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Practice Test 4 - USMLE Step 3

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

  1. Which of the following is the most appropriate choice for her oral anticoagulation?
  2. In addition to a complete blood count, which of the following sets of laboratory tests is most important to obtain as part of her routine annual nutritional screening?
  3. eGFR 18, Hb 9.0, ferritin 120, TSAT 12%. Before epoetin, give?
  4. A 28-year-old G1P1 woman comes to the clinic 8 weeks after an uncomplicated vaginal delivery. She reports feeling overwhelmed, cries frequently, and has lost interest in activities she used to enjoy. She expresses feelings of guilt about not being a "good enough" mother and has difficulty sleeping even when the baby is asleep. Her Edinburgh Postnatal Depression Scale (EPDS) score is 15. What is the most appropriate initial step in management?
  5. Which of the following represents the most significant adverse effect of chronic steroid use in this patient population, requiring diligent surveillance and management?
  6. Based on these results, which of the following is the most accurate conclusion?
  7. What is the most appropriate next step in the management of this child?
  8. A 38-year-old G1P1 woman with a history of chronic hypertension is seen at her 2-week postpartum visit. She is breastfeeding her infant. During pregnancy, her blood pressure was managed with labetalol. At today's visit, her blood pressure is 155/95 mm Hg. She is currently taking labetalol 200 mg twice daily. Which of the following is the most appropriate next step in managing her hypertension?
  9. In addition to his current management, which of the following treatments is most appropriate for this patient?
  10. A 50-year-old man has been in the ICU for two weeks recovering from severe thermal burns covering 40% of his body surface area. He has been receiving total parenteral nutrition (TPN) for the past 12 days. He develops a new fever to 39.0°C (102.2°F), right upper quadrant tenderness, and a white blood cell count of 16,000/mm³. An abdominal ultrasound shows a distended gallbladder with a thickened wall (>4 mm) and pericholecystic fluid, but no gallstones are visualized.
  11. Crush injury, brown urine, potassium 6.1, peaked T waves. Best first step?
  12. A 27-year-old woman with sickle cell disease is transitioning from pediatric hematology to adult care. Background: Frequent pain crises; history of missed appointments; graduating college; wants more independence. Current status/Plan: On hydroxyurea; needs routine labs and vaccination updates. Team: Pediatric hematologist, adult hematologist, PCP, nurse care coordinator, social worker. Coordination: Adult team requests prior complication history and transfusion records; PCP to manage preventive care. Transition plan: Joint visit proposed; emergency plan reviewed. Which strategy best supports the patient's transition from pediatric to adult care?
  13. The patient's poor prognosis is best understood as a failure of which of the following?
  14. A 26-year-old G1P1 woman had a spontaneous preterm delivery at 32 weeks gestation in her first pregnancy. She is now attending a preconception counseling visit. She is otherwise healthy. She asks what can be done to reduce the risk of preterm birth in her next pregnancy. Which of the following interventions is most likely to reduce her risk of recurrent spontaneous preterm birth?
  15. A 36-year-old G1P1 is seen for her 6-week postpartum visit. Her pregnancy was complicated by diet-controlled gestational diabetes mellitus (GDM). She has been monitoring her fasting and postprandial glucose levels at home, and all values have been normal since delivery. She feels well and is asymptomatic. She asks about her future health risks.
  16. Which of the following is the most appropriate contraceptive method to recommend for this patient?
  17. An 80-year-old woman with long-standing hypertension, coronary artery disease, and peripheral artery disease is started on ramipril. One week later, she complains of new-onset nausea and fatigue. Her blood pressure is 140/80 mmHg. Laboratory studies are significant for a serum creatinine that has increased from a baseline of 1.3 mg/dL to 2.9 mg/dL. This patient's acute kidney injury is most likely due to the new medication's effect on which of the following physiologic mechanisms?
  18. A 69-year-old man with HFrEF and chronic kidney disease (stage 3) is found to have a hemoglobin of 9.2 g/dL on routine labs. He reports increased fatigue. Evaluation reveals a ferritin of 45 ng/mL and a transferrin saturation (TSAT) of 15%. His folate and vitamin B12 levels are normal. Which of the following is the most appropriate management for his anemia?
  19. A 66-year-old man has CKD stage 5 for 9 years from diabetes; he is stable and not on dialysis. He takes insulin, carvedilol 12.5 mg twice daily, amlodipine 10 mg daily, torsemide 40 mg daily, and sevelamer with meals. He reports decreased appetite and mild nausea but no dyspnea or confusion. BP is 148/84 mm Hg. Exam shows 1+ edema. Labs: creatinine 6.2 mg/dL, eGFR 9 mL/min/1.73 m², K 5.1 mEq/L, HCO3 18 mEq/L, Ca 8.6 mg/dL, phosphate 6.4 mg/dL, Hgb 10.1 g/dL. Renal ultrasound shows small echogenic kidneys. Which referral is most appropriate for this patient?
  20. A 78-year-old man with a history of type 2 diabetes and hypertension is hospitalized for an acute pulmonary embolism. His baseline serum creatinine is 2.6 mg/dL, with an estimated GFR of 24 mL/min/1.73m². He is being transitioned from an intravenous heparin infusion to a long-term oral anticoagulant. Which of the following is the most appropriate choice for this patient?

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