NBME FORM 5 STEP 3 HIGH-YIELD Q&A REVIEW
GUIDE WITH COMPLETE SOLUTION!!
1. What additional history question is important when evaluating a patient with
suspected tension pneumothorax?
Ask about the use of smoked illicit drugs.
Explanation: Inhaled drugs (e.g., crack cocaine, marijuana) can predispose patients
to the formation of apical blebs or bullae, which can rupture and cause spontaneous
pneumothorax.
2. An 82-year-old patient with a DNR/DNI order needs surgery for acute
cholecystitis. Her guardian agrees to the procedure. What is the next step?
Request temporary suspension of the DNR/DNI order for the duration of the
surgery.
Explanation: Certain procedures require the possibility of life-saving interventions
(airway support, resuscitation). Ethical practice includes clarifying and adjusting
the code status perioperatively.
3. A 2-month-old infant has congestion, low-grade fever, tachypnea, and a history
of neonatal conjunctivitis treated with erythromycin ointment. CXR shows
hyperinflation and interstitial infiltrates. What is the diagnosis?
Chlamydia trachomatis pneumonia.
Explanation: Infants acquire infection during vaginal birth from an infected cervix.
The classic findings are staccato cough, mild fever, and interstitial CXR changes.
,4. A 54-year-old woman has an elevated serum gastrin level and is taking
omeprazole. What is the appropriate next step?
Repeat serum gastrin after stopping the proton-pump inhibitor.
Explanation: PPIs increase gastrin levels due to reduced gastric acidity. Levels
must be reassessed after discontinuation.
5. A newborn develops bleeding from the umbilical stump and petechiae on the
scalp/face. The mother uses phenytoin. What is the diagnosis?
Vitamin K deficiency bleeding.
Explanation: Certain drugs (anticonvulsants, anti-TB medications) reduce vitamin
K–dependent clotting factors in newborns who already have low stores.
6. What condition causes spur cells (acanthocytes)?
End-stage alcoholic liver disease.
Explanation: Excess cholesterol accumulates within red blood cell membranes,
producing irregularly spiculated cells.
7. A 34-year-old with chronic allergies now reports hearing difficulty. He works in
loud noise without ear protection and has a family history of hearing loss. Which
factor most likely explains his symptom?
,His chronic allergies.
Explanation: Allergic congestion can cause eustachian tube dysfunction leading to
conductive hearing loss.
8. A patient with a remote history of partial Roux-en-Y gastrectomy presents with
chronic diarrhea, fatigue, and severe B12 deficiency. Schilling test shows poor B12
absorption not corrected by intrinsic factor. What is the cause?
Small intestinal bacterial overgrowth (SIBO).
Explanation: Bacteria consume vitamin B12, cause malabsorption, and lead to
chronic diarrhea and weight loss.
9. Which environmental exposure carries the highest risk of lung cancer: coal
mine, cotton mill, grain elevator, power company, or shipyard?
Shipyard exposure.
Explanation: Shipyards are strongly associated with asbestos exposure—a major
lung cancer and mesothelioma risk factor.
10. What findings are common in cirrhosis, and what lab abnormalities are
expected?
Symptoms: Ascites, anorexia, hepatomegaly, thin skin, palmar erythema, spider
angiomas, caput medusae, gynecomastia, testicular atrophy.
Labs: Elevated AST/ALT and bilirubin; low albumin and platelets due to impaired
liver function and portal hypertension.
, 11. An 84-year-old stroke patient becomes confused and agitated 12 hours after
admission, despite a normal exam. What is the likely cause?
Environmental change and disruption of routine (delirium in the elderly).
Explanation: Elderly patients—especially post-stroke—are susceptible to delirium
triggered by unfamiliar surroundings.
12. When should women begin DEXA screening and mammography?
DEXA scan: Begin at age 65.
Mammogram: Begin at age 55 and repeat every 2 years.
Explanation: These guidelines target the ages where risk for osteoporosis and
breast cancer significantly rises.
13. A 12-year-old shows signs consistent with mononucleosis. When ordering a
Monospot test, which characteristic matters most?
Specificity.
Explanation: A highly specific test is best for confirming a suspected diagnosis
(“rule in”).
14. A 4-year-old has 5 weeks of high fevers, arthritis in multiple joints,
hepatosplenomegaly, and lymphadenopathy. What is the diagnosis?
GUIDE WITH COMPLETE SOLUTION!!
1. What additional history question is important when evaluating a patient with
suspected tension pneumothorax?
Ask about the use of smoked illicit drugs.
Explanation: Inhaled drugs (e.g., crack cocaine, marijuana) can predispose patients
to the formation of apical blebs or bullae, which can rupture and cause spontaneous
pneumothorax.
2. An 82-year-old patient with a DNR/DNI order needs surgery for acute
cholecystitis. Her guardian agrees to the procedure. What is the next step?
Request temporary suspension of the DNR/DNI order for the duration of the
surgery.
Explanation: Certain procedures require the possibility of life-saving interventions
(airway support, resuscitation). Ethical practice includes clarifying and adjusting
the code status perioperatively.
3. A 2-month-old infant has congestion, low-grade fever, tachypnea, and a history
of neonatal conjunctivitis treated with erythromycin ointment. CXR shows
hyperinflation and interstitial infiltrates. What is the diagnosis?
Chlamydia trachomatis pneumonia.
Explanation: Infants acquire infection during vaginal birth from an infected cervix.
The classic findings are staccato cough, mild fever, and interstitial CXR changes.
,4. A 54-year-old woman has an elevated serum gastrin level and is taking
omeprazole. What is the appropriate next step?
Repeat serum gastrin after stopping the proton-pump inhibitor.
Explanation: PPIs increase gastrin levels due to reduced gastric acidity. Levels
must be reassessed after discontinuation.
5. A newborn develops bleeding from the umbilical stump and petechiae on the
scalp/face. The mother uses phenytoin. What is the diagnosis?
Vitamin K deficiency bleeding.
Explanation: Certain drugs (anticonvulsants, anti-TB medications) reduce vitamin
K–dependent clotting factors in newborns who already have low stores.
6. What condition causes spur cells (acanthocytes)?
End-stage alcoholic liver disease.
Explanation: Excess cholesterol accumulates within red blood cell membranes,
producing irregularly spiculated cells.
7. A 34-year-old with chronic allergies now reports hearing difficulty. He works in
loud noise without ear protection and has a family history of hearing loss. Which
factor most likely explains his symptom?
,His chronic allergies.
Explanation: Allergic congestion can cause eustachian tube dysfunction leading to
conductive hearing loss.
8. A patient with a remote history of partial Roux-en-Y gastrectomy presents with
chronic diarrhea, fatigue, and severe B12 deficiency. Schilling test shows poor B12
absorption not corrected by intrinsic factor. What is the cause?
Small intestinal bacterial overgrowth (SIBO).
Explanation: Bacteria consume vitamin B12, cause malabsorption, and lead to
chronic diarrhea and weight loss.
9. Which environmental exposure carries the highest risk of lung cancer: coal
mine, cotton mill, grain elevator, power company, or shipyard?
Shipyard exposure.
Explanation: Shipyards are strongly associated with asbestos exposure—a major
lung cancer and mesothelioma risk factor.
10. What findings are common in cirrhosis, and what lab abnormalities are
expected?
Symptoms: Ascites, anorexia, hepatomegaly, thin skin, palmar erythema, spider
angiomas, caput medusae, gynecomastia, testicular atrophy.
Labs: Elevated AST/ALT and bilirubin; low albumin and platelets due to impaired
liver function and portal hypertension.
, 11. An 84-year-old stroke patient becomes confused and agitated 12 hours after
admission, despite a normal exam. What is the likely cause?
Environmental change and disruption of routine (delirium in the elderly).
Explanation: Elderly patients—especially post-stroke—are susceptible to delirium
triggered by unfamiliar surroundings.
12. When should women begin DEXA screening and mammography?
DEXA scan: Begin at age 65.
Mammogram: Begin at age 55 and repeat every 2 years.
Explanation: These guidelines target the ages where risk for osteoporosis and
breast cancer significantly rises.
13. A 12-year-old shows signs consistent with mononucleosis. When ordering a
Monospot test, which characteristic matters most?
Specificity.
Explanation: A highly specific test is best for confirming a suspected diagnosis
(“rule in”).
14. A 4-year-old has 5 weeks of high fevers, arthritis in multiple joints,
hepatosplenomegaly, and lymphadenopathy. What is the diagnosis?
