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USMLE Step 3 Preparation Course

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USMLE Step 3 Exam Overview

Opportunity to Become a Doctor in America

Step 3 is designed to assess the knowledge and skills of physicians who take independent responsibility for providing general medical care to patients, with an emphasis on patient management in outpatient settings. It is the final exam in the USMLE series and allows for license to practice medicine without supervision. Exam material is prepared by exam committees that represent the medical profession in general. The committees are made up of recognized experts in their fields, including both academic and non-academic practitioners, as well as members of state medical licensing boards.

The content of Step 3 reflects a data-driven model of general medical practice in the United States. Test items and cases reflect clinical situations that an as yet undifferentiated general physician may encounter in the context of a particular setting. Step 3 provides a final assessment of physicians who assume independent responsibility for providing general medical care.

The Step 3 examination highlights the importance of assessing the knowledge and skills of physicians who assume independent responsibility for providing general medical care to patients. The first day of the Step 3 exam is called Fundamentals of Independent Practice (FIP) and the second day is called Advanced Clinical Medicine (ACM).

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USMLE Step 3 Exam Format

Step 3 consists of multiple choice questions (MCQs) and computer-based case simulations.

Step 3 is a two-day exam. The first day of the test includes 232 multiple choice questions divided into 6 blocks of 38-39 questions; 60 minutes are allotted to complete each test item block. On the first day, there is a 45-minute break in the test session.

There are approximately 9 hours in the test session on the second day. This test day includes an optional 5-minute tutorial followed by 180 multiple choice items divided into 6 blocks of 30 items; 45 minutes are allotted to complete each test item block. The second day also includes a 7-minute CCS training. This is followed by 13 case simulations, each allocated in real time with a maximum of 10 or 20 minutes. A minimum of 45 minutes is available for break time. There is an optional survey at the end of the second day and can be completed if time permits.


Day 1: Step 3 Fundamentals of Independent Practice (FIP)

This exam day focuses on the assessment of knowledge of the basic medical and scientific principles necessary for effective health care. Application of basic sciences among the content areas covered; understanding biostatistics and epidemiology/population health and interpreting the medical literature; and the application of the social sciences, including communication and interpersonal skills, medical ethics, systems-based practice, and patient safety.

The test day also includes assessment of diagnostic and management knowledge, focusing specifically on the use of history and physical examination, diagnostics and diagnostic studies. This test day consists of multiple choice questions only.

Day 2: Step 3 Advanced Clinical Medicine (ACM)

This testing day focuses on assessing the ability to apply comprehensive health and disease knowledge in the context of patient management and the evolving manifestation of disease over time. Content areas covered include the evaluation of diagnostic and management information with a particular focus on prognosis and outcome, health maintenance and screening, therapeutics and medical decision making. The history and physical examination knowledge, the use of diagnostic and diagnostic studies are also evaluated. This test day includes multiple choice questions and computer-based case simulations.

USMLE Step 3 Exam Detailed Information

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USMLE Step 3 Sample Test Questions

A 27-year-old man is brought to the emergency department by his roommates because of an inability to walk. He began to notice some problems with his balance 2 days ago, and his walking has become progressively worse since then. He had an episode of optic neuritis in the right eye 3 years ago. He is 157 cm (5 ft 2 in) tall and weighs 55 kg (121 lb); BMI is 22 kg/m2. His temperature is 37°C (98.6°F), pulse is 55/min, respirations are 10/min, and blood pressure is 110/70 mm Hg. Examination shows spastic lower extremities and moderate weakness of the left lower extremity, more prominently in the flexor than in the extensor muscles. Deep tendon reflexes are normal in the upper extremities but hyperactive in the lower extremities, especially on the left. There is clonus at the left ankle. Proprioception and sensation to vibration are absent over the left lower extremity and decreased over the right lower extremity to the level of the hip. Sensation to pain and temperature is decreased at the lower costal margin and below, most pronounced on the right. Which of the following cell types is most affected by this patient’s condition?

(A) Astrocytes

(B) Ependymal cells

(C) Neurons

(D) Oligodendrocytes

(E) Schwann cells

(Answer: D)

A 54-year-old woman with severe rheumatoid arthritis comes to the office for a routine follow-up examination. Rheumatoid arthritis was diagnosed at age 35 years, and the patient has been unable to work for the past 10 years. She has difficulty bathing and dressing, but she is able to stand and walk independently. Medical history is otherwise unremarkable. Medications include etanercept, methotrexate, prednisone, and tramadol. She tells you that her husband of 30 years left her 6 months ago. She appears depressed. Vital signs are normal. Physical examination discloses marked joint deformities in the hands, wrists, shoulders, and feet; the findings are unchanged from previous visits. The patient says, “I cannot continue to live as I am. I’ve had it.” Which of the following is the most appropriate response?

(A) “Do you think you’re depressed? I can help with that.”

(B) “Have you considered moving to an assisted living facility where your quality of life could be much better?”

(C) “I know just how you feel.”

(D) “I’d like to refer you to a counselor.”

(E) “Would you like to tell me more about why you feel this way?”

(Answer: E)

A 17-year-old boy is brought to the emergency department by a caregiver after sustaining a large knife wound to his left arm. The caregiver reports that the patient cut himself with a knife, but it is unknown whether this was a suicide attempt. The patient lives in a group home with three other individuals and the caregiver; it is apparent from talking to the patient that he has limited intellectual capacity. He has an appointed legal guardian who has been contacted and is due to arrive at the hospital in approximately 45 to 60 minutes. The patient’s vital signs are temperature 36.5°C (97.7°F), pulse 134/min, respirations 22/min, and blood pressure 70/40 mm Hg. He appears pale and he has a large, blood-soaked towel wrapped around his left forearm. Removal of the towel discloses a 9-cm laceration with obvious arterial hemorrhage and tendon exposure. Examinations of the chest and abdomen are unremarkable. A pressure bandage is immediately applied and consultation is obtained with a surgeon, who wants to take the patient immediately to the operating room. Which of the following statements is most accurate regarding consent for this patient?

(A) The caregiver can legally provide consent

(B) The need for consent can be waived

(C) The patient is emancipated and can legally give consent

(D) Psychiatric clearance should be obtained for patient consent

(E) Surgery must be delayed until the guardian arrives

(Answer: B)

A 24-year-old man and a 22-year-old woman come to the office for the first time for premarital evaluation and counseling. Neither of them has ever been sexually active, because they “want to wait” until after marriage to have sexual intercourse. Other discussion reveals that they have never had blood transfusions, used illicit drugs, or drunk excessive amounts of alcohol. They have heard about the test for HIV antibody and wonder whether they should obtain this test before marriage. Compared with persons who have multiple risk factors for HIV, which of the following statements best applies to this couple?

(A) The negative predictive value of the test would be lower

(B) The positive predictive value of the test would be lower

(C) The sensitivity of the test would be higher

(D) The sensitivity of the test would be lower

(E) The specificity of the test would be lower

(Answer: B)

A previously healthy 54-year-old man comes to the emergency department at his wife’s insistence 6 days after a stray dog bit his right leg while he and his wife were walking near the dog during a trip to South America. The bite punctured the skin. He immediately cleaned the wound thoroughly with soap and peroxide and has done so daily since the incident occurred. The area of the bite is not painful, and the patient has not had fever or chills. He takes no medications. He had a tetanus booster vaccination 3 years ago. Vital signs today are normal. Examination of the right lower extremity shows healing bite puncture wounds. There is minimal erythema and the area is not fluctuant. Lymph nodes in the groin are not palpable. Which of the following is the most appropriate next step?

(A) Administer rabies vaccination

(B) Administer tetanus immune globulin

(C) Order cerebrospinal fluid analysis

(D) Order an MRI of the brain and spine

(E) No action is necessary at this time

(Answer: A)

Orientation Feedback for Tension Pneumothorax

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.

In this case, a 65-year-old man is brought to the emergency department by ambulance because of acute chest pain and respiratory distress. Initially the presentation and reason for visit suggest a broad differential diagnosis, but the limited available history narrows the differential. 

The patient had an acute onset of right-sided chest pain 10 minutes before the ambulance arrived. He rates the pain as an 8 on a 10-point scale. The pain is excruciating, sharp, and increases with respiration.

The patient appears pale and in marked respiratory distress. He is moaning and holding his hands over the right side of his chest. Vital signs show tachypnea, tachycardia, and low blood pressure. Physical examination shows no breath sounds; there is tracheal deviation, jugular venous distention, hyperresonance to percussion on the right side of the chest, faint heart sounds, and weak peripheral pulses. The skin is pale, cool, and diaphoretic. The remainder of the physical examination is unremarkable. The patient’s illness, at this point, seems most consistent with an intrathoracic process.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee’s score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee’s score for this case.

Timely diagnosis and management are essential in this case. An optimal, efficient diagnostic approach would include quickly performing a targeted physical examination that includes chest/lung and cardiovascular examination, cardiac monitoring, and assessing oxygen saturation by pulse oximetry. Treatment should be initiated immediately before the patient’s condition worsens. Ordering anything that might delay treatment (eg, a 12 lead ECG, arterial blood gases, or a portable chest x-ray) would be suboptimal in this case if ordered before the patient’s condition is stabilized.

As soon as the absent breath sounds and exam findings consistent with tension pneumothorax are discovered, optimal treatment would include performing a needle thoracostomy for decompression followed by a chest tube insertion for lung reexpansion. A chest x-ray should be ordered to confirm appropriate tube placement and lung reexpansion. The patient’s blood pressure and respiratory rate should be closely monitored until the patient’s condition has stabilized.

Examples of additional tests, treatments, or actions that could be ordered but would be neither useful nor harmful to the patient include:

  • Bronchodilators
  • Complete blood count
  • Electrolytes
  • Analgesics
  • Intravenous fluids

Examples of suboptimal or poor management would include failure to examine the chest, admission before treatment, failure to order a chest x-ray after inserting the chest tube and/or needle thoracostomy, delay in treatment to reexpand the lung, or absence of treatment.

In this acute presentation, timing is critically important. An optimal approach would include completing the above diagnostic and management actions as quickly as possible. Delaying diagnosis or treatment and pursuing alternative diagnoses with tests such as a lung scan will waste valuable time and could be harmful or even fatal to the patient. Other examples of treatments that would waste time, subject the patient to unnecessary discomfort or risk, and add no real benefit to this patient include:

  • CT before lung reexpansion
  • Intubation
  • Pulmonary function testing
  • Thrombolytic therapy

Orientation Feedback for Rheumatoid Arthritis

In evaluating case performance, the domains of diagnosis (including physical examination and appropriate diagnostic tests), therapy, monitoring, timing, sequencing, and location are considered.

In this case, a 32-year-old woman comes to the office because of knee pain and swelling. From the chief complaint, the differential diagnosis is broad. It includes osteoarthritis, infectious arthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), gout, and psoriatic arthritis. The comprehensive history, however, narrows the differential. The patient has experienced increasing fatigue and generalized weakness during the past 4 months. She developed generalized aches and morning joint stiffness during the past 8 weeks and, more recently, pain and intermittent swelling of both wrists, and of the proximal metacarpophalangeal joints, as well as bilateral knee swelling. These signs and symptoms are highly suggestive of a chronic systemic inflammatory process.

Physical examination shows bilateral swollen, warm, and tender wrist, proximal metacarpophalangeal, and knee joints, and bilateral knee effusions. Other physical findings are unremarkable. In the absence of other findings, the patient’s illness, at this point, seems most consistent with rheumatoid arthritis. While the presence of certain clinical features is helpful in excluding other connective tissue diseases and osteoarthritis, further diagnostic evaluation is appropriate to confirm the presumptive diagnosis and establish the severity of the disease.

The computer-based case simulation database contains thousands of possible tests and treatments. Therefore, it is not feasible to list every action that might affect an examinee’s score. The following descriptions are meant to serve as examples of actions that would add to, subtract from, or have no effect on an examinee’s score for this case.

An optimal, efficient approach to diagnosis would include performing an appropriate physical examination (including extremities/spine, chest/lung, cardiovascular, abdominal, skin, HEENT/neck, and lymph node examinations). A rheumatoid factor test or a cyclic citrullinated peptide antibody (Anti-CCP) test would support the diagnosis of rheumatoid arthritis. The diagnostic workup would also include a complete blood count, arthrocentesis with relevant synovial fluid studies (cell count, crystals, and bacterial culture), an antinuclear antibody assay, and an erythrocyte sedimentation rate or C-reactive protein test. These tests serve to assess the severity of the disease and consider the likelihood of SLE, gout, an infectious process, or reactive arthritis. In addition, joint x-rays would provide a baseline assessment.

In adult patients, an optimal approach to treatment would focus on relieving pain, decreasing inflammation, preventing or slowing joint damage, and improving function. It is important to manage the acute phase of the disease and to address the long-term care of the patient in this case. Optimal treatment would include a combination of a nonsteroidal anti-inflammatory drug (NSAID) or corticosteroid with a disease-modifying antirheumatic drug (DMARD) for comprehensive therapeutic treatment. Administration of a DMARD, eg, methotrexate or etanercept, prevents or slows joint damage, and improves joint function. An NSAID or corticosteroid relieves pain and decreases inflammation essential to provide interim symptom relief while the selected DMARD takes effect. To prevent deformity and loss of joint function, the patient would be advised to exercise appropriately. Or, a referral would be made for physical or occupational therapy.

In this case simulation, when NSAID or corticosteroid treatment is initiated, the patient regularly reports both joint and systemic improvements. Therefore, ordering a rheumatology consult or additional monitoring is appropriate but optional during the time frame of this simulation.

Examples of additional tests and treatments that could be ordered but would be neither useful nor harmful to the patient include:

  • Chlamydia trachomatis tests
  • Neisseria gonorrhoeae tests
  • Antibody, anti-single-stranded DNA
  • Thyroid studies
  • Urinalysis
  • Uric acid, serum

Examples of suboptimal management of this case would include delay in diagnosis or treatment, or treatment with NSAIDS or corticosteroids alone. Treatment with salicylates would also be considered suboptimal management in this case. Although they would temporarily relieve pain when administered in high doses, there are other agents with fewer adverse effects that would be better treatment options. Examples of poor management would include failure to order any physical examination or failure to treat rheumatoid arthritis. With the availability of effective treatment for rheumatoid arthritis and concerns about opioid addiction, narcotic analgesics should have a limited role in treatment.

Examples of invasive tests that would subject the patient to unnecessary discomfort or risk and add no useful information include:

  • Arthroscopy
  • Synovial biopsy

While many case scenarios run for a relatively short period of simulated time, a matter of hours or days, this scenario runs for a longer period of time, weeks. This illustrates the importance of allowing sufficient time for the patient to respond to treatment and emphasizes monitoring and long-term management.


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