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STEP 3 Test Question Formats and Tips

Author: ecfmg, Posted on Wednesday, October 27 @ 17:25:11 IST by RxPG  

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USMLE Step 3

Strategies for Answering One Best Answer Questions (Single Items, Multiple Item Sets, and Cases)

* Read the patient description and question carefully. It is important to understand what is being asked.
* Try to generate an answer and then look for it in the option list.
* Alternatively, read each option carefully, eliminating those that are clearly incorrect.
* Of the remaining options, select the one that is most correct.
* If unsure about an answer, it is better to guess since unanswered questions are automatically counted as wrong answers.

Single Items

This is the traditional, most frequently used multiple-choice format. These items usually include a patient vignette followed by four or five response options. The response options for all questions are lettered (eg, A, B, C, D, E). Examinees are required to select the best answer to the question. Other options may be partially correct, but there is only ONE BEST answer.
Example Question 1

A 45-year-old African-American man comes to the office for the first time because he says, "I had blood in my urine when I went to the bathroom this morning." He reports no other symptoms. On physical examination his kidneys are palpable bilaterally and he has mild hypertension. Specific additional history should be obtained regarding which of the following?

A. Chronic use of analgesics
B. Cigarette smoking
C. A family history of renal disease
D. Occupational exposure to carbon tetrachloride
E. Recent sore throats

(Answer C)

Multiple Item Sets

A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question is linked to the initial patient vignette, but is testing a different point. Questions are designed to be answered independently of each other. You are required to select the one best answer for each question. Other options may be partially correct, but there is only ONE BEST answer.

Example Questions 2 to 4

A 38-year-old white woman, who is a part-time teacher and the mother of three children, comes to the office for evaluation of hypertension. You have been her physician since the birth of her first child 8 years ago. One week ago, an elevated blood pressure was detected during a regularly scheduled examination for entrance into graduate school. Vital signs on examination today are temperature 37.0°C (98.6°F), pulse 100/min, respirations 22/min, and blood pressure 164/100 mm Hg (right arm, supine).

2. The physical examination is most likely to show which of the following?

A. An abdominal bruit
B. Cardiac enlargement
C. Decreased femoral pulses
D. Thyroid enlargement
E. Normal retinas

(Answer E)

3. The most appropriate next step is to order which of the following?

A. Complete blood count
B. Determination of serum electrolyte and creatinine concentrations
C. Determination of serum glucose concentration
D. Determination of serum thyroxine concentration
E. Urine culture

(Answer B)

4. To assess this patient's risk factors for atherogenesis, the most appropriate test is determination of which of the following?

A. Plasma renin activity
B. Serum cholesterol concentration
C. Serum triglycerides concentration
D. Urinary aldosterone excretion
E. Urinary metanephrine excretion

(Answer B)

End of Set

A single-patient or family-centered vignette may ask as few as two and as many as three questions, each related to the initial opening vignette. Information is added as the case unfolds. It is extremely important to answer the questions in the order presented. Time often passes within a case and your orientation to a question early in a case may be altered by the additional information presented later in the case. If you do skip questions, be sure to answer earlier questions with only the information presented to that point in the case.

Each question is intended to be answered independently. You are required to select the ONE BEST answer to each question.

Example Questions 5 to 7

A 24-year-old man comes to the office because of intermittent chest pain that began a few weeks ago. You have been his physician for the past 2 years and he has been in otherwise good health. He says he is not having pain currently. A review of his medical record shows that his serum cholesterol concentration was normal at a pre-employment physical examination 1 year ago. You have not seen him since that visit and he says he has had no other complaints or problems in the interim. He reminds you that he smokes 1 pack of cigarettes per day. When you question him further, he says that he does not use any alcohol or illicit drugs. Although the details are vague, he describes the chest pain as a substernal tightness that is definitely not related to exertion.

5. Which of the following findings on physical examination would be most consistent with costochondritis as the cause of his chest pain?

A. Crepitance over the second and third ribs anteriorly
B. Deep tenderness to hand pressure on the sternum
C. Localized point tenderness in the parasternal area
D. Pain on deep inspiration
E. Normal physical examination

(Answer C)

6. In light of the patient's original denial of drug use, which of the following is the most appropriate next step to confirm a diagnosis of cocaine use?

A. Ask the laboratory if serum is available for toxicologic screening on a previous blood sample
B. Call his family to obtain corroborative history
C. Obtain a plasma catecholamine concentration
D. Obtain a urine sample for routine analysis but also request toxicologic screening
E. Present your findings to the patient and confront him with the suspected diagnosis

(Answer E)
Cocaine use is confirmed. The patient admits a possible temporal relationship between his cocaine use and his chest pain and expresses concern about long-term health risks.

7. The patient should be counseled regarding which of the following?

A. Cocaine-induced myocardial ischemia can be treated with blocking agents
B. Death can occur from cocaine-induced myocardial infarction or arrhythmia
C. The presence of neuropsychiatric sequelae from drug use indicates those at risk for sudden death associated with cocaine use
D. Q wave myocardial infarction occurs only with smoked "crack" or intravenous cocaine use
E. Underlying coronary artery disease is the principal risk for sudden death associated with cocaine use

(Answer B)
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