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USMLE Step 3
Practice Quiz!

A 15-year-old previously healthy girl is brought to the emergency department by her mother for evaluation of acute abdominal pain that began suddenly 4 hours ago. The pain is localized primarily to the right lower quadrant but also radiates to the left side. She reports associated nausea but no vomiting or diarrhea. She began menstruating at age 13 and reports regular cycles; she is currently mid-cycle. She became sexually active within the past month and uses condoms inconsistently. She denies fever, urinary symptoms, or vaginal discharge. Her last menstrual period was 13 days ago.

On exam, she appears uncomfortable and is guarding her lower abdomen. Her temperature is 37.2°C (99°F), heart rate 102/min, and blood pressure 110/70 mm Hg. Abdominal examination reveals rebound tenderness and diffuse lower quadrant pain, with maximal tenderness on the right. Pelvic exam is limited due to discomfort but shows no cervical motion tenderness or discharge.

Labs show:

• WBC: 11,800/mm³
• Hemoglobin: 12.9 g/dL
• Platelets: 220,000/mm³
• β-hCG: negative
• Urinalysis: normal

Transvaginal ultrasound shows a 2-cm simple right ovarian cyst and a small amount of free fluid in the pelvis. Appendix is not visualized. A CT abdomen/pelvis without contrast reveals no appendiceal inflammation, confirms the ovarian cyst, and shows no other abnormalities.

Which of the following is the most appropriate next step in management?

A 16-year-old girl is evaluated in the outpatient clinic for recurrent lower abdominal pain over the past 6 months. The pain is typically sharp, crampy, and worsens 1–2 days before her menstrual periods. It occasionally radiates to the thighs and is associated with nausea and loose stools. She reports that her periods are regular, lasting 5–6 days with moderate flow. NSAIDs provide partial relief, but the pain significantly interferes with her school attendance and extracurricular activities. She has never been sexually active and has no history of urinary or gastrointestinal symptoms.

Vital signs and physical exam are normal. No abdominal masses or peritoneal signs are present. Pelvic exam is deferred due to patient discomfort and lack of sexual activity. Transabdominal pelvic ultrasound shows a normal-appearing uterus and bilateral ovaries, with no evidence of cysts or masses.

What is the most appropriate next step in management?

A 12-year-old boy is brought to the outpatient clinic by his mother, who is visibly distressed and states, “He’s completely out of control!” She reports that over the past 15 months, following a contentious and emotionally charged divorce, her son has shown escalating behavioral problems. He frequently leaves the house without permission, sometimes not returning until morning. She suspects his involvement in recent local vandalism and reports he was caught shoplifting last week. He has been suspended from school multiple times due to truancy and fighting. His academic performance has been consistently poor, and she believes he has begun associating with local gang members. She fears he is headed down a path similar to his father, who has a history of criminal behavior.

On evaluation, the patient is defiant, minimally communicative, and refuses to make eye contact. No hallucinations or delusions are noted. He denies drug use, though his mother is unsure. There is no evidence of intellectual disability. His developmental milestones were within normal limits. He has no prior psychiatric diagnoses but had difficulty sustaining attention and following instructions in elementary school.

Question 1: A history of which of the following is most likely to have preceded this patient’s current behavioral pattern?

A 12-year-old boy is brought to the outpatient clinic by his mother, who is visibly distressed and states, “He’s completely out of control!” She reports that over the past 15 months, following a contentious and emotionally charged divorce, her son has shown escalating behavioral problems. He frequently leaves the house without permission, sometimes not returning until morning. She suspects his involvement in recent local vandalism and reports he was caught shoplifting last week. He has been suspended from school multiple times due to truancy and fighting. His academic performance has been consistently poor, and she believes he has begun associating with local gang members. She fears he is headed down a path similar to his father, who has a history of criminal behavior.

On evaluation, the patient is defiant, minimally communicative, and refuses to make eye contact. No hallucinations or delusions are noted. He denies drug use, though his mother is unsure. There is no evidence of intellectual disability. His developmental milestones were within normal limits. He has no prior psychiatric diagnoses but had difficulty sustaining attention and following instructions in elementary school.

Question 2: If the patient’s current behavior is left untreated, which of the following is the most likely long-term outcome?

A 50-year-old man presents to your primary care clinic for a routine annual exam. He has no complaints and requests “a full check-up.” He is married, employed, and lives with his spouse and three children. He does not smoke or use illicit drugs. He drinks one alcoholic beverage per day. He does not exercise regularly. He has no significant medical history and takes only a daily multivitamin. He received a tetanus shot five years ago. Family history includes a father who died of a myocardial infarction at age 78 and a mother with hypertension and osteoarthritis.

Last year’s labs were unremarkable, including:

• Total cholesterol: 172 mg/dL
• HDL: 45 mg/dL
• LDL: 100 mg/dL

Physical exam today is normal.

Question 1: Which of the following physical examinations is most appropriate for this patient as part of routine preventive care?

A 50-year-old man presents to your primary care clinic for a routine annual exam. He has no complaints and requests “a full check-up.” He is married, employed, and lives with his spouse and three children. He does not smoke or use illicit drugs. He drinks one alcoholic beverage per day. He does not exercise regularly. He has no significant medical history and takes only a daily multivitamin. He received a tetanus shot five years ago. Family history includes a father who died of a myocardial infarction at age 78 and a mother with hypertension and osteoarthritis.

Last year’s labs were unremarkable, including:

• Total cholesterol: 172 mg/dL
• HDL: 45 mg/dL
• LDL: 100 mg/dL

Physical exam today is normal.

Question 2: Which of the following tests is recommended for this patient based on current preventive guidelines?

A 50-year-old man presents to your primary care clinic for a routine annual exam. He has no complaints and requests “a full check-up.” He is married, employed, and lives with his spouse and three children. He does not smoke or use illicit drugs. He drinks one alcoholic beverage per day. He does not exercise regularly. He has no significant medical history and takes only a daily multivitamin. He received a tetanus shot five years ago. Family history includes a father who died of a myocardial infarction at age 78 and a mother with hypertension and osteoarthritis.

Last year’s labs were unremarkable, including:

• Total cholesterol: 172 mg/dL
• HDL: 45 mg/dL
• LDL: 100 mg/dL

Physical exam today is normal.

Question 3: Which of the following interventions is most appropriate for this patient?

A 64-year-old woman comes to the clinic for a routine health maintenance visit. She has well-controlled type 2 diabetes mellitus, hypertension, and hyperlipidemia. She received a flu shot last fall and reports no adverse reactions. She has never smoked. Her last tetanus booster was over 10 years ago. She has no history of chickenpox or shingles. Her childhood immunization records are incomplete. She lives with her grandchildren and occasionally travels to visit extended family in other states. She is sexually active in a monogamous relationship and has no history of liver disease or immunosuppression. She takes metformin, lisinopril, and atorvastatin. Vital signs and physical exam are normal.

Which of the following vaccines is most appropriate to administer today?

A 14-year-old previously healthy boy is brought to the emergency department with persistent fever and worsening headache for the past 6 days. He was evaluated 4 days ago at a walk-in clinic, where he was diagnosed with presumed bacterial sinusitis and started on amoxicillin. His symptoms have worsened despite antibiotics. His mother reports that he has been febrile to 103.6°F, has become increasingly lethargic, and has had reduced appetite. He works part-time during the summer clearing vegetation in a wooded park. He denies sore throat, chest pain, gastrointestinal or urinary symptoms.

Vital signs: T 101.9°F, HR 124, BP 79/56 mm Hg, RR 26/min
Exam: Uncomfortable but oriented. Mild pharyngeal erythema without exudates, bilateral cervical lymphadenopathy, mild hepatomegaly, petechial rash on wrists and ankles. No meningeal signs. Lungs clear, heart regular.
Labs: WBC 13,000/mm³ (65% neutrophils, 22% lymphocytes), Hct 35%, platelets 95,000/mm³
Electrolytes: Na 125 mEq/L, K 5.1 mEq/L, Cl 102 mEq/L, HCO₃ 21 mEq/L
BUN and creatinine are normal.

Question 1: What is the most likely diagnosis?