Multiple-Choice Questions

Strategies

  • The term item is used to describe a test question in any format.
  • Read each 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.

One-best-answer formats are used. Questions may stand alone or may be grouped together as a set if 2 to 3 questions. Some sets are considered sequential and function differently than other sets. It is important to study the descriptions in the USMLE Sample Test Questions section. Test questions present detailed clinical situations usually from the patient's perspective. The presentation may be supplemented by one or more pictorials or audio. Assessing the patient's situation in the context of his or her environment or family or clinical setting is an important element of many Step 3 questions.

During the time allotted to complete the test questions in a block, you may answer the questions in any order (excluding sequential question sets), review responses, and change answers. After exiting a block, no further review of questions or changing of answers within that block is possible.

A table of normal laboratory values for frequently ordered laboratory tests, including standard international conversions, will be available as an online reference when you take the examination.

IMPORTANT

Patient Scenario Formats

Patient scenarios for any Single Item or Sequential Item Set may be provided in either Vignette (paragraph) format, or in Chart/Tabular format. Test items using the chart/tabular format are designed to resemble patient charts but are not intended to be an exact representation of a patient chart. Questions written in chart/tabular format will contain relevant patient information in list form, organized in clearly marked sections for ease of review. Familiar medical abbreviations may be used within chart/tabular format questions.

Single-Item Questions

A single patient-centered vignette is associated with one question followed by four or more response options. The response options are lettered (ie, A, B, C, D, E). A portion of the questions involves interpretation of graphic or pictorial materials. You are required to select the best answer to the question. Other options may be partially correct, but there is only ONE BEST answer. This is the traditional, most frequently used multiple-choice question format on the examination.

1. A 30-year-old man comes to the emergency department because of an acute episode of renal colic. Medical history is remarkable for episodes of painful urination and passing of what he calls "gravel in my urine." Urinalysis demonstrates microscopic hematuria with some crystalluria and no casts. Supine x-ray of the abdomen shows no abnormalities. A 4-mm renal calculus is detected in the distal right ureter on ultrasonography. There is no evidence of dilation of the collecting system. The patient's pain is responsive to narcotic medication. In addition to administering intravenous fluids, which of the following is the most appropriate next step?

(A) Acidification of urine by drinking cranberry juice

(B) Cystoscopic removal of the calculus

(C) Cystoscopic ureteral lavage

(D) Shock wave lithotripsy

(E) Straining of the urine

(Answer: E)

Patient Information
Age: 62 years
Gender: M, self-identified
Ethnicity: unspecified
Site of Care: office

History
Reason for Visit/Chief Concern: "My legs hurt when I walk, and it's getting worse."

History of Present Illness:
•   3-month history of worsening leg pain
•   pain exacerbated by walking; peak intensity after 1 block
•   pain resolves completely with rest
•   pain rated 4/10 at worst

Past Medical History:
•   hypertension
•   mild angina
•   type 2 diabetes mellitus

Medications:
•   lisinopril
•   metoprolol
•   furosemide
•   glyburide
•   lovastatin

Allergies:
•   no known drug allergies

Psychosocial History:
•   has smoked one-half pack of cigarettes daily for 44 years

Physical Examination

Temp Pulse Resp BP O2 Sat Ht Wt BMI
36.0°C
(96.8°F)		 72/min 14/min 140/90 mm Hg – 164 cm
5 ft 5 in		 90 kg
198 lb		 33 kg/m2

•   Appearance: no acute distress
•   HEENT: funduscopic shows grade 2/4 arteriovenous nicking
•   Neck: no jugular venous distention
•   Pulmonary: clear to auscultation; mildly diminished lung sounds
•   Cardiac: no bruits; distant heart sounds
•   Abdominal: obese; no tenderness, guarding, masses, bruits, or hepatosplenomegaly
•   Extremities: no joint erythema, edema, or warmth; no hair on toes; no femoral bruits; dorsalis pedis, radial, and femoral pulses intact
•   Neurologic: sensation to vibration intact

Question: Which of the following is the most appropriate diagnostic study?

(A) Ankle brachial index

(B) Arteriography

(C) ECG

(D) Echocardiography

(E) MUGA scan

(Answer: A)

 

Multiple Item Sets

A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question within these sets is associated with the patient vignette and is independent of the other question(s) in the set. The items within this type of format are designed to be answered in any order. You are required to select the ONE BEST answer to each question.

A 52-year-old man returns to the office for reevaluation of an ulcer on his right great toe. The patient has a 15-year history of diabetes mellitus and takes glipizide and rosiglitazone. He first noticed the ulcer 2 months ago. One month ago, a 14-day course of oral amoxicillin-clavulanate therapy was prescribed. He has smoked one pack of cigarettes daily for the past 37 years. He is 178 cm (5 ft 10 in) tall and weighs 102 kg (225 lb); BMI is 32 kg/m2. Today, vital signs are temperature 38.8°C (101.8°F), pulse 96/min, respirations 12/min, and blood pressure 130/85 mm Hg. Physical examination of the right great toe discloses a 1.5-cm nontender ulcer with a depth of 0.5 cm, a moist base, yellow exudate, and surrounding erythema to the level of the malleoli. Vibration sense and sensation to monofilament examination are absent. Pulses are diminished in both feet. Capillary refill time is 2 seconds in the right great toe. Urinalysis discloses 3+ protein.

3. Which of the following historical factors or physical examination findings is most strongly associated with development of this patient's foot ulcer?

(A) Diminished pedal pulses

(B) Neurologic findings

(C) The patient's weight

(D) Proteinuria

(E) Tobacco use

(Answer: B)

 

4. Which of the following is the most appropriate action at this time?

(A) Begin aggressive debridement in the office

(B) Begin intravenous antibiotic therapy

(C) Refer the patient for transmetatarsal amputation

(D) Schedule the patient for a third-degree skin graft

(E) Switch the amoxicillin-clavulanate to oral ciprofloxacin

(Answer: B)

Sequential Item Sets

A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. Each question is associated with the initial patient vignette but is testing a different point. You are required to select the ONE BEST answer to each question. Questions are designed to be answered in sequential order. You must click "Proceed to Next Item" to view the next item in the set; once you click on this button, you will not be able to add or change an answer to the displayed (previous) item.

A 2-year-old girl is brought to the office by her mother for evaluation of fever. You have been the girl's physician since birth. While in the office, the girl stiffens and then has bilateral, symmetrical shaking of her upper and lower extremities; she becomes mildly cyanotic. The episode lasts for approximately 45 seconds, after which she becomes relaxed and appears to fall asleep. Vital signs at this time are temperature 40.0°C (104.0°F), pulse 120/min, and respirations 40/min. On physical examination she has a generally pink complexion and flushed cheeks. She is limp and somnolent and responds with a cry to noxious stimulus. Tympanic membranes are inflamed bilaterally, nose has a scant, clear discharge, and throat is mildly erythematous. Lungs are clear to auscultation except for transmitted upper airway sounds. Heart has rapid rate with a grade 1/6 systolic murmur at the left sternal border. Complete blood count, blood culture, lumbar puncture, and catheterized urine specimen are obtained and sent for stat analysis. Acetaminophen is administered by rectal suppository. Thirty minutes later the patient awakens and is smiling. She is afebrile. Additional history discloses that she was born at term, she had an uneventful neonatal course, she has normal growth and development, and vaccinations are up-to-date. She has never had an episode similar to this. Initial laboratory results are shown:

  Blood

  

      WBC

10,400/mm3

        Neutrophils, segmented

25%

        Neutrophils, bands

5%

        Lymphocytes

65%

        Monocytes

5%

      Cerebrospinal fluid

0 RBC/mm3

      Urinalysis

Normal

  Other laboratory studies are pending.

5. In addition to ampicillin for otitis media and acetaminophen, this child also should receive which of the following?

(A) Oral ethosuximide

(B) Oral phenobarbital

(C) Oral phenytoin

(D) Rectal diazepam

(E) No additional medications

(Answer: E)

6. Two weeks later the patient is brought to the office for a follow-up visit. Her mother says that she is doing well and she has had no recurrence of her symptoms. Examination of the ears shows resolution of the otitis media. Which of the following is the most important diagnostic step at this time?

(A) Audiology testing

(B) Cognitive testing

(C) CT scan of the head

(D) EEG

(E) No additional testing

(Answer: E)

Pharmaceutical Advertisement (Drug Ad) Format

The drug ad item format includes a rich stimulus presented in a manner commonly encountered by a physician, eg, as a printed advertisement in a medical journal. Examinees must interpret the presented material in order to answer questions on various topics, including

  • Decisions about care of an individual patient
  • Biostatistics/epidemiology
  • Pharmacology/therapeutics
  • Development and approval of drugs and dietary supplements
  • Medical ethics

See Example Drug Ad Item

 

Abstract Format

The abstract item format includes a summary of an experiment or clinical investigation presented in a manner commonly encountered by a physician, eg, as an abstract that accompanies a research report in a medical journal. Examinees must interpret the abstract in order to answer questions on various topics, including

  • Decisions about care of an individual patient
  • Biostatistics/epidemiology
  • Pharmacology/therapeutics
  • Use of diagnostic studies

See Example Abstract Item