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Practice Test 3 - USMLE Step 3

20 questions. Answer them in any order, then submit to see your score and every explanation.

  1. Kidney transplant recipient has rising creatinine; urine shows decoy cells. Best next step?
  2. A 49-year-old man has CKD stage 3b for 2 years from IgA nephropathy; he is managed with low-sodium diet and RAAS blockade. Medications include lisinopril 20 mg daily and atorvastatin 20 mg nightly. He asks about diet. BP is 124/72 mm Hg. Exam is normal. Labs: creatinine 1.9 mg/dL, eGFR 38 mL/min/1.73 m², K 4.7 mEq/L, HCO3 23 mEq/L. Urine protein-to-creatinine ratio is 1.2 g/g. What dietary advice should be given?
  3. A 40-year-old construction worker presents with 4 weeks of low back pain after lifting a heavy object. The pain is localized to the lumbosacral area, is worse with activity, and better with rest. There is no radiation of pain, numbness, weakness, or incontinence. His neurologic examination is normal. He is very anxious about his ability to return to work and requests an MRI. Which of the following is the most appropriate response?
  4. A 54-year-old woman is seen for follow-up three months after receiving a liver transplant for cirrhosis due to NASH. She is maintained on an immunosuppressive regimen of tacrolimus, mycophenolate mofetil, and a low-dose prednisone taper. Her blood pressure is 155/92 mm Hg, and her serum creatinine is 1.8 mg/dL (her baseline before transplant was 0.8 mg/dL). Her liver function tests are normal. What is the most likely cause of her hypertension and renal dysfunction?
  5. A 56-year-old man with a history of an unprovoked PE two years ago, for which he completed a 6-month course of apixaban, presents to the emergency department with acute-onset pleuritic chest pain. His vital signs are stable and his oxygen saturation is 98% on room air. He has no signs of a DVT. How does his prior PE history influence the immediate diagnostic workup?
  6. In addition to reinforcing the asthma action plan, which of the following is the most appropriate adjustment to his long-term management?
  7. HPI/Family Planning: 28F G2P2, 8 weeks postpartum, requests contraception. Breastfeeding exclusively; menses not returned. No HTN, no migraines with aura. Prior pregnancy complicated by gestational diabetes; current BMI 34. She had unprotected intercourse 5 days ago. Wants highly effective, reversible method and plans next pregnancy in >2 years. Exam normal. Interpregnancy care: counsel on weight, glucose testing, and spacing. What is the most appropriate next step in management for this patient?
  8. HPI/PP Immunization: 23F G1P1, 1 day postpartum, rubella nonimmune on prenatal labs. Delivered healthy infant; breastfeeding. No immunocompromise. She wants another pregnancy next year and asks about vaccines now. What is the most appropriate next step in management for this patient?
  9. During a routine 3-month follow-up visit, a 76-year-old woman with chronic heart failure reports feeling hopeless and has lost interest in her usual activities for the past month. She also reports poor sleep and appetite. Which of the following is the most appropriate initial action?
  10. A 69-year-old woman has CKD stage 5 for 11 years from diabetic nephropathy; she is stable and not yet on dialysis. She takes insulin, amlodipine 10 mg daily, torsemide 80 mg daily, sevelamer, and sodium bicarbonate. She reports mild anorexia but no dyspnea or pericardial pain. BP is 146/82 mm Hg. Exam shows 1+ edema. Labs: creatinine 6.8 mg/dL, eGFR 7 mL/min/1.73 m², K 5.2 mEq/L, HCO3 19 mEq/L, Ca 8.4 mg/dL, phosphate 6.1 mg/dL. Which referral is most appropriate for this patient?
  11. A 61-year-old man with cirrhosis is being managed for recurrent overt hepatic encephalopathy. He is adherent to a lactulose regimen that results in two to three soft bowel movements per day. Despite this, he continues to have breakthrough episodes of confusion requiring hospitalization every 2-3 months. What is the most appropriate next step in his outpatient management?
  12. A 55-year-old man with a history of poorly controlled hypertension presents to the emergency department with a sudden onset of severe, tearing chest pain that radiates to his back. His blood pressure is 190/110 mmHg, and his heart rate is 115/min. Aortic dissection is suspected, and a CT angiogram is ordered. While awaiting the scan, which of the following is the most appropriate immediate intervention?
  13. What is the most appropriate interval for her next surveillance colonoscopy?
  14. Which of the following is the most appropriate next step to guide further management?
  15. Which of the following is the most likely diagnosis?
  16. Comparing your hospital's C. difficile rate with national data, which metric is best?
  17. A 31-year-old G2P2 who is 6 weeks postpartum after an uncomplicated vaginal delivery asks for advice on family planning. She and her partner would like another child but want to ensure the timing is optimal for the health of both mother and baby. She has no chronic medical conditions.
  18. Which of the following is the most appropriate long-term management strategy for this patient?
  19. A 60-year-old woman with cirrhosis presents for routine surveillance. She has no new symptoms and remains abstinent from alcohol. Labs: bilirubin 1.9 mg/dL, albumin 3.0 g/dL, INR 1.5. Prior ultrasound 6 months ago shows no focal liver lesion. She asks how to monitor for liver cancer. What is the next best step in management for this patient?
  20. A 45-year-old patient undergoes a laparoscopic appendectomy. During the procedure, the surgeon inadvertently causes a thermal injury to a small section of the adjacent cecum. The injury is not recognized at the time of surgery. Three days later, the patient develops peritonitis from a delayed bowel perforation, requiring an emergency laparotomy and bowel resection. This entire sequence of events is best classified as which of the following?

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