
of gastric, not esophageal, bleeding. These agents,
which work by way of H2-receptor blockade and pro-
ton-pump inhibition respectively, can reduce the risk
for recurrent bleeding from acute gastritis, but play no
role in the management of esophageal varices.
Misoprostol (choice B) is a prostaglandin analogue. It
can be used to prevent NSAID associated gastritis in
patients requiring NSAID treatment, but at significant
risk for gastritis. It functions by replacing prostaglandin
normally produced by a COX-1 mediated pathway,
which is blocked by NSAIDs. Prostaglandin is necessary
to produce the mucous layer that protects the stomach
lining from the acidic luminal environment.
Octreotide (choice C) is a somatostatin analogue that
can be used in the acute management of esophageal
bleeds. It also functions to reduce portal pressure,
mainly by inhibiting the release of splanchnic vasodila-
tors (such as glucagon). Splanchnic vasoconstriction
results in reduced portal blood flow and pressures.
Because of its formulation (intravenous only), cost, and
short half-life, its role is limited to emergency inpatient
treatment.
3. The correct answer is A. The first-line therapy for
osteoarthritis, particularly in elderly patients or in
those predisposed to bleeding, is acetaminophen.
Acetaminophen does not increase the risk for a gas-
trointestinal bleed and has been found to be as effective
as NSAIDs in controlling the pain of osteoarthritis.
Further, it does not have the potential to interfere with
aspirin therapy (for coronary artery disease).
Capsaicin cream (choice B) is an adjunct that may pro-
vide some relief in some patients. Given this patient’s
multiple joint involvement, systemic analgesia is a more
appropriate first-line treatment. Additional noninva-
sive, nonsystemic treatments include exercise and phys-
ical therapy, hot and cold packs, and knee bracing.
Increasing this patient’s dose of aspirin (choice C) to
analgesic doses, even though he takes an H2 blocker,
will significantly increase his risk for bleeding. Likewise,
other NSAIDs, whether in analgesic (choice D) or anti-
inflammatory doses (choice E) should be avoided if
possible, given this patient’s risk for gastrointestinal
bleeding.
4. The correct answer is B. This patient is having alcoholic
withdrawal symptoms and seizures and is progressing to
delirium tremens. His presentation to the emergency

department and classic laboratory studies suggesting
alcohol abuse (transaminitis, increased GGT, macrocytic
anemia caused by hepatic dysfunction and/or malnutri-
tion, and hypokalemia and hypomagnesemia) should
not be missed; this patient needs withdrawal treatment
with a benzodiazepine immediately. The patient should
have been started on a benzodiazepine on admission.
There is no indication for broad-spectrum antibiotics
(choice A) or for returning to the OR (choice D). It is
unlikely that this patient is suffering from an infection
or any other direct complication of his operation.
Beta-blockers and clonidine (choice C) are adjunct
treatments for alcohol withdrawal that may be used in
addition to benzodiazepines to treat adrenergic hyper-
activity. The first-line treatment, however, is a benzodi-
azepine such as lorazepam.
Phenytoin (choice E) is of limited effectiveness in treating
withdrawal seizures and should not be used as prophylax-
is in these patients. If the patient progresses to status
epilepticus, intravenous phenytoin or fosphenytoin may
be used in addition to a benzodiazepine.
5. The correct answer is B. The indications for throm-
bolytics include chest pain starting within the last hour
and either an ST segment elevation, not depression
(choice E), of >1 mm, or a new-onset left bundle
branch block (LBBB). An LBBB pattern makes inter-
preting ST segments, indications of cell injury and
death, extremely difficult and is often, in and of itself,
an indication of coronary ischemia.
Diffuse T-wave inversions (choice A) are not an indica-
tion for thrombolytics. T-wave inversions can indicate
ischemia, but may also be normal variants or may be
caused by noncardiac events. Metabolic conditions,
such as hypokalemia, can result in T-wave flattening,
and intracranial bleeds may produce flipped T waves
(cerebral T waves).
Q-waves (choice C) indicate old infarction. As such, Q
waves are not an indication for thrombolytics. Stunned
ischemic myocardium requires urgent reperfusion.
There is no compelling evidence to justify thrombolytic
therapy beyond 12 hours.
Unlike an LBBB, a right bundle branch block indicated
by the R-R′ morphology (choice D) is not an indication
for thrombolytics. Although a right bundle is concern-
ing, it does not render the ST segments uninterpretable
and does not carry as serious a prognosis as an LBBB.
6. The correct answer is A. This patient has aplastic ane-
mia, almost certainly caused by the use of chloram-
phenicol. Chloramphenicol can produce an idiosyncrat-
ic and irreversible aplastic anemia and a dose-dependent
Internal Medicine Answers and Explanations
reversible anemia. Unfortunately, given this patient’s lim-
ited exposure and failure to improve with cessation of the
medication, he likely has a case of irreversible aplastic
anemia. The treatment of choice for healthy young
patients is allogenic bone marrow transplantation.
Immunosuppression with antithymocyte globulin and
cyclosporine (choice B) or other newer immunosup-
pressive regimens is indicated in patients who cannot
tolerate bone marrow transplantation, or as an adjunct
to transplantation. The primary treatment for healthy
young patients with irreversible aplastic anemia is bone
marrow transplantation.
GCSF (choice C) and erythropoietin (choice D) are
unlikely to provide much benefit. These agents stimu-
late marrow precursors, which are absent in aplastic
anemia. The treatment of choice is replacement of dys-
functional marrow.
Watchful waiting and transfusions (choice E) are not
appropriate treatments for this irreversible condition.
Transfusions may temporarily replace some blood
components, though the risks from transfusions (infec-
tion, reaction) and inevitable sensitization limit this
approach. Further, the patient is also leukopenic and at
risk for infection. The best treatment is bone marrow
transplantation as soon as possible.
7. The correct answer is B. Among the different variants
of acute myeloid leukemia (AML), the one to know is
acute promyelocytic leukemia, classified as M3. This
particular variant, which accounts for 15% of AML, is
notable because of its unique clinical manifestations
and different treatment strategies from the other forms
of the condition. It is strongly associated with DIC
induced by a cancer procoagulant and may present as
pulmonary or cerebral hemorrhage in up to 40% of
patients. Additionally, this variant responds well to all-
trans-retinoic acid, which induces differentiation and
maturation of the promyelocytes. Patients can achieve
long-term remission with treatment. The other forms
of AML, including M0 (choice A), M5 (choice C), M6
(choice D), and the extremely rare M7 (choice E) do
not have these defining characteristics.
8. The correct answer is C. Heart block in a patient with
infectious endocarditis is an extremely worrisome sign, as
it often indicates extension into the area surrounding the
heart valve. A ring abscess, not easily seen on transtho-
racic echocardiography, may present only as mild con-
duction delays. Indications for surgical treatment of
infectious endocarditis include heart failure, persistent
infection or emboli on antibiotics, most prosthetic valve
endocarditis, fungal endocarditis, and the presence of
abscess or involvement of the conduction system.
39
USMLE Step 3 Assessment Exam
Cultures indicate a highly resistant organism (choice
A), MRSA. Most MRSA can be treated with van-
comycin, daptomycin, linezolid, and quinupristin/dal-
fopristin and occasionally other antibiotics, however,
depending on the sensitivities of the organism. Only if
the patient remains febrile on treatment is resistance an
indication for surgical treatment.
Surgical treatment may be indicated at this time
(choice B). Further imaging with a transesophageal
echocardiogram may help delineate the extent of this
patient’s vegetation.
Embolic events (choice D), if occurring while on
appropriate antibiotics, are usually considered an indi-
cation for surgical treatment of endocarditis. This
patient has septic emboli to the lungs, but these
occurred before the initiation of antibiotics.
Right-sided lesions and regurgitation (choice E) are not
an indication for surgery. If there is direct valve erosion
rather than a mechanical regurgitation, surgical treat-
ment is usually necessary.
9. The correct answer is C. This patient has an acute inter-
stitial nephritis (AIN), likely caused by ampicillin expo-
sure. Given his pre-existing renal insufficiency, he has
now become hypervolemic and has a uremic pericarditis,
an indication for emergent hemodialysis. Most patients
recover from AIN once the offending agent is removed,
though some have continued symptoms and require
steroids or other immunosuppressives. In the interim,
however, this patient needs dialysis to reverse his peri-
carditis and deal with his volume status.
A fluid bolus (choice A) is risky in this patient, given his
elevated jugular venous pressure and reduced renal
function. The pericardial friction rub is an indication
that dialysis is necessary.
Broad-spectrum antibiotics (choice B) are not indicated.
This patient is suffering from a drug reaction, specifically
AIN.
Renal biopsy (choice D) is the gold standard to diag-
nose AIN, but it is not necessary in patients with a clas-
sic presentation. Rather, the offending agent should be
removed and, if necessary, steroids started. Patients
with severe renal failure may need temporary dialysis as
their kidneys recover.
Furosemide (choice E) is not indicated. There is no dif-
ference in outcomes (in terms of renal function)
between oliguric and nonoliguric renal failure. The
most appropriate immediate treatment for this
patient’s condition is dialysis.
40
10. The correct answer is E. This patient has aspirin-sensi-
tive asthma, which accounts for up to 10% of cases of
asthma. Clues include the age of onset, usually the third
or fourth decade, the presence of nasal polyps, and the
predominance of rhinosinusitis symptoms related to
NSAID use. Inhibition of COX-1 results in a relative
imbalance of leukotrienes and prostaglandins. The rel-
ative excess of leukotrienes results in severe bron-
chospasm. Given the pathophysiology of this condition,
leukotriene modulators, such as Zafirlukast or mon-
telukast, should form the cornerstone of therapy, in
addition to a beta-agonist inhaler for quick relief. This
is in contrast to other forms of asthma, where these
agents are generally used as steroid-sparing agents in
cases of severe disease. Of note, the obvious therapy is
to avoid exposure. However, many patients may need
NSAIDs (e.g., osteoarthritis, cardioprotective baby
aspirin, pain) or are at risk for inadvertent exposure
from medications that contain an NSAID. These
patients need leukotriene inhibition as well as desensi-
tization with daily aspirin use.
Aminophylline and theophylline (choice A) are rarely
used. They cause modest bronchodilatation and may
strengthen diaphragmatic contractions. However, they
have a narrow therapeutic window, have a wide variety
of drug interactions, and are generally less effective
than other agents available to treat the condition. These
agents have no particular benefit in aspirin sensitive
asthma.
Epinephrine (choice B) can treat any form of asthma,
but is not a first-line treatment, as its hemodynamic
effects can be severe. Epi-pens are generally provided to
patients at risk for anaphylaxis induced by bee stings.
Nedocromil (choice C) is a mast cell stabilizer. It is used
prophylactically in exercise-induced and allergic asth-
ma. The inhaler is most useful in the pediatric popula-
tions, and less effective in adult populations.
Leukotriene inhibitors provide greater benefit for
patients with aspirin sensitive asthma.
Salmeterol (choice D) is a long acting beta-2 agonist. Its
primary benefit is in the treatment of nocturnal symp-
toms and cough-variant asthma. There is no need to
provide a long-acting beta-2 agonist to someone with
intermittent symptoms.
11. The correct answer is D. This patient meets the criteria
for Alzheimer dementia. Diagnosis does not require
invasive testing or advanced neurodiagnostic studies
(choice E), but can be made in the office based mainly
on history and a mini-mental status examination. The
diagnostic criteria set forth in the DSM-IV include the
following four points:

1) the gradual and progressive decline in cognitive
function that results in impairment in social or occu-
pational function;
2) impairment in recent memory, disturbance of lan-
guage, inability to execute skilled motor activities in
the absence of weakness, disturbance of visual pro-
cessing, or disturbance in executive function (includ-
ing abstract reasoning and concentration);
3) the deficits must not occur exclusively in the setting
of delirium;
4) the cognitive deficits are not caused by other illnesses.
If there is any doubt about a patient meeting these cri-
teria, further testing to rule out other conditions is war-
ranted, as the diagnosis can be devastating. Patients
often receive vitamin B12, thyroid function studies,
VDRL (or other neurosyphilis screen), and occasion-
ally, neuroimaging studies, though these studies rarely
reveal a reversible cause of dementia.
Brain biopsy (choice A) can confirm Alzheimer demen-
tia, but is not necessary to make the diagnosis. Given
the expense and morbidity of a brain biopsy, particu-
larly in a patient already facing a neurocognitive deficit,
the test is not warranted.
The pathogenesis of Alzheimer disease in part includes a
relative deficiency of acetylcholine. Testing for CNS
acetylcholine levels (choice B), however, is not routinely
performed.
Magnetic resonance imaging (choice C) can rule out
other conditions, particularly the rare tumor. CT scan
also can be used and is generally a cheaper and quicker
way to evaluate for a subdural or mass lesion if one is
suspected. It is not necessary to image the brain to diag-
nose Alzheimer dementia.
12. The correct answer is D. This patient likely has alcoholic
hepatitis and alcoholic fatty liver, which often coexist. As
the liver fails to produce clotting factors, patients devel-
op a severe coagulopathy with a markedly elevated
PT/INR. Among patients with severe coagulopathy and
elevated bilirubin, steroids have been found to improve
survival. If the patient survives, much of the damage
from acute alcoholic hepatitis and alcoholic fatty liver is
reversible. Of note, prednisolone is the preferred agent,
as prednisone requires hepatic conversion (presumably
limited in severe hepatitis) to prednisolone.
Intravenous albumin (choice A) is sometimes used in the
management of cirrhotic patients, but is not indicated in
the treatment of acute hepatitis. Its role is controversial,
though generally it is believed to improve outcomes if
used in cirrhotic patients with spontaneous bacterial
peritonitis.
Internal Medicine Answers and Explanations
Broad-spectrum antibiotics, such as ceftriaxone (choice
B), are not indicated in this patient, who has no obvi-
ous foci of infection. This patient’s low-grade fevers are
entirely consistent with acute hepatitis. Rupture of hep-
atic Kupffer cells (macrophages), which are rich in
interleukin-1, a cytokine responsible for febrile reac-
tions, presumably plays a role in the pathogenesis of
hepatitis-related fever.
Octreotide (choice C) is a somatostatin analogue that
can be used in the acute management of esophageal
bleeds. It lowers portal pressure mainly by inhibiting
the release of splanchnic vasodilators such as glucagons,
thus reducing portal blood flow. There is no role for the
use of octreotide in this patient.
Propranolol (choice E) is used as prophylaxis against
esophageal bleeds in patients with known esophageal
varices. It plays no role in the management of acute
hepatitis. This patient does not have evidence of chron-
ic liver disease and cirrhosis, though his current behav-
ior is certainly likely to result in such conditions if
unchanged.
13. The correct answer is E. This patient likely has Reiter
syndrome or a reactive arthritis. Reiter syndrome is
defined by the triad of uveitis, urethritis, and arthritis
and is most common in younger men. Additional
lesions classic for reactive arthritis, of which Reiter syn-
drome can be considered a subset, include keratoderma
blennorrhagica (which this patient has), circinate bal-
anitis, and oral/genital ulcers. Enthesitis, sausage digits,
and inflammatory back pain also may be present. These
conditions are associated with nongonococcal urethritis
(Chlamydia and Ureaplasma) and infectious diarrhea
(Campylobacter, Shigella, and Salmonella).
This patient’s condition, a reactive arthritis, is not asso-
ciated with a family history of malignancy (choice A) or
a family history of skin disease (choice B).
Occupational history and exposures (choice C) should
always be evaluated when trying to determine the cause
of a rash with discrete margins, as a contact dermatitis
often is to blame. This patient’s particular constellation
of symptoms is classic for a reactive arthritis, however,
often seen after a sexually transmitted disease or an
episode of infectious diarrhea.
Previous dermatologic complaints (choice D) are
important if one suspects psoriatic arthritis. Psoriatic
arthritis is often associated with marked psoriasis
(patchy, silvery scaled lesions). Pitting of the finger-
nails is a fairly sensitive indicator of patients who will
progress to the arthritic form of the disease, which
often affects distal joints, in particular the distal
interphalangeal (DIP) joint. This patient’s dystrophic
41
USMLE Step 3 Assessment Exam
toenails are caused by the keratoderma blennorrhagi-
ca, and his fingernails are normal.
14. The correct answer is A. This patient has the most
common coronary heart disease (CHD) equivalent,
diabetes mellitus. ATP III guidelines recommend that
these patients have a goal low-density lipoprotein
(LDL) of less than 100 mg/dL. If this patient’s LDL level
were near goal, diet and exercise might be adequate to
reach this target. This patient deserves therapy with an
HMG-CoA reductase inhibitor (statin), however, for
two reasons. First, she is not near goal. Patients with
CHD or CHD equivalents with an LDL of 130 mg/dL or
greater should start lipid-lowering therapy. Second,
there is mounting evidence (specifically, the Heart
Protection Study) that patients with diabetes benefit
from statin therapy regardless of LDL level.
Exercise and dietary changes (choice B) are unlikely to
be successful in this patient. First, she is already on a
diabetic diet and exercise plan that presumably should
provide some benefit. Second, given her level of LDL
cholesterol (≥130 mg/dL), she warrants lipid-lowering
drug therapy.
There is no need to increase metformin (choice C). Her
hemoglobin A1c, which is a better predictor of glycemic
control than a one-time fasting glucose, is within
acceptable limits for a patient with diabetes (common-
ly less than 7%). Further, metformin and improved
glycemic control will only indirectly affect her lipid
profile. Her lipid panel warrants starting medical treat-
ment now.
Goal LDL for this patient is less than 100 mg/dL. As
such, further action (choice D) is warranted now, not in
1 year.
Gemfibrozil (choice E) is not the best choice for this
patient. If she had low HDL or high triglycerides, then a
fibrate would be an ideal first choice. Given the potency
of the statins in lowering LDL cholesterol and possible
non-cholesterol-mediated benefits in CHD and diabetic
patients, simvastatin is a better first choice agent.
15. The correct answer is C. This patient is not in a stable
rhythm. Whether multifocal atrial tachycardia (MAT,
more common in patients with pulmonary disease) or
atrial fibrillation, the treatment algorithms are similar.
This patient’s low blood pressure, anginal pain, and
orthostatic symptoms warrant emergent cardioversion.
Once this patient is cardioverted, amiodarone (choice
A) may be appropriate to maintain sinus rhythm. This
patient’s condition warrants electrical cardioversion,
however, which is more successful than chemical car-
dioversion. Further, the patient’s low blood pressure
42
makes using other agents, whether amiodarone, dilti-
azem, or metoprolol (choice B) difficult, as all of these
medications cause hypotension.
A transvenous pacemaker (choice D) is not warranted
for atrial tachyarrhythmias. Rather, episodes of com-
plete heart block or prolonged symptomatic pauses jus-
tify pacemaker placement.
If time permits, a transesophageal echocardiogram,
precardioversion anticoagulation, and then electrical
cardioversion (choice E) is a reasonable strategy. This
patient’s blood pressure is not adequate to perfuse his
organs, however, and he is having chest pain.
Cardioversion should not be delayed for other inter-
ventions or medications.
16. The correct answer is E. This patient has a classic pre-
sentation of aspiration pneumonia. Aspiration pneu-
monia, in contrast to a chemical aspiration pneumonitis
(from acidic gastric fluid), is usually caused by indolent
anaerobic oral flora that usually resides in the gingival
crevices. Radiographs show infiltrates predominantly in
the right mid or lower lung zones and often display areas
of necrosis. The preferred agent is clindamycin, which
provides good anaerobic and gram-positive coverage,
though combination treatment with metronidazole and
penicillin is also a proven regimen.
Trimethoprim/sulfamethoxazole (TMP/SMX) and
prednisone (choice A) is a combination commonly
used for PCP pneumonia. It is not appropriate for
anaerobic infections, as TMP/SMX has little to no effect
against anaerobes, and resistance rates among gram-
positive organisms are high.
A high-resolution CT scan (choice B) or further evalua-
tion with bronchoscopy (choice C) is not necessary. This
patient has a classic presentation for anaerobic aspira-
tion pneumonia. She has a predisposing factor—a
recent CVA. Her coughing at dinner probably represents
continued aspiration. Further, the purulent sputum is a
big clue to the presence of anaerobes.
Ceftriaxone and azithromycin (choice D) is an appropri-
ate combination for community-acquired pneumonia. It
is not proven for aspiration pneumonia; clindamycin is
the standard of care.
17. The correct answer is D. This patient has a classic pre-
sentation of idiopathic thrombocytopenic purpura
(ITP), an immune-mediated destruction of platelets.
ITP is seen in pediatric populations and in young
women and may be initiated by a viral infection or may
be associated with a variety of autoimmune conditions.
The typical presentation, at least for the purposes of
taking boards, is an otherwise healthy patient with

petechiae and bleeding, usually oozing, not gushing,
and an isolated decrease in platelets (i.e., other cell
counts are near normal). The first line treatment is a
steroid for 4 to 6 weeks, followed by gradual taper.
DDAVP or factor VIII replacement (choice A) is useful
for treating von Willebrand disease. These patients pre-
sent with “platelet-type bleeding,” specifically petechiae,
gingival bleeding, and difficult to control epistaxis, for
example, but they have normal platelet counts. Bleeding
time, which effectively measures the time of clot forma-
tion following a skin puncture, will be elevated.
Platelet transfusions (choice B) should be avoided if the
patient is not bleeding uncontrollably. Transfusions can
increase the production of autoantibodies and, if the
patient is not bleeding, are not necessary. Most patients
can tolerate platelet counts as low as 10,000/mm3 with-
out spontaneous bleeding, though there are no clear
transfusion cutoffs.
IVIG (choice C) is extremely expensive and offers an
additive advantage to prednisone. It is generally a
second-line treatment, though one that works quickly,
used if an acute increase in platelet counts or if a large
platelet transfusion is required. Its ability to bind
autoantibody and to inhibit splenic filtering will pro-
long the functional half-life of circulating platelets.
Fresh frozen plasma (choice E), also known as FFP, is
not necessary, as this patient has a normal PT and PTT.
FFP is used to correct clotting factor deficiencies, not
thrombocytopenia.
18. The correct answer is D. This patient has chronic lym-
phocytic leukemia, a disease predominantly affecting
people over age 50 years. The condition can present
with dramatic symptoms, such as recurrent infections,
hemolytic anemia, bulky, painful lymphadenopathy
and splenomegaly, or classic B symptoms (fevers, night
sweats, and weight loss). Up to one quarter of patients,
however, have an indolent course with few to no symp-
toms. In these patients, watchful waiting is the most
appropriate therapy, particularly in older patients who
are less likely to tolerate treatment and have less (in
terms of life span) to gain from treatment. In this
patient, a repeat CBC should be performed to assess
doubling time of the WBC count. If the patient has
worsening symptoms or a rapid doubling time, treat-
ment should be started. For the time being, however,
watchful waiting is appropriate.
A common single-agent treatment for chronic lympho-
cytic leukemia is chlorambucil, though there is no evi-
dence that favors either high-dose (choice A) or low-dose
(choice B) regimens.
Internal Medicine Answers and Explanations
Followup should be scheduled at routine times, such as
every 3 months, not as needed or in the distant future
(choice C). It is necessary to check repeated blood
smears and perform serial clinical examinations to
monitor for signs of disease progression.
Prednisone (choice E) is an additional regimen that can
be used alone or as part of a CHOP (cyclophos-
phamide, doxorubicin, vincristine, and prednisone)
regimen. It is particularly effective for patients with pre-
dominant autoimmune manifestations, such as
hemolytic anemia, or autoimmune-mediated thrombo-
cytopenia. Fludarabine is an additional agent also used
to treat chronic lymphocytic leukemia.
19. The correct answer is C. This patient has a cellulitis by
history and clinical examination. Nothing further is
necessary to make the diagnosis. Predisposing factors in
this patient include venous insufficiency, a skin break
(tinea), and some degree of immunocompromise and
reduced circulation from diabetes. In diabetic patients,
empiric coverage for gram-positive and gram-negative
organisms is necessary. Oral second generation
cephalosporins or an oral penicillin with a beta-
lactamase inhibitor (amoxicillin/clavulanate) often are
used.
A full laboratory workup, such as blood count,
chemistries, and blood cultures (choice A) is not indi-
cated. The patient can be treated empirically for celluli-
tis. If the patient appeared systemically ill, then this
workup, in addition to a surgical biopsy to rule out
necrotizing fasciitis, may be appropriate.
Ultrasonography (choice B) and venography (choice E)
can be used to evaluate for deep venous thrombosis,
which presents in a similar fashion. This patient is anti-
coagulated and does not have any obvious clinical clues
to suggest a DVT. As such, neither study is warranted at
this time. In general, an ultrasound, which avoids
nephrotoxic contrast dye, is the preferred of the two
studies for evaluating deep venous thrombosis.
Skin biopsies (choice D) have a low yield when used to
diagnose cellulitis and are not recommended.
20. The correct answer is C. This patient has rhabdomyoly-
sis, or muscle breakdown, in this case caused by pro-
longed prone positioning. The fundamental pathophysi-
ology involves the release of intracellular contents and
pigment dye, which results in massive electrolyte abnor-
malities and pigment-induced renal tubular damage.
Calcium salts (such as with phosphate) form and deposit
in damaged tissue, resulting in significant hypocalcemia
that needs to be monitored and corrected in patients with
rhabdomyolysis.
43
USMLE Step 3 Assessment Exam
Release of intracellular contents results in a metabolic
acidosis. The pH is expected to decrease, and one
should not find a high arterial blood pH (choice A) if
there is significant rhabdomyolysis.
Rhabdomyolysis results in renal tubular obstruction
from heme pigment casts and tubular injury from free
chelatable iron. The myoglobin in the urine will cross-
react with urine dipstick assays for hemoglobin.
Microscopic analysis, however, will reveal a low, not
high, urine red blood cell count (choice B).
Phosphate (choice D) and potassium (choice E) are
usually stored intracellularly. Severe rhabdomyolysis
results in release of these cellular constituents from
damaged cells. These electrolyte abnormalities can be
severe and need to be monitored. Severe rhabdomyo-
lysis may require emergent dialysis.
21. The correct answer is D. Asthma is a symptomatically
intermittent condition, and thus has intermittent PFT
abnormalities. This patient, with exercise-induced asth-
ma that is worsened by cold weather, is currently without
airflow limitation, as evidenced by a normal examination
and lack of acute symptoms. The PFTs will be normal
but, given the patient’s sensitive airways, will display evi-
dence of bronchospasm after the administration of
methacholine, as cholinergic stimulation results in air-
way constriction.
This patient should have normal flow rates using a peak
expiratory flow meter (choice A), not elevated or
depressed rates. He is currently asymptomatic, and thus
does not likely have significant airflow obstruction. A
peak flow meter is a simple device patients can use to
monitor the severity of their asthma symptoms. As
bronchospasm worsens, peak flows decline.
In an acute attack, one would expect an FEV1/FVC ratio
of less than 60 to 70% of the predicted value (choice B).
Air is trapped behind constricted bronchi and takes a
long time to be fully exhaled. As such, the FEV1 declines
to a greater amount than the FVC. The patients can still
get air out (the FVC); it just takes longer (the FEV1).
A reduction in the total lung capacity, with preserved
FEV1/FVC ratio (choice E) indicates a restrictive, not
obstructive, defect. A restrictive defect, such as obesity
or lung fibrosis, limits the expansion of the lung, thus
reducing lung volume, but does not limit the rate of
exhalation. As such, the FEV1 and FVC are proportion-
ally reduced.
An increase in the DLCO (choice C) is seen in an acute
attack, as high negative thoracic pressures bring more
blood into the lungs, resulting in greater capillary
recruitment and blood flow. In this patient, the DLCO
will be normal.
44
22. The correct answer is D. This patient has Guillain-
Barré syndrome, characterized by the three As of paral-
ysis: acute, areflexic, and ascending. The condition
often follows a recent Campylobacter or herpes virus
infection, though it may occur without obvious precip-
itating illness. The mortality rate is 3-4% and is caused
by respiratory failure from paralysis of respiratory mus-
cles. As such, respiratory support and early intubation
are advisable. Additional treatments shown to improve
outcomes include plasmapheresis and immunoglobulin
treatment (IVIG).
Antibiotics (choice A) and antitoxin (choice B) are use-
ful in the treatment of botulism, which also can present
with an acute paralysis that may result in respiratory
failure. The key difference is that botulism is a descend-
ing paralysis; the cranial nerves are usually the first part
of the nervous system affected. A history of intravenous
drug use (which predisposes to wound botulism) or
home-canned food is a big clue to the diagnosis.
Interferon (choice C) is useful for the treatment of mul-
tiple sclerosis. Lesions often occur in the descending
tracts or the brain and result in upper motor neuron
signs, mainly spasticity and focal neurologic deficits,
rather than a diffuse and ascending paralysis. This
patient is, however, at approximately the age when mul-
tiple sclerosis often first presents.
Steroids (choice E) have not been shown to be effective
in the treatment of Guillain-Barré syndrome.
23. The correct answer is D. This patient has carpal tunnel
syndrome. Although the condition is often idiopathic, it
also is associated with endocrinopathies, such as
hypothyroidism and acromegaly. The bilateral presenta-
tion should raise suspicion for an underlying systemic
cause of her carpal tunnel syndrome. In addition to
endocrine disorders, the condition also is associated with
amyloidosis, pregnancy, and rheumatoid arthritis. The
patient’s other complaints, such as fatigue, constipation
(perhaps misdiagnosed as irritable bowel syndrome),
and weight gain, may be caused by hypothyroidism.
Antinuclear antibody titers (choice A) are not indicated.
There is no reason to suspect that this woman has an
autoimmune disease.
A hemoglobin A1c level (choice B) is not indicated.
Diabetes can present with neuropathic pain in a stocking-
glove manifestation, though this patient has a description
more classic for carpal tunnel syndrome. If diabetes is sus-
pected, the appropriate test for diagnostic purposes is a
fasting glucose level or an oral glucose tolerance test.
Additional testing (choice C) is necessary. Given this
patient’s bilateral presentation and particular complaints,
diagnosis and treatment of hypothyroidism will help

resolve her symptoms, likely more effectively than splint-
ing, steroid injections, physical therapy, and ergonomic
redesign, all commonly prescribed noninvasive treat-
ments for carpal tunnel syndrome.
If this woman were younger, a urine pregnancy test
(choice E) may be reasonable. She is unlikely to be
pregnant, however, and has symptoms that warrant
thyroid functional studies.
24. The correct answer is B. This patient has classic symp-
toms of gastroesophageal reflux disease (GERD).
Patients with a typical presentation can be tried on
empiric acid suppression, such as omeprazole (now
available in over-the-counter formulations). If there are
any warning signs, such as presentation at an advanced
age, weight loss, abdominal pain, bleeding, or systemic
symptoms, then an upper endoscopy (choice D) should
be performed before an empiric trial is started so that
more serious conditions that may mimic or cause
GERD, such as gastric and esophageal carcinoma, can
be ruled out.
Testing for Helicobacter pylori, whether with a breath
urease test (choice A) or blood or stool tests, is not nec-
essary for the management of GERD. The role of H.
pylori in GERD is unclear; some evidence suggests that
H. pylori seropositivity may correlate with lower rates of
GERD, though the mechanism of such an association is
not clear. In any case, testing and treating H. pylori with
an appropriate regimen such as omeprazole, amoxi-
cillin, and clarithromycin (choice E) is not part of the
management of GERD.
Lifestyle modifications, such as cessation of smoking,
limiting alcohol intake, eating small meals for dinner,
and elevating the head of the bed, can help modestly
reduce GERD symptoms. Avoiding spicy food (choice
C), however, has not been shown to be helpful. After all,
the acid causing the pain is derived from gastric parietal
cells, not from the consumed food.
25. The correct answer is choice B. This patient has Graves
disease, the most common cause of hyperthyroidism in
the United States. Among the causes of hyperthy-
roidism, findings unique to Graves disease include
exophthalmos, periorbital and conjunctival edema,
limitation of ocular motion, and infiltrative dermopa-
thy (pretibial myxedema). These findings are caused
directly by host responses to the presence of TSH recep-
tor antibodies rather than the resulting hyperthy-
roidism. Up to 70% of patients with Graves disease have
exophthalmos, making it an extremely useful clinical
finding.
Internal Medicine Answers and Explanations
Diarrhea (choice A) is a result of hyperthyroidism,
regardless of the underlying cause of the condition. It is
not a specific finding in Graves disease.
Goiter (choice C) is not specific to Graves disease,
occurring in a variety of causes of hyperthyroidism.
Further, a goiter may occur in euthyroid or hypothyroid
patients.
Hyperreflexia (choice D) is a result of hyperthyroidism,
regardless of the underlying cause of the condition. It is
not a specific finding in Graves disease.
Lid lag and stare (choice E) are distinct from exoph-
thalmos. Exophthalmos is a protrusion of the eyes
resulting from a complex host response to circulating
TSH receptor antibodies. TSH receptor antibodies
induce retro-orbital connective and adipose tissue
accumulation and the accumulation of glycosamino-
glycans. This excess tissue displaces the globe forward.
This is in contrast to a stare and lid-lag, which are
caused by lid retraction from sympathetic hyperactivi-
ty seen in all forms of hyperthyroidism.
26. The correct answer is A. Unfortunately, this patient has
required a massive blood transfusion for a likely diver-
ticular bleed. Although these bleeds often stop on their
own, they can continue, requiring surgical intervention
(usually preceded by colonoscopy or radionucleotide
scintigraphy to localize the site of bleeding) or angiog-
raphy with embolization. Packed red blood cells con-
tain citrate to prevent coagulation during storage.
Citrate can bind calcium, resulting in low levels of ion-
ized free calcium (though total levels may be normal).
This can present as a prolonged QT interval, tetany, or
frank seizures. Ionized calcium levels or an EKG should
be checked as the transfusion total approaches 10 U.
Massive transfusions can result in dilution of coagula-
tion factors, thus requiring the additional transfusion
of fresh frozen plasma (choice B). The cause of this
patient’s seizure is low ionized calcium, however;
replacement of calcium is necessary now.
Typical treatments for seizures, including lorazepam
(choice C) and phenytoin (choice D), are not necessary.
If this patient’s calcium is replaced, he will not continue
to suffer seizures.
Massive blood transfusions may be associated with
hyperkalemia; giving empiric potassium (choice E) is
not recommended. Stored blood leaks potassium and
the older the unit transfused, the higher the potassium
level. This is not usually a concern, except when large-
volume transfusions are required.
45
USMLE Step 3 Assessment Exam
27. The correct answer is C. Polymorphic ventricular
tachycardia, also known as Torsade de Pointe, is associ-
ated with hypomagnesemia. Empiric magnesium
replacement in these patients, in addition to electrical
defibrillation, can be effective in converting these
patients to a more stable rhythm.
Junctional tachycardia (choice A) and pulseless electri-
cal activity (choice D) are not treated with magnesium.
Magnesium is used primarily for primary ventricular
arrhythmias, and is particularly efficacious when treat-
ing Torsade de Pointe. According to the ACLS algorithm,
magnesium may be tried in monomorphic ventricular
tachycardia (choice B), though epinephrine, vaso-
pressin, and lidocaine should be considered first.
Ventricular fibrillation (choice E) is unlikely to respond
to magnesium. If any response is to be had, it is most
likely with a combination of electrical defibrillation and
either epinephrine or vasopressin.
28. The correct answer is D. Hydroxyurea increases the
proportion of hemoglobin F. Increased levels of
hemoglobin F are partially protective against sickling
and decrease the frequency of painful vaso-occlusive
crises. Hydroxyurea is used in the long-term treatment
of sickle cell disease and is not used in the acute setting.
Exchange transfusion (choice A) is used in the acute
setting and not in the long-term management of sickle
cell disease. For patients who fail to respond to oxygen,
hydration, and pain control and who continue to have
significant hypoxia, consider exchange transfusion
rather than simple blood transfusions (always a contro-
versial topic in the management of sickle cell patients).
Folate supplementation (choice B) is important in
managing the anemia associated with sickle cell disease.
Chronic hemolysis and cell turnover can quickly
exhaust the body’s stores of folate, and thus can com-
pound an already severe anemia. Folate will not, how-
ever, reduce the frequency of sickle cell crises.
Hydroxyurea is the primary agent for this purpose.
Although hypoxia can induce a sickle cell crisis, there is
no evidence that home oxygen (choice C) is an effective
treatment to reduce the occurrence of sickle cell crises.
Home oxygen therapy has a very limited role that
focuses on patients with severe COPD. It is not used in
the management of any form of anemia.
In most patients, sickle cell pain is not chronic, but
rather is characterized by an acute pain crisis caused by
a vaso-occlusive chain reaction of sickling. As such,
most patients do not need long-term outpatient nar-
cotics, such as transdermal fentanyl (choice E). Narcotic
therapy, however, is a cornerstone of the acute treat-
ment of a sickle crisis, which can be extremely painful.
46
29. The correct answer is E. A noncontrast spiral CT scan
is one of the most sensitive tests to detect nephro-
lithiasis. The test has the advantage not only of high
speed, availability, and excellent sensitivity, but also
avoids the contrast dye necessary for older tests, such as
an IVP. As a stone is radiopaque, it appears best in the
ureter without contrast. Radiopaque dye can bypass the
obstruction and light up the entire ureter, or at least
obscure the margins of the stone, making the film more
difficult to interpret.
Abdominal and renal ultrasound (choice A) is a good test
to search for renal stones. A CT scan is more sensitive,
however, particularly in obese patients. In obese patients,
ultrasound is usually technically limited by the large
amount of fat that the sound waves must penetrate.
Additionally, a CT scan can see a stone in the pelvis,
which can be difficult to visualize with an ultrasound.
Contrast enhanced CT scans (choice B) are not indicated
when searching for kidney stones.
An IVP (choice C) should be avoided in this patient
with baseline compromised renal function. The large
dye load can result in worsening renal function and, in
an already predisposed patient, may result in the need
for dialysis.
A KUB (choice D) has a sensitivity of up to 80% when
interpreted by a skilled radiologist. Ultrasound (in the
right patients) and CT scan, however, have significantly
greater sensitivity.
30. The correct answer is B. Patients with one pathologic
fracture from multiple myeloma are at risk for repeat
fractures. A complete skeletal survey is necessary to look
for lytic lesions, caused by plasma cells actively secreting
IL-6, an osteoclast activating cytokine. Lesions can be
treated surgically (rods and pins) or with external beam
radiation. The best study is a full body skeletal survey
with conventional radiographs.
CT scan (choice A) provides a great deal of information
about internal structures, but is technically not as easy
to review when searching for bony lesions. It is also
more expensive than plain radiographs. When search-
ing for metastatic cancer in other sites, a CT of the
chest, abdomen, and pelvis is often ordered. It is not
necessary, however, when looking for osteolytic lesions
from multiple myeloma.
Similar to CT scan, MRI (choice C) can provide a great
deal of information about internal organs. As MRI
requires more time, is more costly, and does not pro-
vide much more information than radiographs, it is
generally a second-line test. For patients with bony pain
who have normal roentgenograms, MRI may be an
appropriate next test.

PET scan (choice D) and technetium-99m bone scans
(choice E) are not useful for these lesions. Both scans are
best suited for metabolically active lesions, not the lytic
lesions of multiple myeloma. The lesions are not caused
by direct tumor infiltration and growth, but rather by
hyperactive osteoclasts. As such, these lesions are “cold”
and will not light up on these scans. An example of an
osteoblastic lesion that would show up well on either
scan is metastatic prostate cancer, which also can present
with pathologic fractures and bony pain.
31. The correct answer is A. This patient has acute cholan-
gitis most likely caused by a stone in the common bile
duct. The initial treatment for acute cholangitis focuses
on stabilizing the patient with intravenous fluids and
antibiotics that provide adequate gram-negative and
anaerobic coverage. Approximately 80% of patients
respond to this treatment alone, eventually clearing the
obstruction or stabilizing to the point that elective bil-
iary drainage can be arranged. For patients who do not
improve within 24 hours of treatment, emergent biliary
drainage needs to be arranged.
Endoscopic ultrasound (choice B) has an excellent sen-
sitivity for detecting common bile duct lesions. It is not
a therapeutic intervention, however, and will not suc-
cessfully treat this patient’s condition, though it may be
useful if ERCP and other imaging studies fail to delin-
eate the pathology of this patient’s obstruction.
Endoscopic retrograde cholangiopancreatography
(ERCP; choice C) does not need to be performed at
3 AM and should not be started until the patient is sta-
bilized. There is no need to wake the GI fellow. Rather,
admit the patient for fluids and antibiotics, and call GI
in the morning.
If this patient continues to have pain and ERCP is not
successful, surgical decompression and treatment with
a T-tube (choice D) or exploratory laparotomy (choice
E) may be necessary. Neither, however, is the first step in
the treatment of this patient. Remember, most patients
with ascending cholangitis improve with fluids and
antibiotics.
32. The correct answer is B. Only two interventions have
been shown to improve mortality in patients with
COPD: smoking cessation and continuous oxygen.
Moreover, continuous oxygen therapy has been proven
beneficial only in patients with baseline hypoxemia,
specifically a PaO2 of less than 55 mm Hg, or a satura-
tion of less than 88%. This patient has severe COPD
and would benefit from home oxygen therapy.
Albuterol (choice A) and ipratropium (choice C) pro-
vide symptomatic relief and are essential components
Internal Medicine Answers and Explanations
of COPD treatment. Ipratropium is generally more
effective in COPD, though albuterol can provide a
quicker response. Many patients with severe symptoms
require both, conveniently available in a combined
inhaler. Neither provides a survival benefit.
Pulmonary rehabilitation (choice D) can improve quali-
ty of life through a program of exercise, breath training,
and psychosocial support. It does not improve mortality.
Other interventions that may improve symptoms
include lung reduction surgery and tracheostomy to
reduce physiologic dead space.
Steroid inhalers (choice E) only benefit a small percent-
age of patients with COPD and should not be a routine
component of COPD management (though they are).
Parenteral steroids, however, are indispensable in the
treatment of an acute exacerbation. These two different
uses of steroids in the treatment of COPD should not
be confused.
33. The correct answer is B. This patient has temporal
arteritis and is now developing visual changes. The
most pressing issue is to start steroids, the main treat-
ment for temporal arteritis. The pretest probability of
this patient having temporal arteritis is extremely high
given her physical findings and laboratory studies con-
sistent with significant inflammation. As such, steroids
can be started even before a temporal artery biopsy
(choice E) is obtained. Steroids on occasion may reduce
the amount of inflammation seen on biopsy, but usual-
ly not to the point at which diagnosis is hindered. An
outpatient referral for a biopsy is not a reason to delay
starting treatment.
Broad-spectrum antibiotics (choice A) and a lumbar
puncture for CSF analysis (choice C) would be appro-
priate if meningitis were suspected. This patient’s con-
stellation of symptoms, including unilateral visual
impairment, temporal artery tenderness, and signs of
systemic inflammation (e.g., fever, elevated sedimenta-
tion rate) are much more consistent with temporal
arteritis than meningitis.
An MRI of the brain (choice D) is unlikely to reveal any
abnormalities in this patient, as the vasculitis is
extracranial and does not involve the brain parenchy-
ma. Some centers are using ultrasound to image the
temporal arteries in lieu of biopsy, though this is still
controversial.
34. The correct answer is E. Gastric cancer can present as a
bleeding or nonhealing gastric ulcer. Biopsy is essential
to rule out malignancy. In general, it is recommended
that, if safe, the ulcer be biopsied during the initial
endoscopy. Eight to 12 weeks later, a repeat endoscopy
47
USMLE Step 3 Assessment Exam
and biopsy should be performed to determine if the
ulcer has healed with acid suppression therapy and to
increase the yield from more tissue samples. It is hoped
this patient has bled because of his alcohol and NSAID
use, rather than from a malignant gastric ulcer.
A barium swallow study (choice A) can show ulcer
craters, though the sensitivity is much lower than
endoscopy. Further, it is impossible to obtain tissue
samples with a barium study, essential to determine if
an ulcer is malignant or not. As such, endoscopy, not
barium, is recommended as the primary tool to evalu-
ate gastric ulcers.
A CT scan of the chest, abdomen, and pelvis (choice B)
is not appropriate at this time. If this patient is deter-
mined to have a malignant ulcer, then a “pan-scan” is
appropriate to stage the malignancy.
Although this patient should be followed clinically
(choice C), further testing, specifically an upper
endoscopy, is essential regardless of his symptoms.
36.
Early gastric cancer may have a subtle presentation. By
the time symptoms are prominent, the disease may
have progressed significantly.
Helicobacter pylori testing (choice D) does not need to
be repeated. Assays used for H. pylori are extremely sen-
sitive. Further, antibody tests (as opposed to breath ure-
ase) stay positive after exposure, resulting in a high
false-positive rate. It is unlikely, then, that this patient’s
test represents a false-negative result.
35. The correct answer is B. This patient has a classic pre-
sentation of a pulmonary embolus after a period of
immobilization (a 2-day bus ride). All of the listed
studies may be useful in the workup of a suspected
pulmonary embolus. With this patient’s pre-existing
lung disease, however, the most appropriate diagnostic
study is CT angiography, also known as a spiral CT. CT
angiography, which also often includes in the protocol
a scan of the lower extremities, has a sensitivity of more
than 90%. Further, missed emboli are often small and
may not have the same clinical consequences (i.e., the
missed 1 in 10 may not carry the same mortality as the
average untreated pulmonary embolus). As the proce-
dure requires a significant infusion of potentially
nephrotoxic contrast dye, it is not appropriate for
patients with renal disease.
A chest radiograph (choice A) is not a sensitive or spe-
cific study to diagnose a pulmonary embolus. Rarely an
area of hyperlucency (Westermark sign), pulmonary
infarction (Hampton hump), or large pulmonary
artery may be seen. The most common radiographic
manifestation of a pulmonary embolus is nonspecific
atelectasis.
48
A D-dimer level (choice C) can be used to rule out pul-
monary embolus in low-risk patients. A positive D-dimer,
however, adds little to the management of high-risk
patients and is not necessary for this man’s diagnosis.
Pulmonary angiography (choice D) is the gold standard
for diagnosing pulmonary emboli. As the procedure is
invasive, has a high degree of mortality and morbidity,
and is not always readily available, however, it is not a
recommended first choice in diagnosing a pulmonary
embolus.
A ventilation/perfusion scan (choice E) is an excellent
tool to diagnose a pulmonary embolus, but is often
indeterminable in patients with pre-existing lung dis-
ease. This patient has a history of silicosis and chronic
bronchitis; this study likely will come back as indeter-
minate. A CT angiography can allow examination of
the vessels for filling defects, even if pre-existing
parenchymal lung disease is present.
The correct answer is C. This patient has systemic scle-
rosis. Her physical examination is classic for diffuse,
systemic disease rather than a more limited CREST syn-
drome. Her dyspnea is worrisome for pulmonary
hypertension, her GERD is classic for the condition
and, most worrisome, the new-onset hypertension rais-
es questions of sclerodermal renal crisis, a common
cause of death in these patients. Her serologies are clas-
sic for the disease. Rheumatoid factor is nonspecific for
rheumatoid arthritis and is often present in systemic
sclerosis, as are antinuclear antibodies. Anticentromere
antibodies strongly suggest CREST syndrome, whereas
the highly specific but not sensitive anti-SCL-70 highly
correlates with systemic sclerosis. This patient’s hyper-
tension, elevated creatinine, and proteinuria indicate
the early stages of sclerodermal renal crisis, which is
treated with an ACE inhibitor.
Hydrochlorothiazide (choice A) is not indicated for this
patient’s hypertension. An ACE inhibitor can reduce
glomerular damage from altered filtration pressures
caused by sclerosis and narrowing of the renal arteries.
Further, given this patient’s acute decline in renal func-
tion, HCTZ is unlikely to be particularly effective; the
agent usually loses effect as its filtration into the renal
tubule declines.
Ibuprofen (choice B) is not indicated for the treatment
of systemic sclerosis and, in general, should be avoided
in patients with impending renal failure, particularly if
diminished glomerular perfusion is believed to be the
underlying pathogenesis of their renal failure.
Methotrexate (choice D) is a disease-modifying agent
commonly used to treat rheumatoid arthritis. It is not
used in the treatment of systemic sclerosis.

Prednisone (choice E) is used for a variety of condi-
tions, including lupus flares. This patient has systemic
sclerosis, one of many antinuclear antibody-positive
conditions other than lupus.
37. The correct answer is D. Statistically, papillary carcinoma
is the most likely diagnosis, as this type of malignancy
accounts for 60 to 70% of all thyroid carcinomas. Further,
papillary carcinoma is associated with calcifications seen
on radiograph and with a history of radiation exposure. If
this patient’s fine needle aspiration reveals this diagnosis,
surgical resection is the most appropriate treatment for
an isolated, nonmetastatic papillary carcinoma.
Anaplastic carcinoma (choice A) is rare, accounting for
at most 10% of thyroid malignancies. It is also more
common in females and elderly patients. Classically, the
lesion enlarges quickly and painfully. Most patients die
within a year of diagnosis.
Follicular carcinoma (choice B) accounts for 15% of
thyroid cancers and is also more common in elderly
and female patients. Statistically this patient is more
likely to have papillary carcinoma, particularly given
the radiographic findings and the history of radiation
exposure.
Medullary carcinoma (choice C) is rare, accounting for
5% of thyroid carcinomas. The tumor is metabolically
active, producing calcitonin. An additional clue to the
presence of medullary carcinoma is a family history of
the disease or the presence of pheochromocytoma,
parathyroid hyperplasia, or neuromas, as this condition
often occurs as part of multiple endocrine neoplasia
syndromes.
Thyroid lymphoma (choice E) is an extremely rare
form of non-Hodgkin lymphoma. It occurs mainly in
elderly patients, particularly in those with a long-stand-
ing history of Hashimoto thyroiditis. This entity repre-
sents less than 1 to 2% of thyroid tumors.
38. The correct answer is B. This patient has stable angina
and has not been taking his medications as prescribed.
As the pattern is well established and the pain is not
new in frequency or intensity and resolves with rest,
further workup is not warranted. Patients with coro-
nary artery disease gain a proven survival benefit from
81 mg of aspirin daily, however, which should be added
to this patient’s regimen. Beta-blockers and, for patients
with reduced ejection fractions, ACE inhibitors also can
improve survival.
This patient does not need a cardiac catheterization
(choice A). The lack of ongoing pain, the chronicity of
the problem, and the absence of EKG changes argue
against urgent intervention.
Internal Medicine Answers and Explanations
This patient does not need to be ruled out for a myocar-
dial infarction (choice C). This is a chronic problem, and
the demand ischemia is entirely exertional. There is noth-
ing to suggest that this patient’s pain is something new.
A stress echocardiogram or nuclear perfusion study
(choice D) is useful in evaluating patients with unstable
angina to see if there are areas that may be amenable to
coronary reperfusion techniques, such as stenting or
bypass. This patient has stable angina and will not ben-
efit from evaluation for reperfusion at this time.
A stress electrocardiogram (choice E) can be used to
evaluate patients with suspected coronary artery dis-
ease. This patient already has angina, and thus little is to
be gained from an outpatient stress electrocardiogram.
39. The correct answer is E. This patient is supratherapeu-
tic on his warfarin dose to dangerous levels that have
likely precipitated his gastrointestinal bleed (likely gas-
tritis caused by an NSAID, though only an endoscopy
will answer this question). In addition to stopping his
warfarin, there are two ways to reverse the coagulopa-
thy. First, the patient can be given fresh frozen plasma
that contains the missing endogenous factors inhibited
by warfarin. This will rapidly reverse the coagulopathy
and is useful if the patient continues to bleed. Second,
the patient can be given vitamin K, which can compet-
itively overcome the effects of warfarin. Vitamin K takes
longer to act, as the liver has to synthesize these clotting
factors (II, VII, IX, X), but lasts considerably longer.
Cryoprecipitate (choice A) is high in some specific clot-
ting factors and is useful for patients who receive large-
volume transfusions or who have specific factor defi-
ciencies. It is not necessary to reverse warfarin toxicity.
DDAVP (choice B), or desmopressin, is used mainly for
two functions. First, it induces endothelial release of
von Willebrand protein, and thus can be used to treat
von Willebrand disease. Second, it can reverse some
platelet dysfunction caused by uremia, and is thus a
treatment, together with dialysis, for uremia-induced
platelet dysfunction.
A platelet transfusion (choice C) is not necessary for
this patient’s borderline reduced platelets. In patients
who are actively bleeding with thrombocytopenia,
platelet levels are generally kept greater than
50,000/mm3, though there are no absolute transfusion
thresholds.
Protamine (choice D) can reverse heparin, not warfarin.
This patient’s high PT/INR reflects his supratherapeutic
warfarin levels, likely caused by a combination of poor
vitamin K intake, antibiotic use, and drug interactions.
49
USMLE Step 3 Assessment Exam
40. The correct answer is D. Polycythemia vera (PV) is a
chronic myeloproliferative disorder that can result in an
elevation of all cell lines, but mainly in myeloid cell
lines. It is a primary disorder, as opposed to a secondary
erythrocytosis caused by chronic hypoxic states. This
patient could have PV, but may also have a reactive ery-
throcytosis caused by chronic hypoxia (sleep apnea,
tobacco history). If this is a reactive increase in hemat-
ocrit, one would expect an elevated erythropoietin
level, as this is the autoregulatory modulator of
increased red blood cells. Additionally, if this patient’s
condition is caused by a renal cell carcinoma, which
may present with increased hematocrit, one also would
expect elevated erythropoietin levels. Incidentally, the
presentation of pruritus after a shower is classic for PV,
as is a constellation of facial plethora, splenomegaly,
and erythromelalgia, or burning in the hands and feet,
believed to represent microvascular occlusive disease
from sludging of the blood.
This condition is characterized by high, not low, blood
viscosity and red cell mass (choice A). The increased
blood viscosity from an absolute erythrocytosis results
in an increased risk for thrombotic events.
Also in the differential diagnosis of this patient is
chronic myelocytic leukemia (CML), which may pre-
sent with similar abnormalities on a blood smear. CML
has a low leukocyte alkaline phosphatase level (choice
B), whereas PV has a high level (representing red cell
turnover), making this a useful test to differentiate the
two conditions. Similarly, the cyanocobalamin, or vita-
min B12, level (choice C) is elevated also, reflecting red
cell turnover and abnormal erythropoiesis.
Often all cell lines are elevated, including white blood
cell and platelet counts (choice E), though the predom-
inant abnormality is an absolute erythrocytosis.
41. The correct answer is B. This patient has Listeria mono-
cytogenes meningoencephalitis. This pathogen should
be considered and empirically covered in neonates,
elderly patients, or immunosuppressed patients, such as
those on steroids (this patient) or those with HIV infec-
tion. Listeria meningoencephalitis often presents with
seizures. Listeria is a small, gram-positive rod, a specif-
ic though highly insensitive Gram stain result.
Cephalosporins have no activity against Listeria; rec-
ommended treatments include high-dose penicillin or
ampicillin, though some agents (such as the carbapen-
ems) have activity against the organism.
Acyclovir (choice A) can be used for treatment of sus-
pected herpes meningoencephalitis. Viral meningitis or
meningoencephalitis usually presents with a lymphocyt-
ic predominance on cerebrospinal fluid (CSF) analysis.
50
Further clues specific to HSV infection include tempo-
ral lobe hemorrhage on CT scan and severe derange-
ments in behavior.
Dexamethasone (choice C) is increasingly being used in
the early treatment of meningitis. It has been proven to
reduce post-meningitis neurologic complications, par-
ticularly in streptococcal infections. It does not have a
proven survival advantage, however, and would not have
changed this patient’s course. Appropriate antibiotics
would have improved her chances of survival, though
the low CSF glucose is a poor prognostic indicator.
Piperacillin/tazobactam (choice D) is a broad-spectrum
antibiotic, but is not recommended for the treatment of
meningitis. Specific third-generation cephalosporins,
such as ceftriaxone and cefotaxime, provide better cen-
tral nervous system penetration and provide coverage
for most common causes of meningitis.
Vancomycin (choice E) is not a great agent to treat
meningitis, as it has poor central nervous system pene-
tration and is a bacteriostatic, not bacteriocidal, agent.
It is often used, however, as empiric treatment in
patients at risk for methicillin-resistant Staphylococcus
aureus infections. If this patient had had a recent neu-
rosurgical procedure or had come from a nursing home
or hospital, vancomycin would be appropriate empiric
treatment. Vancomycin, however, has little (though
some) action against Listeria. The recommended agent
is ampicillin.
42. The correct answer is B. This patient has hyponatremia
caused by SIADH (syndrome of inappropriate antidi-
uretic hormone), likely from a small cell lung cancer.
The most appropriate initial treatment for SIADH is
fluid restriction, though occasionally a loop diuretic
(which loses relatively more water than sodium) or
hypertonic saline is needed. In general, when evaluating
hyponatremia, fluid restriction is always an appropriate
initial treatment until the cause is known. SIADH does
not respond to fluids, which paradoxically may make the
situation worse.
Demeclocycline (choice A) is rarely used to treat chronic
SIADH. It works by inducing a nephrogenic diabetes
insipidus, rendering the renal tubule relatively insensitive
to ADH. It is not an appropriate initial treatment.
Hydrochlorothiazide (choice C) and other thiazide
diuretics are contraindicated in hyponatremia. They
function by inhibiting the distal convoluted tubule reab-
sorption of sodium and chloride. This portion of the
kidney serves to dilute urine. By inhibiting this function,
this drug results in relatively salt-concentrated urine,
and thus can induce hyponatremia.

Hypertonic saline (choice D) is needed only in emer-
gencies. If this patient were obtunded or seizing, then
initial correction to approximately 120 mEq/L would be
appropriate, together with fluid restriction.
Normal saline (choice E) should not be given to
patients with SIADH. The antidiuretic hormone results
in reabsorption of the free water, whereas the 154
mEq/L of sodium is simply wasted in the urine. This
can result in a paradoxic worsening of the patient’s
hyponatremia.
43. The correct answer is B. This patient has sarcoid, a con-
dition significantly more common in African American
women. The disease is characterized by an inappropriate
T-cell response to self-antigens, resulting in the forma-
tion of noncaseating granulomas. Classic findings
include hilar lymphadenopathy in a young, African
American woman, erythema nodosum, and elevated
ACE levels (present in 75% of patients with sarcoid).
Occasionally, a large granuloma burden will result in
hypercalcemia. This is caused by granuloma production
of active vitamin D, or 1,25-dihydroxy cholecalciferol,
which results in increased calcium absorption by the gut
(its main mechanism).
Acid-fast bacillus (choice A) would indicate TB or atyp-
ical mycobacterium in this setting. This patient has
nothing to suggest TB exposure and recently had a neg-
ative PPD.
Granulomas with central necrosis (choice C) are seen
commonly in tuberculosis. Sarcoid is characterized by
noncaseating granulomas. The final diagnosis of the
condition rests on histopathologic confirmation, which
requires lymph node or parotid biopsy. If there are no
peripheral sites of active disease, biopsy by way of bron-
choscopy or mediastinoscopy is necessary.
Sarcoid is a disease of T-cell dysfunction, and patients
are somewhat immunocompromised. In most patients,
however, CD4 cell counts (choice D) are normal. A
reduction in CD4+ T cells is consistent with HIV,
though up to 10% of patients with sarcoid have a gen-
eral lymphopenia.
Skin biopsy (choice E) is unlikely to reveal noncaseating
granulomas. This patient has erythema nodosum, a
nonspecific nodular rash commonly appearing on the
tibias. It is believed to represent a delayed hypersensi-
tivity reaction and is actually a good prognostic indica-
tor, as it shows a healthy host immune response. These
lesions are caused by this reaction, not by direct infil-
tration with granuloma.
44. The correct answer is D. This patient likely has normal
pressure hydrocephalus (NPH), a rare but potentially
Internal Medicine Answers and Explanations
reversible cause of dementia caused by a relative over-
abundance of CSF fluid with resultant distention of the
ventricles and compression of the limbic system. The
clinical presentation is one of moderate to severe
dementia (though often less so than in Alzheimer
dementia), a wide-based gait, and urinary inconti-
nence. The treatment of choice is a CSF shunt or
repeated large volume lumbar punctures.
Often there is some overlap in presentation with
Parkinson disease, and patients may be started inappro-
priately on carbidopa/levodopa (choice A). The CT
findings and urinary incontinence, together with a
wide-based gait without true weakness or ataxia, argue
in favor of a diagnosis of NPH, which will not improve
with this treatment.
Vitamin E and donepezil (choice B) are two treatments
that have shown promise in the treatment of Alzheimer
dementia. Both can delay the rate of cognitive decline
and delay the need for a nursing home. Neither is used
to definitively treat NPH.
Only approximately 21% of patients improve with
shunting. Given the potential to reverse the dementia,
however, further treatment (choice C) should be offered.
Patients with NPH often have a mild hyponatremia,
believed to be caused by compression of the posterior
pituitary, resulting in release of ADH. This patient’s
sodium is not low enough to explain her symptoms and
does not need to be replaced to normal (choice E).
45. The correct answer is A. This patient likely has hepatic
encephalopathy and needs evaluation for spontaneous
bacterial peritonitis, which can exacerbate or initiate
the condition in a patient with previously compensated
liver disease. Patients often have asterixis, though it may
be difficult to get an encephalopathic patient to extend
the wrists. Other neurologic findings may include rigid-
ity, not flaccidity (choice C), hyperreflexia, not hypore-
flexia (choice D), and focal neurologic findings such as
hemiplegia.
Fetor hepaticus (choice B) correlates with severe end-
stage liver disease but is not usually present in cases of
hepatic encephalopathy. Fetor hepaticus is a foul, musty
smell associated with the presence of mercaptans in the
blood.
Nystagmus (choice E) is associated with Wernicke-
Korsakoff syndrome, which this patient is certainly at
risk for given his history of alcoholism. The patient’s
quick response to lactulose is classic for hepatic
encephalopathy, however, which is likely his primary
diagnosis. The question now is what triggered his
encephalopathy. Although many patients will not have
51
USMLE Step 3 Assessment Exam
a clear cause for their decompensation, many others will
have an underlying infection, such as an early pneumo-
nia, a urinary tract infection, or spontaneous bacterial
peritonitis. Dietary and medical compliance are also
common precipitants. Failure to take outpatient lactu-
lose, a sudden increase in protein consumption or
dehydration (which may be caused, ironically, by too
much lactulose) can induce hepatic encephalopathy.
46. The correct answer is B. TSH is the single most useful
test when evaluating hypo- (as in this patient’s case) or
hyperthyroidism. It is also used to monitor a patient’s
response to treatment, as changes in the TSH are
believed to be more indicative of a response to treat-
ment than changes in the free T4.
The free T4 index (choice A) is an old test used to indi-
rectly measure free T4. It is no longer used, now that
assays to measure free T4 directly are ubiquitous.
Free T4 (choice C) is a useful test to gauge the extent of
hypo- or hyperthyroidism. TSH is considered the most
useful test of determining if a patient is euthyroid, how-
ever, and is the most useful test for monitoring a
response to treatment with supplemental thyroxine.
Total T4 (choice D) is a test that is not used often. A vari-
ety of conditions can alter levels of thyroid-binding
globulin, which causes a fluctuation in the total T4 level.
The free (unbound) T4, however, which is metabolically
active, is maintained at homeostatic levels that may not
correlate with the total T4 levels.
Free T3 (choice E) rarely needs to be ordered in the
workup of hypo- or hyperthyroidism. T3 levels are reg-
ulated mainly at the tissue level and are much less likely
to be abnormal than are T4 levels.
47. The correct answer is E. Positive anti-Smith and anti-
dsDNA antibodies are very specific for systemic lupus
erythematosus (SLE). Unlike a positive ANA that may
be present in a variety of autoimmune diseases and in
many unaffected people, anti-Smith and anti-dsDNA
rarely are seen in conditions other than SLE. As such,
this is a good test to rule in the condition, though many
patients with SLE may have the condition without hav-
ing these antibodies present. The other choices listed
are not specific to SLE.
This patient’s rash (choice A) is not specific for SLE.
The rash described is most consistent with a discoid
rash, as it involves mainly the scalp and ears, rather than
appearing as an erythematous band across the malar
areas. Most patients with discoid lupus do not progress
to SLE, and most patients with SLE (approximately
75%) do not have this rash.
52
Low complement levels (choice B) indicate active
lupus, but occur in a variety of conditions. A host of
inflammatory, autoimmune, and infectious conditions
activate the complement pathway, resulting in con-
sumption of complement components and low mea-
sured levels.
A positive ANA (choice C) is extremely sensitive, not
specific. It is negative in less than 3% of cases of SLE,
but is positive in up to 10% of normal patients.
Positive anti-RNP (choice D) is seen most commonly in
mixed connective tissue disorder, but may be positive if
present in more than half of patients with SLE.
48. The correct answer is E. The standard of care for the
treatment of a single episode of pulmonary embolus is
3 to 6 months, preferably the latter, with warfarin. Only
patients who fail warfarin therapy (i.e., those who have
a recurrent clot) or have a contraindication to antico-
agulation require treatment with a mechanical filter,
such as a Greenfield filter (choice B).
Antiplatelet agents such as aspirin or clopidogrel
(choice A) are inappropriate for the management of a
pulmonary embolus. The coagulation cascade needs to
be interrupted with agents such as warfarin, heparin,
enoxaparin, and newer direct thrombin inhibitors.
Heparin (choice C) is an appropriate immediate treat-
ment for a pulmonary embolus, as it rapidly reaches ther-
apeutic levels compared with oral warfarin. It is difficult
to administer, however, and requires frequent monitoring
of the activated partial thromboplastin time. As such, it is
not an ideal agent for long-term treatment. Patients who
have a contraindication to warfarin, such as those who are
pregnant, may require warfarin or enoxaparin.
Enoxaparin (choice D) is a subcutaneously administered
low-molecular weight heparin. It rapidly reaches thera-
peutic levels, usually does not require monitoring, and
can be self-administered by patients. Warfarin, however,
is considered to be cheaper, easier, and has a longer track
record in treating a pulmonary embolus. As such, enoxa-
parin usually is used as a bridge to warfarin treatment. It
is started together with warfarin and then stopped once
the INR reaches therapeutic levels (an INR of 2 to 3).
49. The correct answer is D. Among the listed agents,
spironolactone is the only one to show a survival bene-
fit. The mechanism is believed to be reduced cardiac
fibrosis and remodeling, by way of modulation of the
renin-angiotensin-aldosterone system. Low daily doses
are adequate to see this effect. Other agents that improve
survival are aspirin, beta-blockers (usually metoprolol
or carvedilol), ACE inhibitors, and the combination of
hydralazine and nitrates.

Digoxin (choice A) has been studied extensively, but has
never imparted a survival advantage. It can result in
improved symptoms and fewer hospitalizations, but
also can be extremely toxic, having a narrow therapeu-
tic window.
Furosemide (choice B) improves symptoms, and, like
fluid and salt restriction, is essential to managing con-
gestive heart failure. Loop diuretics do not, however,
improve survival.
Hydrochlorothiazide (choice C) is used occasionally in
difficult to treat edema. The combination of
hydrochlorothiazide and furosemide (or any other loop
diuretic) serves to synergistically enhance diuresis.
Although this may help manage otherwise refractory
edema, it has not been shown to improve survival.
Alpha-blockers, such as terazosin (choice E), are no
longer used to treat congestive heart failure. Afterload
52.
reduction is better achieved with hydralazine or an
ACE inhibitor, agents that have been proven to
improve survival.
50. The correct answer is C. This patient has a classic pre-
sentation of an asymptomatic case of lupus anticoagu-
lant. This common condition can predispose patients
to recurrent thrombotic (not hemorrhagic) events. If
the patient is asymptomatic, further treatment is not
necessary. Classic clues include a false positive VDRL
for syphilis (but a negative specific test such as an FTA-
ABS or dark-field spectroscopy), an elevated PTT, and,
if symptomatic, a history of spontaneous abortions or
recurrent venous clots.
Vitamin K (choice A) and fresh frozen plasma (choice
B) play no role in the management of this patient’s con-
dition. She is not suffering from vitamin K deficiency or
inhibition, which would result in an elevated PT/INR,
rather than an elevated PTT, and she does not have a
deficiency of factors that can be treated with plasma.
Warfarin should be used for long-term management of
patients with this condition who develop thrombotic
events. Unlike the usual treatment for deep venous
thrombosis, which is a goal INR of 2 to 3 seconds
(choice D), these patients need more powerful antico-
agulation. The goal INR is usually set higher, at 2.5 to
3.5 seconds (choice E), though individual institutions
may vary.
51. The correct answer is D. Prostate nodules and asym-
metric prostates need to be biopsied, particularly in
patients at risk for prostate cancer, such as this patient.
Even if the PSA level is low, this patient, based on
pretest probability and the poor specificity and sensitiv-
ity of the PSA test, will need a prostate biopsy. As such,
Internal Medicine Answers and Explanations
the biopsy should be arranged for as soon as possible
rather than waiting (choice B).
A CT scan of the abdomen and pelvis (choice A) is not
indicated at this time. If this patient has a positive biopsy,
a CT scan is often part of the staging workup, though it
has questionable sensitivity. Similarly, a radionucleotide
bone scan (choice C) is indicated only if there is suspicion
of metastatic disease; a tissue diagnosis of prostate cancer
is necessary before progressing to this test.
A transrectal ultrasound (choice E) is not necessary as
part of the workup for a prostatic nodule, though it
may be used to guide a biopsy. Because the consistency
of a cancerous nodule varies, it may be hypo-, hyper-,
or isoechoic, resulting in a substantial number of false
negatives. Regardless of the result of transrectal ultra-
sonography, the patient will require a biopsy.
The correct answer is D. This patient likely has sponta-
neous bacterial peritonitis (SBP), a common infection
in patients with long-standing ascites. Patients sponta-
neously seed their peritoneum, leading to an often
indolent infection that is caused by a single organism.
The most common organisms are E. coli,
Enterobacteriaceae, and S. pneumoniae. Given the vari-
ability in clinical presentation, the only way to make the
diagnosis is by paracentesis. A positive paracentesis is
one with greater than 500 total WBCs, of which greater
than 250 cells are neutrophils. Organisms are rarely
seen on the Gram stain, and the presence of a large
organism burden, particularly if polymicrobial, should
prompt one to think of a perforated viscus.
Additional diuretics, such as furosemide (choice A), may
be necessary, but should not be started until it is clear
what is causing this patient’s worsening symptoms.
Cefotaxime (choice B) is the treatment of choice for
SBP. A paracentesis should be performed before treat-
ment, however, to determine if the infection is indeed
present. Unlike bacterial meningitis, delaying antibi-
otics by an hour or two will not increase the risk for
poor disease outcomes.
An abdominal CT scan or ultrasound (choice C) may
be necessary in this patient’s management, particularly
if SBP is not the cause of his worsening symptoms. A
sudden increase in ascites may indicate a serious com-
plication of cirrhosis, such as the development of hep-
atocellular carcinoma or a clot in the hepatic veins.
The first test for this patient, however, should be a
diagnostic paracentesis.
A thoracentesis (choice E) is not necessary. Many
patients with liver disease and ascites have right-sided
effusions, as fluid easily moves through small pores in
53
USMLE Step 3 Assessment Exam
the diaphragm above the inflamed liver. If there is
doubt about this patient’s effusion, old radiographs
should be obtained to determine if the effusion is
chronic, in which case it could be left alone.
53. The correct answer is E. This patient has a clinical pre-
sentation consistent with pyelonephritis. No additional
tests are needed, though the culture data, once avail-
able, should be used to tailor initial empiric antibiotic
therapy. If the patient fails to improve on appropriate
treatment, then one needs to consider a complication of
pyelonephritis or another cause. Likely complications
might include perinephric abscess, papillary necrosis,
or emphysematous pyelonephritis.
Ultrasound (choice A) can be used to look for obstruc-
tion and hydronephrosis, and may also show a renal
abscess. A CT scan (choice B) reveals the same infor-
mation and may have a higher sensitivity. At this point,
however, neither test is warranted, as there is no reason
to suspect this patient has something more than a bad
case of pyelonephritis.
An IVP (choice C) can be used to look for renal stones
and will reveal the anatomy of the ureter. The test is not
appropriate in this patient, however, who has a presen-
tation more consistent with pyelonephritis than with
renal stones. Further, if stones were suspected, ultra-
sound or noncontrast CT scan are often the first test, as
these modalities avoid potentially nephrotoxic dye.
A KUB (choice D) is generally low yield, though it may
show emphysematous pyelonephritis or emphysematous
cystitis, if present. It is generally a useful test for evaluat-
ing for bowel obstruction or perforation and will often
pick up renal stones. It is not indicated in this patient,
however, with a classic presentation of pyelonephritis.
54. The correct answer is D. A positive PPD in a healthcare
worker is an area of induration of greater than 10 mm,
read 48 to 72 hours after placement of the skin test.
Erythema is also often present, and may be quite signif-
icant. The induration, not the erythema (which may
have quite a large diameter), is what needs to be read
when interpreting a PPD.
The area of erythema, whether 5 mm (choice A), 10
mm (choice B), or 15 mm (choice E) is irrelevant. The
induration is used to determine a positive PPD, as the
erythema may be quite variable and nonspecific. If
there is any confusion, the lesion should be palpated or
marked with a ballpoint pen to determine the extent of
the raised area.
An area of induration greater than 5 mm (choice C) is
considered a positive test in patients who are immuno-
compromised (mainly HIV patients) and those with
close contacts who have active tuberculosis.
54
55. The correct answer is B. This patient has Parkinson
disease. The primary symptoms are resting tremor in
the hands, arms, legs, jaw, and face, rigidity or stiffness
of the limbs and trunk, bradykinesia, and postural
instability or impaired balance and coordination.
Patients may also have difficulty walking, talking, or
completing other simple tasks. The initial treatment for
moderate to severe Parkinson disease (such as in this
case) is dopamine or a dopaminergic agonist, such as
bromocriptine. L-dopa is given with carbidopa, which
inhibits peripheral breakdown of L-dopa.
Amantadine (choice A) has some mild anti-Parkinson
effects, believed to be caused by increased central
dopamine release. The agent is a distant third to
dopamine and dopaminergic agonists, however, and
should not be the initial or primary treatment for mod-
erate to severe cases.
Donepezil (choice C) is a cholinesterase inhibitor that
may delay the progression of Alzheimer dementia in
some patients. It is not useful in the treatment of
Parkinson disease.
Sertraline (choice D) is an SSRI useful in the treatment
of pseudodementia, or depression, which can present as
a patient with near catatonia. The tremor and gait
instability are more suggestive of a disease of the basal
ganglia, however, such as Parkinson disease.
Vitamin B12 and folate (choice E) would be useful if this
patient had a deficiency of either. Vitamin B12 deficiency
in particular can result in a dementia with an abnormal
gait caused by posterolateral spinal cord degeneration. A
macrocytic anemia, however, would be expected on lab-
oratory values. Further, the bradykinesia, lack of facial
expression, and resting tremor are classic for Parkinson
disease.
56. The correct answer is A. All patients with long-standing
cirrhosis, particularly if from chronic hepatitis B or C,
should be screened periodically for the development of a
hepatoma. Screening strategies include the use of period-
ic ultrasounds and laboratory evaluation for the presence
of serologic tumor markers. Additionally, in patients
with cirrhosis who suddenly develop a deterioration or
increased ascites, the development of a hepatoma needs
to be considered, in addition to spontaneous bacterial
peritonitis and clots in the inferior vena cava or hepatic
veins. AFP is a tumor marker that is markedly elevated
in patients with hepatoma or a germ cell tumor.
Although the marker is nonspecific, high elevations are
more likely to be associated with these tumors than with
other cancers.
Beta-hCG (choice B) is elevated in some cases of testic-
ular cancer and in gestational trophoblastic disease

(which includes hydatidiform mole, choriocarcinoma,
and other placental site trophoblastic tumors) and
ectopic or intrauterine pregnancy.
CA-125 (choice C) is a tumor marker often seen in ovar-
ian cancer that is used occasionally as a screening test in
high-risk populations, though it still has a low positive
predictive value. It is not associated with hepatoma.
CEA (choice D) is elevated in a variety of gastrointesti-
nal malignancies and is generally too nonspecific to be
used for tumor screening, even in high-risk popula-
tions. It is useful, however, in patients with known
treated malignancies (particularly colon cancer) who
need to be monitored closely for evidence of tumor
recurrence. It is not strongly associated with hepatoma.
PSA (choice E) is a tumor marker often seen in prostate
cancer that is often used as a screening test. It is not
associated with hepatoma.
57. The correct answer is A. Morning hyperglycemia in
patients with diabetes needs close evaluation. Two dif-
ferent causes of morning hyperglycemia need to be dif-
ferentiated, as they require opposite treatments. Choose
the wrong one and you can kill your diabetic patient!
The Somogyi effect is rebound hyperglycemia caused
by counter-regulatory cortisol release in response to
nocturnal hypoglycemia. This occurs mainly when
patients or physicians provide too much of a medium
(such as NPH) or long-acting insulin, which peaks
many hours after administration. These patients need
less of their evening dose of long or medium-acting
insulin. The alternative and much more common cause
of pre-breakfast hyperglycemia is the Dawn phe-
nomenon. Regular circadian release of cortisol results
in a peak release between the hours of 3 and 8 AM.
Patients are relatively hypoinsulinemic and should
receive additional medium- or long-acting insulin the
evening prior. This patient has signs of nocturnal hypo-
glycemia. Her insulin level should be reduced and she
should be advised to wake up and check her 3 AM blood
glucose level for a few nights so that her insulin can be
dosed accordingly.
Decreasing the dose of regular insulin before dinner
(choice B) is unlikely to be beneficial. Regular insulin
peaks quickly. The patient’s late night hypoglycemia
and early morning hyperglycemia cannot be attributed
to her dose of regular insulin.
Patients with type 1 diabetes should be allowed to have
snacks (choice C). They often develop an excellent
sense of when they are suffering from low blood glucose
levels and usually know what sources and quantities of
sugar they need to turn things around.
Internal Medicine Answers and Explanations
NPH insulin often peaks 6 to 8 hours after administra-
tion. As such, increasing the dose of morning NPH
insulin (choice D) is unlikely to help control this
patient’s blood glucose levels.
Increasing the dose of regular insulin before breakfast
(choice E) will help control her morning hyperglycemia.
It does not address the likely nocturnal hypoglycemia,
however, or the resultant hyperglycemia that is likely
occurring for hours before she awakes.
58. The correct answer is A. Patients with severe rheuma-
toid arthritis may have involvement of C1 and C2,
resulting in atlantoaxial subluxation. Hyperextension,
such as that during intubation, can result in spinal cord
injury. Patients need a screening radiograph or, in an
emergency, airway management by an expert (anesthe-
siologist, preferably with a fiberoptic intubation kit).
The patient’s pattern of injury, involving all of her
extremities and compromising her ability to breathe
spontaneously, is highly suggestive of a high cervical
spinal injury.
A cervical epidural hematoma (choice B) could conceiv-
ably cause similar symptoms. Without a pre-existing
reason to bleed into her spinal cord (an exceedingly rare
event), however, she is unlikely to do so, even after
receiving a thrombolytic agent.
Hypoxic brain injury (choice C) and intracerebral hem-
orrhage (choice D) are unlikely to create this pattern of
quadriplegia. More likely would be either global deficits
(including cognition) or focal neurologic findings.
Prednisone (choice E) has a variety of long-term side
effects, including osteopenia. Although it may con-
tribute to spinal fractures from bone demineralization,
the most likely cause of this patient’s spinal condition is
a pre-existing atlantoaxial subluxation worsened by an
emergency intubation.
59. The correct answer is D. This patient has Wernicke
encephalopathy, characterized by the triad of ocular
abnormalities (classically nystagmus and a lateral rectus
palsy), gait ataxia, and encephalopathy. One way to
remember this is that alcoholic patients have a NAC (nys-
tagmus, ataxia, confusion) for getting themselves in
trouble. Wernicke encephalopathy may be triggered by
not being given adequate thiamine (a.k.a. vitamin B1)
replacement together with glucose. These patients have
a high carbohydrate diet and low thiamine stores. The
sudden glucose load can exhaust thiamine reserves, which
are consumed as a Krebs cycle cofactor. Extreme Wernicke
can result in Korsakoff amnestic syndrome, characterized
by confabulation and anterograde amnesia.
55
USMLE Step 3 Assessment Exam
Calcium (choice A) needs to be replaced in massive
blood transfusions (typically greater than 8 to 10 U of
PRBCs). Citrate used to preserve blood chelates ionized
calcium. This patient is unlikely to be suffering from
severe hypocalcemia, which, in any case, would be
unlikely to explain his constellation of syndromes.
Folate (choice B) deficiency does not explain this patient’s
symptoms. Folate deficiency can result in a megaloblastic
anemia and often contributes to the multifactorial mega-
loblastic anemia seen in alcoholic patients.
Magnesium (choice C) should be given to alcoholic
patients empirically, together with thiamine, folate, and
a multivitamin, as they are often total body-deficient in
magnesium, though their measured blood levels may be
normal.
Vitamin B12 (choice E) deficiency may be seen in
severely malnourished alcoholic patients and can result
in gait disturbances and a reversible dementia. Given
the acuity of this patient’s symptoms and the character-
istic triad and presentation, however, thiamine defi-
ciency is a more likely etiology.
60. The correct answer is A. Cilostazol is a phosphodi-
esterase inhibitor that causes arterial vasodilatation and
inhibits platelets. It is a useful treatment for claudica-
tion symptoms, particularly when used in conjunction
with lifestyle modifications (structured exercise pro-
gram and smoking cessation) and other medications,
such as aspirin, clopidogrel, a statin, and an ACE
inhibitor, all of which have been shown beneficial in
the treatment of peripheral vascular disease.
Pentoxifylline (choice B) may provide a slight improve-
ment in claudication symptoms but has been shown to
be less effective than cilostazol in head-to-head trials.
There has never been shown any benefit to increasing
the dose of aspirin (choice C) from 81 mg a day (a baby
aspirin) to 325 mg a day. Presumably, 81 mg is an
adequate dose to inhibit platelets.
Clopidogrel (choice D) has been shown to be more
beneficial than aspirin in the treatment of claudication
symptoms. It should not be stopped in this patient.
Beta-blockers, such as metoprolol (choice E), were once
believed to have the potential to worsen peripheral vascu-
lar disease. This has never borne out and, given that these
patients almost always have significant coronary artery
disease, there is no reason to withhold a beta-blocker.
61. The correct answer is E. This patient has hereditary
hemochromatosis, a condition characterized by dysreg-
ulation and increased uptake of iron. Patients often pre-
sent with vague complaints related to iron deposition.
56
Weakness and lethargy, arthralgias, impotence, and
liver function abnormalities are common presenting
complaints. Occasionally patients may develop a bronze
hue to their skin, resulting in the “bronze diabetes” of
hemochromatosis. The most effective, simplest, and
cheapest way to remove excess iron is with regular phle-
botomy.
Deferoxamine (choice A) and penicillamine (choice D)
are chelating agents. Although it is possible to chelate
the iron, this treatment is rarely used, as phlebotomy is
more effective. If patients present with conditions
requiring immediate removal of the excess iron, then
deferoxamine and phlebotomy may be appropriate.
Penicillamine is used mainly to bind copper and used to
be a main agent in the treatment of Wilson disease.
This patient is iron overloaded. Ferrous sulfate (choice
B) will only worsen the patient’s symptoms.
Liver transplant (choice C) is only necessary in advanced
cases of cirrhosis and hepatocellular carcinoma. There is
no evidence this patient has significant cirrhosis or irre-
versible liver disease.
62. The correct answer is E. There is no evidence that
screening for lung cancer, even in smokers, reduces the
risk for dying of lung cancer. Some early trials have
shown a difference in survival, but this is believed to be
simply because of lead time bias, in which the diagno-
sis was simply made earlier in the normal lifespan of the
disease. As such, it is not recommended to screen for
lung cancer at this time.
Radiographs (choice A), cytology (choice C), and com-
binations of the two (choice B), lack the sensitivity and
specificity necessary to be effective screening tools.
CT scans (choice D) may at some point provide ade-
quate sensitivity, but currently are not considered cost
effective and, given the high rate of false positives, actu-
ally may be detrimental if they result in unnecessary
biopsies.
63. The correct answer is C. Chronic hepatitis B should be
treated, as chronic active disease can progress to cirrho-
sis, hepatoma, or fulminant liver failure. Early treatment
used interferon monotherapy (choice A), a difficult to
administer medication with many side effects, including
significant psychiatric effects. Poorly controlled depres-
sion or bipolar disorder is a relative contraindication.
More recently, lamivudine, originally developed for HIV
treatment, has become the first line agent for treating
chronic HBV, though its efficacy is similar to interferon.
For patients who fail either, adefovir is a new nucleotide
analog that can be used for patients who do not respond
to interferon or who become resistant to lamivudine.

Interferon and ribavirin (choice B) are used in the
treatment of chronic hepatitis C, not HBV. The
Pegylated version allows for less frequent injections of
the medication.
This patient should receive additional treatment
(choice D), as his prolonged state of infection puts him
at significant risk for the development of a hepatoma.
Ribavirin monotherapy (choice E) is never used and is
completely ineffective in the treatment of viral hepatitis.
64. The correct answer is D. This patient likely has a stru-
vite stone. Such stones represent 5 to 10% of all kidney
stones and generally form only in alkaline urine. The
most common culprit is Proteus, which, by way of ure-
ase, creates an alkaline environment. Other common
causes of urinary tract infections, such as E. coli (choice
A) and staphylococcal infection (choice E) do not alka-
linize the urine.
Nephritic syndrome (choice B) and nephrotic syn-
drome (choice C) may or may not be present in this
woman. Her current urine dipstick findings and hyper-
tension are most likely caused by the presence of a uri-
nary tract infection and renal stone (which often creates
hematuria) and the resultant pain. She is, however, at
risk for diabetic nephropathy, and this may explain the
dramatic proteinuria.
65. The correct answer is B. This patient’s effusions are
almost certain to be caused by heart failure. Significant
pulmonary edema often results in bilateral pleural effu-
sions, which are transudates. Transudates classically
appear yellow or straw-colored, are fairly clear, have a
protein level that is less than half the serum level, and
have an LDH level less than 60% of the serum level
(and less than two thirds the upper limit of normal).
Hemorrhagic pleural fluid (choice A) is exudative and
should raise concern for malignancy or pleural infarction.
Pleural fluid with a low glucose and low pH (choice C),
particularly if it grossly appears to be pus, is character-
istic of an empyema, not heart failure. Rheumatoid
arthritis also may cause a low glucose effusion.
An elevated LDH level in the pleural fluid (choice D)
suggests an exudate. If the level is greater than two
thirds the upper limit of normal for serum LDH or the
ratio of pleural to serum LDH is >0.6, the fluid is
exudative.
A total protein level similar to serum protein (choice E)
makes the effusion exudative. A ratio of pleural protein
to serum protein of >0.5 characterizes the effusion as
an exudate.
Internal Medicine Answers and Explanations
66. The correct answer is C. The constellation of findings
given in the vignette is good for Cushing syndrome. We
often think of that diagnosis when shown a picture of a
patient who exhibits a Cushingoid appearance, but
sometimes body habitus is not present in its florid, fully
developed, typical pattern. In that case, the other “coin-
cidences” (diabetes, osteoporosis, irregular menses, easy
bruisability, and mood swings) should trigger suspicion.
The other four options given address classic conditions
associated with surgically correctable hypertension, all
of which can be seen in young women, but as it happens,
each is negated by some of the descriptors.
In hyperaldosteronism (choice A), serum potassium is
typically low. Furthermore, hypertension caused by that
condition does not coincide with diabetes, osteoporo-
sis, irregular menses, easy bruisability, or mood swings.
Renovascular hypertension (choice B) is likewise not
associated with the five additional findings listed,
whereas it is often suggested by the presence of an
upper abdominal or flank bruit.
Coarctation of the aorta (choice D), when seen in the
adult, often has the classic scalloping under the ribs that
results from the large collateral vessels that develop over
the years. As in the other examples given, none of the
five additional findings present in this patient are seen
in coarctation. The same could be said for pheochro-
mocytoma (choice E).
67. The correct answer is A. This patient has subclinical
hypothyroidism, defined as an elevated TSH with a nor-
mal T4. Although there is some controversy over whom
to treat, most patients generally benefit from treatment.
In patients with cardiac disease or a history of psychiatric
disorders, the evidence in favor of treatment is strong.
Patients are at risk for accelerated atherosclerosis and
recurrent depression if they are not treated (choice C).
Antithyroid peroxidase antibody levels (choice B) may
provide further evidence as to the cause of the patient’s
subclinical hypothyroidism. They are not necessary in
determining whether to treat this patient.
Isolated T3 deficiency is extremely rare and unlikely to
explain this patient’s abnormal laboratory values.
Further, T3 supplementation is dangerous because of its
variable bioavailability and ability to induce cardiac
arrhythmias, and it would not be a good agent for an
asymptomatic patient. There is no need to order a T3
level or start supplemental T3 treatment (choice D).
Close followup, perhaps with an appointment in 3
months (choice E), is appropriate if this patient does
not wish to start T4 treatment. In this patient, however,
treatment is beneficial and should be started if the
patient so desires.
57
USMLE Step 3 Assessment Exam
68. The correct answer is A. This patient is in acute
pulmonary edema in the setting of rapid atrial fibrilla-
tion that is now causing hypotension as well. Her
increased heart rate is causing diminished ventricular
filling. It is not known how long she has been in atrial
fibrillation. The immediate goal of treatment must be
to slow the heart rate or to restore sinus rhythm. Given
the life-threatening presentation, urgent cardioversion
is indicated. She must also be anticoagulated to prevent
thromboembolic episodes after the event.
Intravenous metoprolol (choice B) would have been
useful had the patient not been decompensating.
However, a beta-blocker is relatively contraindicated in
a patient with chronic obstructive pulmonary disease.
Intravenous digoxin (choice C) may reduce the ventric-
ular rate slightly. However, given its vagal mode of func-
tion, the rate is unlikely to be controlled as effectively.
Intravenous diltiazem (choice D) would be useful in rapid
atrial fibrillation if the patient were not in pulmonary
edema or hypotensive. It is in fact an effective modality to
control rapid atrial fibrillation in a stable patient.
Intravenous adenosine (choice E) will be effective only
transiently. It would be helpful to clarify the rhythm
and distinguish it from multifocal atrial tachycardia.
69. The correct answer is B. This patient likely has urethri-
tis. Urethritis is classified as gonococcal or nongonococ-
cal. Gonococcal urethritis is caused by Neisseria gonor-
rhoeae. Nongonococcal disease is caused by Chlamydia
trachomatis, Ureaplasma urealyticum, Mycoplasma homi-
nis, and Trichomonas. The best treatment for this patient
is to treat empirically with a single dose of ceftriaxone
and azithromycin. This regimen covers gonococcal and
nongonococcal infections. Patients are often infected
with both organisms, so single-dose treat for both to
insure compliance.
Treatment for gonorrhea alone (choice A) may miss a
significant number of cases of coexistent nongonococ-
cal urethritis. Treatment for both infections helps lessen
the chance of further disease spread and it is therefore
best to treat patients empirically for both infections.
Prophylaxis for HIV (choice C) is not indicated.
Patients with needle sticks can receive prophylaxis for
HIV within 25 hours of the incident, but there is no
evidence that prophylaxis several days after an unpro-
tected sexual intercourse effectively decreases transmis-
sion of HIV. This patient should receive an HIV test
now and in 6 months.
This patient does not need treatment for syphilis
(choice D). He has no lesions consistent with syphilis at
this time. He should, however, receive a screening test
for syphilis.
58
Withholding treatment at this time (choice E) is not the
best course of action. This patient should be treated
now to avoid further spread of the infection. He also
should inform his sexual partners of his infection so
that they can be treated. He needs counseling about safe
sex practices for the future.
70. The correct answer is C. This patient has a classic pre-
sentation of a subarachnoid hemorrhage, which often
occurs from a ruptured saccular aneurysm (berry
aneurysm). The sentinal headaches, family history, and
sudden development of symptoms are classic. A brief
period of loss of consciousness or the occurrence of
seizures is not uncommon. CT scan may miss an acute
bleed in up to 10% of patients. If there is a high index
of suspicion, a lumbar puncture should be performed,
which will reveal xanthochromic CSF (pink or yellow
tinged from breakdown of red blood cells).
Cerebral angiography (choice A) is almost never per-
formed, particularly at 4 AM. If a CT scan and a lumbar
puncture are negative, it is a test to consider.
A CT scan with contrast (choice B) should not be per-
formed if there is concern for an acute bleed. A non-
contrast study is sensitive for bleeding and avoids the
risk for extravasation.
Magnetic resonance imaging (choice D) is less sensitive
than a CT scan for early bleeds. If this patient presented
later, an MRI might be appropriate. At this point, how-
ever, a lumbar puncture is more likely to confirm the
diagnosis.
A radiograph (choice E) does not provide more infor-
mation than the CT scan and is generally only useful if
a skull fracture or bony lesion is suspected, in which
case it may be superior to a CT scan.
71. The correct answer is C. As a result of his major trauma,
this patient is suffering from disseminated intravascular
coagulation (DIC). Large amounts of trauma to vascu-
lar beds and release of cytokines related to the inflam-
matory reaction can lead to massive overactivation of
the coagulation cascade. Excessive conversion of
prothrombin to active thrombin also leads to activation
of antithrombin III to counterbalance the coagulation
cascade. Antithrombin III, though, is quickly consumed,
leaving thrombin unopposed. Depletion of antithrom-
bin III seems to be the crucial event in the initiation of
DIC. This depletion leads to formation of diffuse
microthrombi, resulting in vessel occlusion and end-
organ ischemia. Such multiple organ failure is evident in
this patient who has developed acute renal failure and
respiratory compromise. After this initial hypercoagula-
tive state, clotting factors and platelets are consumed,
leading to uncontrolled bleeding as noted in this patient.

Surprisingly, fibrinogen levels may be normal or only
slightly decreased in DIC. This stems from the fact that
patients are invariably fighting another source of
inflammation, such as infection, trauma, surgery, or tox-
emia. Because fibrinogen is an acute phase reactant, its
levels initially are elevated as the patient mounts an
inflammatory response. As DIC progresses, fibrinogen is
consumed together with the other clotting factors, but is
not depleted to the same extent because of the initially
high levels.
Activated partial thromboplastin time and prothrom-
bin time (choices A and E) are incorrect because by this
time, the patient has consumed large quantities of
coagulation factors. A prolonged PT and aPTT are
almost universally elevated in DIC, except in the earli-
est stages of the disease. This patient has started to bleed
and so is clearly in the later stages.
Antithrombin levels (choice B) is incorrect because, as
stated, the depletion of antithrombin III is likely the
event that begins the downward spiral of DIC.
Platelet count (choice D) is incorrect because although
platelets are also acute phase reactants, their levels do
not increase as dramatically early in acute inflamma-
tion. Also, they are consumed more rapidly than is fib-
rinogen, and so patients in DIC always develop some
degree of thrombocytopenia.
72. The correct answer is C. Microcytic anemia and con-
stipation in a man who has presumably not had age-
appropriate colon cancer screening must be evaluated
for colon cancer. Given this patient’s anemia, a full
colonoscopy, which can visualize a significantly greater
area of the colon than a flexible sigmoidoscopy (choice
B), is an appropriate next step.
Fecal occult blood testing (choice A) has utility as a
screening test in asymptomatic patients. However, given
that this patient has symptoms that are consistent with
colon cancer, such as microcytic anemia and constipa-
tion, a full colonoscopy is warranted. Regardless of the
results of the fecal occult blood testing, which can have
variable sensitivity and specificity, this patient will need
a colonoscopy, rendering the stool test results irrelevant.
Senna (choice D) is a stimulant laxative that should be
used for the short-term treatment of constipation. It is
not an appropriate long-term therapy for constipation
because patients can become stimulant-dependent, and
it is certainly not an appropriate treatment for someone
who may have more significant pathology.
A trial of fiber, fluids, and stool softeners (choice E) is
an appropriate treatment for constipation once organic
causes of diseases are excluded. It is not appropriate in
Internal Medicine Answers and Explanations
patients with “red flags” such as anemia, weight loss,
abdominal pain, or evidence of gastrointestinal blood
loss.
73. The correct answer is A. Chronic transfusion therapy
results in a variety of long-term complications. One of
these complications is the development of alloanti-
bodies—antibodies that are directed against minor
antigen groups on transfused red blood cells. While the
presence of these antibodies may or may not produce
frank hemolysis, they will shorten the life of transfused
blood and complicate locating appropriate blood. The
blood bank performs a cross-match that needs to be
negative (no coagulation or hemolysis) except in the
case of emergencies.
Autoantibodies (choice B) do not explain the difficulty
in finding blood for this patient. Chronic transfusions
result in immune sensitization against transfused (for-
eign) blood, not in the development of autoantibodies.
Patients who are planned to undergo transplantation or
who have had transfusion reactions will often have spe-
cially filtered blood. This patient has no need for special
filtering of the blood (choice C) that would explain the
need to look far and wide for an appropriate specimen.
Anti-HLA antibodies (choice D) are antibodies against
major blood groups. It is extremely unlikely that a
blood bank would not be able to quickly match a
patient’s HLA type.
Progression of this patient’s myelodysplasia (choice E)
does not explain the difficulty in finding appropriate
blood for him. Progression of the disease results in less
production of red blood cells but does not explain why
it is difficult to find appropriate blood for a transfusion.
74. The correct answer is B. This patient has polyarteritis
nodosa (PAN), a vasculitis strongly associated with hep-
atitis B. Multiorgan system involvement should suggest
a vasculitis. Among the different types of vasculitis, this
patient’s symptoms are consistent with PAN. Most
patients complain of systemic symptoms such as weight
loss, malaise, and fever. Additionally, approximately half
have evidence of neuropathy, commonly mononeuritis
multiplex or polyneuropathy. Diffuse arthralgias and
myalgias are common. Commonly, renal involvement is
also present, evidenced by an increased creatinine,
hematuria, or glomerulonephritis. Skin involvement
often takes the form of livedo reticularis, seen in this
patient. Other clues include new-onset hypertension,
stroke or coronary disease in an otherwise low-risk
patient, orchitis, and unexplained pulmonary infiltrates.
59
USMLE Step 3 Assessment Exam

Hepatitis A (choice A) is an acute, self-limiting disease

and is not associated with long-term systemic condi-
tions. It is not associated with any common forms of
vasculitis.
Hepatitis C (choice C) is associated with the formation
of cryoglobulins. Cryoglobulinemia can cause a similar
condition. The main distinguishing feature of cryo-
globulinemia is palpable purpura seen commonly on
the lower extremities, though it may also cause renal
disease, arthralgias, and other systemic manifestations.
Hepatitis D (choice D) can cause fulminant hepatic
failure when it occurs as a coinfection with hepatitis B.
It does not cause these symptoms of vasculitis.
Hepatitis E (choice E) is rare in the United States and
generally causes an acute, self-limited hepatitis, though it
may cause fulminant hepatic failure in pregnant women.

75. The correct answer is C. This patient has a right ventri-

cle infarction, as evidenced by the fact that her left atrial
pressure is lower than that in the right atrium. She is
exquisitely preload-dependent. At this time, the course of
action should include aggressive fluid resuscitation so
that her wedge pressure starts coming up.
Positive inotropic agents in this patient may be required
in the form of digoxin (choice A) as this patient’s med-
ical course progresses. This is not required in the acute
setting, however.
Similarly, dobutamine (choice B) is not required
before fluid resuscitation. If the patient’s cardiac out-
put is diminished, however, this agent may be
required. Care must be taken to ensure that her
ischemia is not worsened.
Because this patient is exquisitely preload-dependent,
using a nitric oxide derivative such as isosorbide
mononitrate (choice D) is not advisable because
preload decreases as a result of vasodilation.
If the patient does not respond to the initial medical
intervention, afterload reduction may be required in
the form of the placement of an intraaortic balloon
pump (choice E).

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