USMLE STEP 3 PRACTICE EXAM QUESTIONS AND
CORRECT ANSWERS NEW MODIFIED GRADED A+
TESTED AND APPROVED 2026 LATEST UPGRADE
when do you use ACE/ARBs in ischemic cardiac disease --CORRECT ANSWER--cardiac
failure (e.g. chf, systolic dysfunction or low ef).
Elderly woman with SOB + rales and edema:
1. what tests do you order?
2. what meds do you order?
3. most likley dx:
4. if still symptomatic: --CORRECT ANSWER--1.EKG, CXR, echo, oximetry, monitoring
unit, ABG, BMP
2. O2, morphine, nitrates, furosemide
3. CHF exacerbation
** transfer to ICU in CCS!**
4. order an inotrope (milrinone, amrinone or dobutamine).
Valvular lesion ^VR .....dec VR ..grip.. amylN
(effect on M). (squat) (valsalva)
AS......... ..........X ............X ..........X .........X
AR ......... .........X ............X ..........X .........X
MS ......... .........X ............X ..........X .........X
MR ......... .........X ............X ..........X .........X
Page 1 of 230
,VSD ......... .......X ............X ..........X .........X
HOCM ........ ....X ............X ..........X .........X
MVP ..... ..........X ............X ..........X .........X --CORRECT ANSWER--Valvular lesion ^VR
.....dec VR ..grip.. amylN
(effect on M). (squat) (valsalva)
AS ...................^ .........dec ........dec .........^
AR ..................^ .........dec ........dec .........^
MS ...................^ .........dec.......... - ...........-
MR .................^ ..........dec .........^.......... dec
VSD.................^ ..........dec .........^.......... dec
HOCM ...........dec ........^ ...........dec......... ^
MVP ..............dec ........^ ...........dec......... ^
what is the optimal treatment for:
1. murmurs that improve on valsalva (and which murmurs are these?)
2. murmurs that improves with amyl nitrate (and which murmurs are these?)
3. best therapy for regurgitant lesions
4. best therapy for stenotic lesions --CORRECT ANSWER--1. Valsalva = diuretics (AS, AR,
MS, MR, VSD)= L heart murmurs
2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
3. diuretics
4. repair (baloon for MS, replace for AS)
75 yo M with hx HTN now with chest pain/ syncope. hear a crescendodecrescendo systolic
murmur at the 2nd R intercostal space that radiates to the carotids.
Page 2 of 230
,what is the dx, w/u, tx? --CORRECT ANSWER--Dx: AS
workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do
EKG and CxR (LVH)
treatment: Diurese, but overdiuresis is best--> valve replacement is best
75 yo M with hx HTN now with SOB/ fatigue. You hear a decrescendo-crescendo diastolic
murmur at the LSB
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: AR
workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do
EKG and CxR (LVH)
treatment: ACE/ARB, nifedipine (add loop diuretic in CCS)--> surgery if EF <55% and LV
end systolic diameter >55 mm
75 yo immigrant M now with dysphagia and afib. You hear an extra sound in diastole with
S1>S2.
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: MS
workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do
EKG and CxR (LAH- straightening of LH border and elevation of L mainstem bronchus)
treatment: diuretics (best initial, but don't alter progression)--> balloon valvuloplasty (incl
preg women)
75 yo M w/ PMH MI now with dyspnea on exertion. You hear holosystolic murmur at the
apex, radiating to axilla
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: MR
workup: TTE (best initial test), TEE (more accurate) also do EKG and CxR
Page 3 of 230
, treatment: ACE/ ARBS, Nifedipine (best initial, decreases rate of progression), add loop
diuretic in CCS--> surgery if EF <60% and LV end systolic diameter >45 mm
7 yo M now with no complaints, on exam You hear holosystolic murmur at the LLSB.
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: VSD
workup: echo first--> cath (determine degree of L-->R shunting
treatment: if mild, will close on its own.
7 yo M now with no complaints, on exam You hear fixed splitting of S2.
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: ASD
workup: ?
treatment: PCI, repair when shunt ratio >1.5:1
what to think about when you hear wide splitting of S2 with delayed P2 --CORRECT
ANSWER--RBBB
PS
RVH
Pulm HTN
what to think about when you hear paradoxical delayed A2? --CORRECT ANSWER--LBBB
AS
LVH
HTN
Page 4 of 230
CORRECT ANSWERS NEW MODIFIED GRADED A+
TESTED AND APPROVED 2026 LATEST UPGRADE
when do you use ACE/ARBs in ischemic cardiac disease --CORRECT ANSWER--cardiac
failure (e.g. chf, systolic dysfunction or low ef).
Elderly woman with SOB + rales and edema:
1. what tests do you order?
2. what meds do you order?
3. most likley dx:
4. if still symptomatic: --CORRECT ANSWER--1.EKG, CXR, echo, oximetry, monitoring
unit, ABG, BMP
2. O2, morphine, nitrates, furosemide
3. CHF exacerbation
** transfer to ICU in CCS!**
4. order an inotrope (milrinone, amrinone or dobutamine).
Valvular lesion ^VR .....dec VR ..grip.. amylN
(effect on M). (squat) (valsalva)
AS......... ..........X ............X ..........X .........X
AR ......... .........X ............X ..........X .........X
MS ......... .........X ............X ..........X .........X
MR ......... .........X ............X ..........X .........X
Page 1 of 230
,VSD ......... .......X ............X ..........X .........X
HOCM ........ ....X ............X ..........X .........X
MVP ..... ..........X ............X ..........X .........X --CORRECT ANSWER--Valvular lesion ^VR
.....dec VR ..grip.. amylN
(effect on M). (squat) (valsalva)
AS ...................^ .........dec ........dec .........^
AR ..................^ .........dec ........dec .........^
MS ...................^ .........dec.......... - ...........-
MR .................^ ..........dec .........^.......... dec
VSD.................^ ..........dec .........^.......... dec
HOCM ...........dec ........^ ...........dec......... ^
MVP ..............dec ........^ ...........dec......... ^
what is the optimal treatment for:
1. murmurs that improve on valsalva (and which murmurs are these?)
2. murmurs that improves with amyl nitrate (and which murmurs are these?)
3. best therapy for regurgitant lesions
4. best therapy for stenotic lesions --CORRECT ANSWER--1. Valsalva = diuretics (AS, AR,
MS, MR, VSD)= L heart murmurs
2. amyl nitrate = ACE inhibitor (AR, MR, VSD)
3. diuretics
4. repair (baloon for MS, replace for AS)
75 yo M with hx HTN now with chest pain/ syncope. hear a crescendodecrescendo systolic
murmur at the 2nd R intercostal space that radiates to the carotids.
Page 2 of 230
,what is the dx, w/u, tx? --CORRECT ANSWER--Dx: AS
workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do
EKG and CxR (LVH)
treatment: Diurese, but overdiuresis is best--> valve replacement is best
75 yo M with hx HTN now with SOB/ fatigue. You hear a decrescendo-crescendo diastolic
murmur at the LSB
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: AR
workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do
EKG and CxR (LVH)
treatment: ACE/ARB, nifedipine (add loop diuretic in CCS)--> surgery if EF <55% and LV
end systolic diameter >55 mm
75 yo immigrant M now with dysphagia and afib. You hear an extra sound in diastole with
S1>S2.
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: MS
workup: TTE (best initial test), TEE (more accurate) L heart cath (most accurate), also do
EKG and CxR (LAH- straightening of LH border and elevation of L mainstem bronchus)
treatment: diuretics (best initial, but don't alter progression)--> balloon valvuloplasty (incl
preg women)
75 yo M w/ PMH MI now with dyspnea on exertion. You hear holosystolic murmur at the
apex, radiating to axilla
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: MR
workup: TTE (best initial test), TEE (more accurate) also do EKG and CxR
Page 3 of 230
, treatment: ACE/ ARBS, Nifedipine (best initial, decreases rate of progression), add loop
diuretic in CCS--> surgery if EF <60% and LV end systolic diameter >45 mm
7 yo M now with no complaints, on exam You hear holosystolic murmur at the LLSB.
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: VSD
workup: echo first--> cath (determine degree of L-->R shunting
treatment: if mild, will close on its own.
7 yo M now with no complaints, on exam You hear fixed splitting of S2.
what is the dx, w/u, tx and other physical findings? --CORRECT ANSWER--Dx: ASD
workup: ?
treatment: PCI, repair when shunt ratio >1.5:1
what to think about when you hear wide splitting of S2 with delayed P2 --CORRECT
ANSWER--RBBB
PS
RVH
Pulm HTN
what to think about when you hear paradoxical delayed A2? --CORRECT ANSWER--LBBB
AS
LVH
HTN
Page 4 of 230
