USMLE STEP 3
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A 65-year-old man presents to the emergency room with complaints of weakness, generalized swelling in his extremities, and right leg pain. At the time of presentation, he appears to be in moderate distress from the leg pain. The patient states that his symptoms started two days ago. The patients also has frequent urination and increased thirst. He states that he has felt weak for the past few months. Physical examination reveals a tender, erythematous, and swollen right calf. He also has 2+ pitting edema in all extremities. Blood pressure is 107/55 mm Hg, and temperature is 100.3 F. Venous ultrasound is seen in the image.
Laboratory studies reveal:
White cell count 11,000/mm3
K 4.0 mEq/L
BUN 24 mg/dL
Creatinine 1.7 mg/dL
PT/PTT - Normal
AST 28 U/L
Albumin 1.9 g/dL
Cholesterol 326 mg/dL
Triglycerides 425 mg/dL
Urine dipstick shows protein 3+, hemoglobin 1+, white cells 1+; 24-hour urine shows 6.2 grams of protein. What is the next step in the treatment of this patient?
A. Renal biopsy
A 52-year-old woman presents to the emergency department with fever, weakness, and abdominal pain for the past three days. It has been associated with nausea and three episodes of vomiting. Her husband states that her temperatures have been as high as 103.5 F and that she has not been herself lately, appearing confused and lethargic. She has a history of hypothyroidism and migraine headaches. She appears lethargic, dehydrated, and is oriented only to person. Her blood pressure is 75/50 mm Hg, temperature is 102.9 F, and pulse is 108/min. She has a dry oral mucosa and hyperpigmented areas of her skin spread diffusely over the posterior neck, hands, and knuckles. Rales are heard over the right lower lung field, and the chest x-ray is seen in the image below. The EKG is normal. The patient is placed on intravenous hydration. Laboratory studies show a white cell count of 6,300/mm3, and the differential shows 82% neutrophils, 7% lymphocytes, and 9% eosinophils. The sodium level is 112 mEq/L, with a potassium of 5.9 mEq/L and a chloride of 92 mEq/L. Bicarbonate level is 20 mg/dL, and BUN is 32 mg/dL. The creatine level is normal. The glucose level is 60 mg/dL, and the urinalysis is normal. What is the best initial test to diagnose this disorder?
A. Immediate cortisol and assess ACTH level
B. Metyrapone stimulation test
C. Early morning cortisol
D. A cosyntropin stimulation test
E. 24-hour urine cortisol
A 67-year-old man comes to the office because of "ringing in his ears," a feeling of "spinning", and a progressive loss of hearing in his right ear over the past 5 months. He says that this all began "a while ago with a slight feeling of unsteadiness." He never went to a doctor because he thought he was "going crazy," but now his wife is getting worried because the television needs to be much louder and he constantly says "what?" when she speaks to him on his right side. He has no chronic medical conditions, does not take any medications, and does not drink alcohol. Examination shows nystagmus, but no other abnormalities. The most likely diagnosis is?
A. Benign positional vertigo
B. Benign recurrent vertigo
C. Menieres disease
D. Toxic labyrinthitis
E. Vestibular neuronitis
A 64-year-old man comes to the ED because of the inability to void for 14 hours. He notes that he has not urinated all day and cannot pass urine despite feeling the urgent need to urinate. He complains of severe lower abdominal discomfort secondary to benign prostatic hyperplasia and denies any history of sexually transmitted diseases. His past medical history is also significant for hypertension. He has never had surgery. His medications include doxazosin and metoprolol. He notes that he recently ran out of his doxazosin pills. The rest of his history is non-contributory. Examination reveals a healthy looking male in moderate to severe distress holding his lower abdomen. His vital signs are: temperature 37.2 C (99.0 F), blood pressure 155/90 mm Hg, pulse 104/min, and respirations 24/min. Physical examination shows tenderness and fullness of the suprapubic region. His prostate is enlarged and slightly firm by digital rectal examination. The most appropriate next step in management is to?
B. Insert a foley catheter
C. Order a metabolic profile
D. Order a renal ultrasound
E. Place a suprapubic catheter
A 34-year-old IV drug abuser who is HIV+ is admitted to the hospital because of gastrointestinal bleeding. He was admitted to the hospital 2 months ago for HIV treatment. At the time of discharge, he was in good health, able to tolerate regular diet, and take minimal medications. He went back to work and was feeling well. Two days before presenting to the hospital, he developed nonspecific abdominal discomfort, which he attributed to food poisoning and treated himself with lots of hydration. The abdominal discomfort persisted and he noticed more blood per rectum, and alarmed by that, decided to come to the hospital. His temperature is 37 C (99.1 F), blood pressure is 110/70 mm Hg, and pulse is 96/min. His hematocrit is 28% compared with 34% on discharge a couple of months earlier. There are no signs of hemodynamically instability. Blood is sent for cross match and stool is sent for ova and parasites. A nasogastric tube is inserted and returns clear fluid. What is the next step in the investigation of this patients gastrointestinal bleeding?
A. Barium enema
C. CT scan of the abdomen and pelvis
D. Small bowel series
E. Upper gastrointestinal endoscopy
A 14-year-old boy is brought to the office by his mother because of "bedwetting" episodes that have been occurring about twice a week for the past few months. The mother says that she noticed this "problem" when she washed his pajamas, and he "refused" to talk about it when she tried to bring it up. She is hoping that he will talk to you. You ask her to leave the room so you can have some privacy with her son. He starts the conversation by stating that "this is getting embarrassing" and he "doesn't understand what's going on." He says that he gets up and finds his pajamas "wet and sticky." He denies any dysuria or frequency during the day, and denies any problems at school or at home. He is on the basketball team, socializes with friends, and get good grades. Physical examination is unremarkable and shows a pubic hair stage of Tanner IV and genital development Tanner state III. The next best step is to?
A. Advise him to stop drinking water at 8pm and urinate before bed
B. Begin a 3-day treatment regimen with trimethoprim-sulfamethoxazole
C. Obtain a urine sample for culture and sensitivity
D. Order a renal ultrasound
E. Reassure him that this is a completely normal part of puberty
A 34-year-old man is admitted to the intensive care unit after an exploratory laporatomy. The patient was in a high-speed motor vehicle accident a few hours prior and on arrival to the emergency department there was evidence of a severe liver laceration. The patient was brought emergently to the operating room. While under anesthesia, the patient had a left subclavian central line placed. The line was used for drug and blood product delivery during the surgical procedure with no apparent complications. The most important management when he arrives in the intensive care unit is to?
A. Aspirate of the central line port
B. Do nothing since the line was used without issue
C. Obtain a chest radiograph
D. Order an echocardiogram
E. Order an intravenous contrast study under fluoroscopy
A 32-year-old woman is brought to your emergency department following a suicide attempt. She tells you that she has ingested an entire bottle. approximately 250 tablets, of acetaminophen prior to calling the emergency medical technicians. On arrival, she is complaining of nausea and diaphoresis. Her medical history is significant for depression and multiple prior suicide attempts. She is not on any medications and denies allergies. She also denies ingestion of other substances. She is awake and communicative. Her temperature is 37 C (98.6 F), blood pressure is 120/67 mm Hg, pulse is 78/min, and respirations are 25/min. Physical and neurologic examinations and unremarkable. A tube is placed into the stomach and multiple pill fragments are obtained with aspiration. Based upon the available data, the most appropriate intervention is?
A. Administration of acetyl cysteine
B. Administration of amyl nitrate
C. Administration of ethanol
D. Administration of methanol
E. Administration of pyridoxine
A 36-year-old woman comes to the emergency department because of a severe headache. She states that the headache woke her up from sleep 6 hour ago, and was not relieved by aspirin or acetaminophen. She also noticed that she has neck stiffness and that "it hurts" during neck extension and flexion. The was recently diagnosed with Hodgkin's disease, but before that, she was usually "pretty healthy," except for a few urinary tract infections and hypertension. Her temperature is 39.0 C (102.2 F), blood pressure is 130/80 mm Hg, pulse is 75/min, and respirations are 17/min. She appears lethargic. Physical examination shows nuchal rigidity, flank tenderness, and mid-systolic click. Fundoscopic examination shows bilateral optic disc swelling. After blood cultures are obtained the most appropriate next step it to?
A. Administer ceftriaxone, IV
B. Order a CT scan of the head
C. Order a MR angiogram of the head
D. Order an MRI of the head
E. Perform a lumbar puncture