Explanations for the 2022 Official Step 3 Practice Questions

Here are my explanations for the August 2022 update of the official practice materials. (As of 2024, the PDF of these questions is no longer available, but the 2020 set is still archived and nearly identical to the 2022 PDF.)

The asterisks (*) signify one of the only two new questions compared with the prior set.

My explanations for the old 2020 set are here and the 2018/2019 set are here. There were 71 new questions in 2020 vs 2019, so going through that older set may still be worth your time. The one before that, which I explained here, was revised in November 2017.

You can find my thoughts on preparing for Step 3 here. Since writing that post, the main substantive change in the exam has been the ability to schedule CCS on a nonconsecutive day. In short, I think the free materials and UWorld should be enough for most folks. If you want book recs, they’re in that post. If you need another question source, I haven’t tried any of them, but you can get 10% off the popular BoardVitals if you’re interested by using code BW10.

As for this free 137-question practice exam, Blocks 1 and 2 are “Foundations of Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are “Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each. Total practice time should be no more than 3:30 if taken under test-day conditions.

Block 1

  1. E – Rash and arthritis after exposure to a sick kid with a “facial rash” and fever. The kid’s vague description is a perfectly good fit for the slapped cheek of Parvovirus B19. Adults most commonly get polyarthralgia (and sometimes, dangerously, aplastic anemia).
  2. A – Of the choices, the best explanation for a liver mass in an otherwise healthy female is a hepatic adenoma, a benign lesion for which the patient’s OCPs are a common modifiable risk factor. These do have a tendency to bleed, especially when large, which is an indication to stop her hormonal contraceptive.
  3. C – She has glomerulonephritis in the setting of what looks like strep throat. Post-strep glomerulonephritis is a type III hypersensitivity, an immune-complex deposition disease that consumes complement (C3).
  4. D – That’s a lot of hyperthyroidism symptoms. Onycholysis (Plummer’s nails) is one of them, but as long as you didn’t somehow let it distract you, the rest of the question info (cold intolerance, anxiety, low BMI) points you in the right direction as well.
  5. C – Retinitis pigmentosa most commonly has an autosomal dominant inheritance pattern, but the tree we have shows clear X-linked inheritance. In this case, her husband has the disease, meaning his one X copy carries the mutation. However, her son’s X-chromosome must come from her, so her male children have no chance of being affected. Her daughters, however, would be obligate carriers.
  6. E – First-line therapy for OCD is SSRIs.
  7. E – Stratification is the partitioning of subjects by a non-treatment factor and should be your knee-jerk response as a method to control for confounding variables (i.e. potentially important variables nonetheless not being directly studied). By stratifying people into groups by the variable in question, you remove its possible confounding influence.*
  8. E – I think the answer here is probably intuitive even if you don’t actually know why. But anyway, recall that sickle cell RBCs have a decreased lifespan, so they don’t stick around as long to accumulate glucose as normal RBCs do, which artificially lowers the A1C value.
  9. A – You can’t hold records hostage.
  10. A – Bleeding in cirrhosis is more complicated and multifactorial than you’d think, but the elevated INR in cirrhosis is primarily secondary to synthetic dysfunction. Recall that elevated PT/INR is related to decreases in Factors II, VII, IX, and X, and the liver makes fibrinogen and factors II, V, VII, IX, X, XI, and XII. Of the choices, Factor VII deficiency is the biggest bleeding risk.
  11. E – Classic features of scleroderma. Skin-tightening about the mouth can complicate airway management.
  12. C –Number needed to treat (NNT) is 1/(ARR = difference in outcome). There was a 20% difference (35% vs 15%) of recurrent encephalopathy. 1/.2 = 5.
  13. B – This is a well-designed study. The main problem is that EPCS is technically challenging to perform and sclerotherapy is available basically everywhere.
  14. B – B is true (it’s in the table and has an itty-bitty p-value). A confidence interval including 0 (choice A) means the two options are not significantly different.
  15. E – Signs and symptoms of secondary syphilis. It’s usually prudent to keep STIs as a differential for most cases of young-healthy-person-suddenly-develops-a-constellation-of-weird-symptoms.
  16. C – While there’s overlap between exposure-related/allergic-type symptoms and viral URIs, in this case, RSV is the only virus they gave you, and that’s not going to pan out for this combination cough/coryza/itchy eyes in older kids. As we’ve learned with COVID, viruses travel between people and don’t stay localized to a single physical environment like mold from poorly mitigated water damage.
  17. A – When someone seems like a truly awful adult, antisocial personality disorder (apparent “charm” is a test-favorite). When under the age of 18, conduct disorder.
  18. B – You want to nonjudgmentally hear about what happened from the patient in his own words in order to evaluate. I do love that they included truth serum though.
  19. B – Irregular tachycardia? Could she have symptomatic a-fib? Would an ECG provide the diagnosis immediately? Yes and yes and yes.
  20. B – He is sick leading to decreased PO intake leading to prerenal physiology and hypovolemic hyponatremia. This is very common and the cause of the majority of AKI we see in the hospital when literally anyone is sick. Treat with fluids.
  21. E – Posterior knee dislocation often results in vascular injury (there is no discrete fracture on the radiographs).
  22. A – His party foul was cataplexy (the awkward passing out at moments of excitation), which is common in narcolepsy. Decreased sleep latency and the need for frequent (but restorative) naps are also characteristic. See this adorable video.
  23. C – The control group needs to have radiographs in order to prevent a systemic ascertainment bias from unintended differences in the composition of the two groups.
  24. D – We have no reason to doubt the patient’s decision-making capacity, and he doesn’t want treatment. He does, however, have metastatic cancer. Hospice is a very underutilized program that can help patients with terminal illnesses navigate the end of life by prioritizing their care goals and comfort.
  25. A – Infectious bloody diarrhea is dysentery. Of the choices, only Campylobacter jejuni causes dysentery.
  26. C – Reactive arthritis is associated with HLA-B27. You probably remember this most as the young man with arthritis after an STI (most often chlamydia trachomatis), but bowel infections also do the trick (typically Campylobacter, Salmonella, Shigella, or Yersinia).
  27. A – The most common cause of bloody/black nipple discharge is an intraductal papilloma, which can be diagnosed via ductography. That said, in real life, ultrasound is highly user-dependent and most people would probably at least do another targeted ultrasound to try to find the lesion now that there’s new discharge. For one thing, it’s easiest to biopsy a lesion that is seen on ultrasound.
  28. D – Math.
  29. B – Toxic shock syndrome, caused by exotoxin-producing Staph and Strep. They don’t have to mention the word tampon.
  30. A – Old man with shoulder girdle pain and/or stiffness, nonspecific somatic complaints, and an elevated ESR? Polymyalgia rheumatica, a disease of exclusively old people.
  31. C – Benzos, like alcohol, suppress respiratory drive. That’s why they’re potentially lethal.
  32. A – Looks like a combination of chemo-related side effects and pancytopenia.
  33. E – Isolated elevated respiratory rate in an otherwise healthy and well-oxygenated baby after a C-section is typically TTN, felt to be a result of retained lung fluid that would normally be squeezed out/resorbed during the normal birthing process.
  34. D – The ulna is fractured, and the radial head is dislocated (way too high). The eponym for this pattern is called a Monteggia fracture-dislocation.
  35. A – The diagnosis of inflammatory bowel disease can be made with colonoscopy.
  36. A – She might be doing drugs, but a little coke and MJ don’t cause papilledema (a sign of increased intracranial pressure) and cerebellar signs. A cerebellar tumor could, commonly a medulloblastoma in a patient of this age.
  37. C – It’s cholangitis because of the stone lodged in and obstructing the common bile duct, which is why the CBD is dilated; you would suspect this clinically before the ultrasound essentially confirmed it due to the combination of upstream liver and pancreatic issues. Only a stone in the distal CBD will affect both organs.
  38. A – Intention tremor that’s improved with alcohol is classic for essential tremor, which can be exacerbated by SSRI therapy.

Block 2

  1. D – A-fib isn’t ideal, but it’s the giant pleural effusion that’s causing her SOB and hypoxia. Thoracentesis will be diagnostic and therapeutic.
  2. D – Very long question, but we have a combination of post-op severe abdominal pain, fever, and leukocytosis. Of the choices, an ultrasound can (more or less) evaluate the aortic repair and look for free fluid. It would also evaluate for the possibility of acalculous cholecystitis in this old sick patient, which is likely the thrust of this question. In real life, this patient would definitely get a CT scan, but that’s not a choice here.
  3. E – An ultrasound is used to assess for a tappable joint effusion, particularly in order to exclude septic arthritis. Transient synovitis (aka “toxic synovitis”) is the most common cause of acute hip pain in children aged 3-10 years and is what this child likely has. It frequently occurs after a URI, and a low-grade fever is typical.
  4. E – She has a-fib with rapid ventricular response based on the irregularly irregular rhythm and tachycardia. You don’t really need to know the murmur part to get this question correct, but remember that mitral stenosis results in a diastolic fill murmur loudest at the apex (the snap is the stenotic valve finally and dramatically opening thanks to the increased pressure). Chronic MS predisposes to a-fib due to left atrial enlargement, which stretches and deforms the conduction pathways.
  5. B – Diabetic gastroparesis in a long-standing diabetic.
  6. E – Vitamin D deficiency is rampant with symptoms including fatigue, muscle aches, and depression, among others. Checking a vitamin D level is also just helpful to make sure we’re treating osteoporosis sufficiently.
  7. D – Gas exchange requires both the ventilation of alveoli and the circulation of blood through the capillary bed. Hypoxygenation with a lung infection is usually due to a VQ mismatch and shunting as blood still travels through lung tissue that is poorly ventilated. This is the opposite of a pulmonary embolism, where the perfusion is low to the normally ventilated lung.
  8. C – An intoxicated physician can’t work due to patient safety, obviously, but you also can’t cover for them and try to hide the event.
  9. D – The first imaging study for any musculoskeletal complaint outside of spine trauma is a radiograph.
  10. B – You want the first test to be highly sensitive in order to catch most cases of the disease. You want the confirmatory test to be highly specific so that only true positive cases make it through.
  11. C – You want to make sure she is taking the prescribed medication and confirm she’s not taking anything else on the side.
  12. A – That isn’t the “opening remark” you might want to use, but it is absolutely the only one that’s appropriate from the list.
  13. C – Tubal injuries/scarring like those resulting in hydrosalpinx are often secondary to STIs, particularly Chlamydia, and are a common cause of infertility.
  14. A – Leg claudication in a heavy smoker is concerning for the PAD. The initial test is an ABI.
  15. D – From the data provided, no one with a negative D-dimer had a PE (high negative predictive value, D), but a positive D-dimer was seen in tons of normal people (low positive predictive value).
  16. D – Lying is bad.*
  17. C – The p-value column only demonstrates one significant value: HIV co-infection.
  18. C – Ah, the halcyon days before Covid. You’re not done with him yet. But, he could have TB, so mask up.
  19. E – Clear alcohol withdrawal seizures. What else were you hoping to find? If “no further evaluation” is an option, be extra sure you don’t want to pick it.
  20. A – Only A is true. B is the opposite (hypoxemia was less impactful). As for C, the CI for the odds ratio of lung infiltrates includes 1, meaning that it was not statistically significant (which also means that D is wrong).
  21. C – Spontaneous panic-like sympathetic overload episodes in a person with a family history suggesting MEN2A (comprised of medullary thyroid carcinoma, pheochromocytoma, and parathyroid hyperplasia or adenomas). We need to work up a pheo, which we can do laboratorily by measuring serum metanephrines.
  22. B – You can gently correct incorrect statements, catastrophizing, etc. Denying someone’s feelings (D) is unhelpful, blowing someone off from their story in the middle of evaluation is absurd (C), and just giving advice (A) like an over-credentialed coach isn’t going to work.
  23. A – Acute-onset LBP and radiculopathy are typically related to a herniated disc.
  24. E – Dementia in the setting of multiple strokes sounds great for vascular dementia. This is especially likely given the rapid course and association with focal neuro deficits, but be aware in real life that dementing processes are not mutually exclusive.
  25. A – Lots of lymph nodes and splenomegaly with weight loss and fevers is concerning for lymphoma. In this case, mediastinal nodes are also causing airway compression.
  26. D – An uncontrolled seizure disorder and driving don’t mix.
  27. D – Power is 1 minus the type II error (aka the false-negative threshold).
  28. D – Liver disease was a contraindication in the drug ad (red box at the end), and the patient has cirrhosis.
  29. D – The ad shows that all three doses were similar vs placebo. Remember, when in doubt, the exam loves to test the difference between measurable differences (or even statistical significance) and clinical significance. 
  30. B – Most cases of sinusitis are viral and result in mucosal swelling/edema.
  31. C – Middle-aged female with muscle aches, proximal muscle weakness, and an elevated CK indicating muscle breakdown. The skin cracking is a description of “mechanic’s hands.”
  32. C – Likelihood ratios are often used to judge the performance of a diagnostic test by determining the likelihood that a test result changes the probability of the underlying condition being present. LR = sensitivity / (1 – specificity). In this case, that’s (120/336) / (1 – [365/375]). Note that we use 365 because we’re calculating the true negative rate and they provided us with 10 false positives out of the 375 individuals negative for HIV.
  33. B – This question is actually straight-up bad. There are multiple societal players and guidelines, which complicates things, but the move over the past decade has been to try to biopsy fewer lesions because we’re dramatically overdiagnosing and overtreating thyroid cancer. Basically, a 1 cm nodule should really only be biopsied if it has concerning ultrasound characteristics like microcalcifications. Just saying it’s solid doesn’t really count. The alternative to FNA is observation though, so at least A, C, and D are unworkable.
  34. D – Working outside in the “southwest United States” with nonbacterial pneumonia (no improvement on antibiotics, eosinophilia) is a great setup for coccidiosis.
  35. D – Sounds like the patient is behaving like a prototypical American. A family meeting would be appropriate because family meetings are basically always appropriate. Legal guardianship for liking fast food and cigarettes is absurd, Down syndrome or not.
  36. E – OTC cold medications often contain decongestants that cause vasoconstriction.
  37. E – Fever + flank pain + UTI = pyelonephritis. No further workup is needed for a woman’s first episode of pyelo, despite common ER practice. If she fails treatment, then she’ll need imaging.
  38. F – Lateral medullary syndrome from vertebral dissection taking out PICA. This causes a Horner’s-like syndrome due to loss of descending sympathetic fibers in addition to vertigo, nystagmus, and crossed findings of ipsilateral facial sensory/cranial nerve deficits and contralateral pain and temperature loss.
  39. E – Analgesia abuse nephropathy. That’s a lot of Advil.

Block 3

  1. A – Trigeminal neuralgia is classically treated with carbamazepine.
  2. C – Pain with passive flexion is a classic exam finding of compartment syndrome. In this case, muscle breakdown (evidenced by the elevated CK) is the source of the swelling that is poised to threaten the limb.
  3. C – Radiofemoral delay and pulse/BP differentials between upper and lower extremities are physical exam findings of aortic coarctation. The stiff/noncompliant narrowed aorta increases afterload and results in hypertension.
  4. E – Pregnancy of unknown location. She doesn’t have a tubal mass to suggest an ectopic pregnancy, so we perform serial HCGs to see if this is an early intrauterine pregnancy, an early ectopic pregnancy, or a failed pregnancy.
  5. C – Postpartum psychosis is an even bigger risk factor for future peripartum psychiatric issues including depression than run-of-the-mill postpartum depression.
  6. C – LDL is just above the normal range. In an otherwise healthy adult, the statin treatment threshold is 190. Everyone should have a “heart-healthy diet” and exercise.
  7. C – ABCs.
  8. C – He’s in as good of shape as he can be. But no one feels comfortable after getting stabbed, receiving a chest tube, getting a thoracotomy, and then keeping a chest tube or two. The tachycardia may or may not be an objective sign of pain here as well.
  9. E – It would seem he has developed decompensated acute right heart failure in the setting of constrictive pericarditis. An effusion with tamponade is theoretically possible as well, especially keeping in mind that acute effusions often don’t result in the water bottle heart on x-ray that you learned about because it takes some time for the pericardium to stretch, but the X-ray showing a normal size heart is a tip-off here that the pericardium has thickened and hardened, preventing normal heart-filling (and therefore no cardiomegaly as we so often see in heart failure from most causes). Even if the new heart failure was from another cause, an echo would still be the right choice to see what’s going on.
  10. A – Clear-cut varicose veins. The initial treatment of choice is compression stockings. Venous imaging is really only indicated if there are signs to suggest DVT or pre-procedurally prior to an ablative procedure.
  11. A – Cat bites on Step exams classically result in infection by Pasteurella multocida. Beta-lactams work just fine, so Ampicillin would be a great choice. Amp has the benefit (unlike a fluoroquinolone) of also covering anaerobes since most bite injuries are actually polymicrobial.
  12. E – Initial cervical cancer treatment is all about staging. Low-stage localized disease gets surgery and higher stages get chemoradiation.
  13. D – He has hypertension.
  14. D – Trich is often asymptomatic. (Rapid) reinfection is common, and he (and any other occult partners) should be treated empirically even if asymptomatic to prevent reinfecting the girlfriend.
  15. A – HIV+ with CD4 < 200 means full-blown AIDS, hence the oral hairy leukoplakia (painless, un-scrapable unlike thrush). He needs antiretroviral therapy, which addresses the root cause of his current complaints. He does also need opportunistic infection prophylaxis/treatment, but that’s not an option and would be in addition to antiretroviral therapy.
  16. A – She has somatic manifestations of a targeted anxiety disorder/phobia. This would best be treated with CBT.
  17. A – Not just pharyngitis or even tonsillitis, the swollen oozing tonsil displacing the palate and uvula and resulting in trismus suggests a peritonsillar abscess, which requires drainage.
  18. C – It would seem he’s a hemophiliac given the bleeding diathesis with an X-linked inheritance. With that inheritance pattern, his daughters will be obligate carriers and his sons will be totally fine. Therefore, the sons of his daughters will have a 50% chance of having the disease.
  19. E – Smooth small objects like dimes should pass. A rule of thumb is that anything around 1 inch or larger (i.e. quarter or larger) is a problem and should be retrieved if accessible, as well as coin batteries (if still in the esophagus), multiple magnets (which can bind bowel loops together and cause obstruction/perforation), and probably most things with super pointy edges. Once a single smooth object makes it to the stomach, it’ll usually be fine. Some recommend a radiograph if the object hasn’t passed by three days.
  20. D – Back pain is a way of life for the morbidly obese.
  21. C – Abnormal uterine bleeding in a woman over 45 requires an endometrial biopsy to rule out endometrial cancer. For patients younger than 45, EMB is also recommended for those not responding to medical therapy or who have prolonged periods of unopposed estrogen stimulation.
  22. C – Smoking is by far the worst modifiable risk factor of all time.
  23. A – You know you want more PEEP, but PEEP isn’t always like cowbell. Sometimes you can have too much. Forcing all that air into noncompliant lungs can raise intrathoracic pressure, which reduces right heart venous return, hence the JVD and systemic hypotension (the latter secondary to the Starling mechanism). Tidal volume and respiratory rate might also be reduced, but the bottom line is that we need to tweak the ventilation settings.
  24. D – Small anal fissures are treated with a bowel regiment/stool softening. This isn’t a hemorrhoid or perirectal abscess.
  25. A – Intravenous calcium is used to prevent bad-news cardiac effects of hyperkalemia. Not sure the peaked T-wave on the ECG are really necessary for this question when they give you a serum potassium of 6.4.
  26. D – Rifampin is meningococcal prophylaxis used for close contacts. You do not want to get meningococcal meningitis.
  27. E – She is severely anemic, which can certainly cause chest pain by itself irrespective of her underlying sickle cell disease, and she needs a blood transfusion. Analgesia is also critical in any potential sickle cell crisis, but that isn’t an option here.
  28. B – Patients with Parkison’s and other old, weak, and/or demented folks are at high-risk for aspiration. PNA in this population, particularly involving the RLL, could be aspiration pneumonia, and steps should be taken to make sure an appropriate diet plan is in place.
  29. E – IV metoprolol is great for rate-control. It even worked already during this admission; it just doesn’t last very long. Rapid onset, short duration. He’ll need continued IV rate control until oral meds (or other therapy) can treat his RVR or it resolves on its own.
  30. C – Anthracycline-induced (e.g. doxorubicin) cardiomyopathy can occur years after treatment and warrants screening echocardiography.

Block 4

  1. D – He has toxo from eating cat feces in the dirt (oops). That doesn’t address the why of his pica (geophagia, in his case). I don’t know about you, but I don’t think managing dirt-eating in five-year-olds is part of most people’s practice, even in “Advanced Clinical Medicine.”
  2. D – We should be worried about a spinal cord lesion or cord compression, possibly from spinal metastasis in the setting of breast cancer. Recall that the spinothalamic tract crosses in the spinal cord unlike the main sensory and motor tracts, which cross in the brainstem, which is why a right-sided lesion would affect right-sided strength, sensation, and reflexes but left-sided pain/temperature. The inguinal ligament is the T12 sensory level, but you might remember that the fibers travel 1-2 segments before crossing, so the sensory level will often be below the lesion level (i.e. our lesion could be at T10).
  3. C – The combination of fever and back pain is concerning for osteomyelitis. MRI is the test of choice.
  4. E – You might recall that children with sickle cell disease are at risk for salmonella osteomyelitis in addition to the more common bugs like MRSA. Empiric treatment should cover both: vanc for MRSA and a third-gen cephalosporin like cefotaxime for the salmonella.
  5. D – Pain control is always a priority. Obviously, you’re going to get an imaging study and give antibiotics, but the question here is getting at how to address his symptomatic misery.
  6. C – Lactic acid lotions are used for exfoliating and moisturizing super dry skin. There is no evidence for an infection or inflammatory condition.
  7. D – It’s all from outlet obstruction. We need to drain that bladder, so if a foley can’t be passed, then it’s time for a suprapubic catheter.
  8. A – Abscesses get drained.
  9. E – She has cerebral edema, which is the leading cause of death in DKA. Signs, in this case, were somnolence, lethargy, headache, n/v, and incontinence. Seizures, bradycardia, and eventually respiratory arrest are also bad news. Mannitol decreases ICP.
  10. B – Hormonal therapy with estrogen is the most effective treatment for the symptoms of menopause like hot flashes. Nonhormonal therapies like gabapentin and certain antidepressants carry lower risks but are not as effective and therefore not “most likely to alleviate” her symptoms. She has evidence of prior TB, but that’s a distractor.
  11. E – Thinking psoriasis with the raised red, scaly plaques, and even some nail involvement, but every rash can be treated with steroids right? (kidding not kidding.) I presume the episode of joint pain is a toss-out to suggest psoriatic arthritis.
  12. D – Try not to fight “normal patient just needs a high five” questions.
  13. D – Cocaine can cause chest pain and even MI due to alpha-mediated coronary artery vasoconstriction and spasm. He hasn’t responded to the first-line treatments of ASA, NTG, and BZD, so next up is phentolamine, an alpha-blocker that can loosen things up.
  14. D – He has the four-liner description of hypovolemia. You treat hypovolemia with saline. Remember your ABCs.
  15. C – Thrush is common in newborns and young infants and is almost always initially treated with topical nystatin. Difficult cases can be treated with oral (systemic) fluconazole. In a newborn, the two most common sources of a white tongue are milk residue and thrush. Milk residue comes off easily. You of course can scrape thrush off, but not necessarily with “gentle” scraping, and doing so will often leave red, inflamed areas underneath.
  16. B – MDD is treated first-line with SSRIs. He has complicated depression (with hallucinations), not bipolar disorder.
  17. D – That late systolic murmur is concerning for aortic stenosis. Untreated aortic stenosis is a rapid killer of old people, especially if it’s already symptomatic.
  18. E – Super common safe combination.
  19. C – Most patients with Bell’s palsy have a complete recovery.
  20. E – Asthma exacerbations are treated with steroids. Even though her flow rates aren’t that bad, she is not getting relief with her rescue inhaler.
  21. A – Gestational diabetes is pretty likely in this overweight patient with a history of a large baby delivery and now measuring greater than dates.
  22. E – Immediate and most effective pharmacotherapy to help firm up the uterus and stop postpartum hemorrhage is oxytocin.
  23. A – This is an example of cold urticaria, a rash that forms on cold-exposed skin and typically worsens as the skin warms (hence why it happened after she returned home). Mild reactions don’t require treatment (such as antihistamines or an EpiPen), but avoiding cold exposure will allow the reaction to fade and prevent future occurrences. Anaphylaxis can occur.
  24. B – Community-acquired pneumonia (possibly with an atypical pathogen suggested by the addition of diarrhea) in a pregnant patient. Patients with comorbidities (e.g. COPD, alcoholism, diabetes) should get levoflox, moxiflox, or a combination of a beta-lactam like amoxicillin or third-gen cephalosporin like ceftriaxone PLUS a macrolide (e.g. azithromycin). Fluoroquinolones are generally avoided in pregnancy when effective alternatives are available, making B a better answer than C.
  25. D – Lovenox is the DVT prophylaxis of choice in patients with reasonable renal function. Recent knee surgery isn’t a contraindication; orthopedic surgery is a huge risk factor!
  26. C – Addison’s disease presenting with Addisonian crisis–indicated by the combination of skin bronzing, generalized weakness/failure to thrive, and salt wasting with hyponatremia and hypotension–will immediately need fluids and steroids. This is a commonly fatal condition when insufficiently untreated.
  27. D – Super duper classic gout. Big angry MTP joint full of white cells but no organism (Podagra). Treatment of an acute attack would be indomethacin. Prophylaxis is allopurinol.
  28. D – The AAFP actually recommends a single dose of oral steroid (usually dexamethasone) in all (even mild) cases of croup to help with airway edema. Croup is viral, so no antibiotics.
  29. B – The diagnosis of shingles here is clinical and does not require any further testing itself. However, given multiple sexual partners and a case of shingles way younger than typical, HIV testing is prudent. HIV significantly increases the risk of reactivation diseases like shingles.
  30. B – Condyloma acuminatum (genital warts) can be treated with imiquimod, a topic immune-response modifier.

I’m a fallible human being. Questions/thoughts are welcome in the comments as always.


bee 12.04.22 Reply

113 is an example of ichthyosis vulgaris

Nadir 12.20.22 Reply

Thank you sir!!

Marcus 02.04.23 Reply

Thanks so much for making this! 76 is lateral medullary (Wallenberg) syndrome, likely due to vertebral artery dissection from the neck manipulation resulting in blocking the PICA. So it’s the descending sympathetic fibers in the medulla rather than the cervical ganglia that are damaged.

Ben 02.07.23 Reply


Cassie 02.07.23 Reply

Thank you so much. This was really helpful, I liked your use of words too😊

Kaiser 03.24.23 Reply

Long time reader, first time commenter.

For question 95, my first answer was Hemophilia, but the uncle threw me off. I may have overthought it, but XR disorders should skip generations. AD and AR don’t fit, but the uncle really shouldn’t be affected.

Thanks for regularly updating these!

KK 04.06.23 Reply

Yeah uncle swung me the wrong way too, odd

Arthur 04.21.23 Reply

Hello. Thank you for this correction. I have 3 questions:

– 7.e: why not “matching”. First Aid says that matching helps in reducing confounding vs. stratification helps in reducing effect modification.

– 118. E: why not MTX if the patient also has joint pain?

-16.C : Did you pick Mold over Asbestos just because they mention water pipes? Because I think that Asbestos can also happen from Fire and present with similar symptoms.

Nirav K Mungalpara 06.08.23 Reply

7 e = Matching is good choice for prospective cohort or RCT. here they were given case control. so After result, stratification is feasible choice to rule out confounder.

118 e = Read carefully. Patient had transient joint pain but no recurrence. that means treat only rash.

16. TBH I am just gonna mug that up. Too strange to remember logically.

Nirav K Mungalpara 06.08.23 Reply

Thanks a lot. Nice write up.

Shashank Gupta 09.03.23 Reply

Q. 109. Explanation is incorrect. Diagnosis is Transverse Myelitis. Patient has fever. Cord Compression will not result in fever

Ben 09.03.23 Reply

This a specifically a work up question, not a diagnosis question. It’s about knowing how to evaluate a clinical scenario (new spinal cord level) and, to an extent, what the differential considerations include. If you knew with certainty the spinal cord lesion was TM, what value would an MRI really have?

G 10.29.23 Reply

Q15 is HIV not syphilis.

Ben 10.29.23 Reply

I don’t believe that’s true, no. Just for fun, I just asked ChatGPT, which after totally botching it by thinking of Parvovirus B19/Fifth Disease, had this to say after I narrowed it down to an STI:

The symptoms described in the medical exam question, particularly the history of a flu-like illness followed by a rash, are suggestive of secondary syphilis, which is a sexually transmitted infection (STI). Syphilis is caused by the bacterium Treponema pallidum.

aisel 12.07.23 Reply

Hello Ben!
Hope you are doing well.
I wanted to take free137 today but I see that your current explanations don’t match to the form. Was it updated recently?

Ben 12.08.23 Reply

Yes, those are from the 2022 set. I haven’t made a post for the 2023 set.

aisel 12.08.23

got you. thanks! do you have by a chance the old free137 version? exam is on next monday(

Ben 12.08.23

That particular PDF doesn’t seem to be available via the WayBack Machine. But please see the link above to the 2020 set explanations, which are almost identical and includes a working link to an archive of that PDF.

aisel alikhanova 12.08.23 Reply

thank you!

TKhan 03.03.24 Reply

Hello Mr.Ben
Any chance you are going to do an explanation for the December 2023 update for the USMLE Step 3 Questions?
Looking forward to your explanations as always!
Best Regards

Ben 03.03.24 Reply

Honestly, I’m not confident I’ll be working on USMLE questions again in the future.

TKhan 03.04.24 Reply

Dr.Ben …I am sorry to hear that. Thankyou for providing all the explanations previously though!
Have a wonderful day!

TKhan 03.04.24 Reply

Just in case you change your mind… I will be waiting :)

TKhan 03.04.24 Reply

Plus I just wanted to add one more thing… I think the questions are going to be re-written anyways… which is a good thing for people who study honestly… I took step 2 last December and half the questions were SOAP style and took a while just to read through! The current questions in USMLE website are not like anything I saw on the actual exam.
Advice to myself- Don’t let cheaters make you feel bad about being honest. Like Dr.Conrad Fischer always says- “Persist”. I would add -“Persist being honest”.
Thanks Dr.Ben for everything you do. Please don’t let anything get you down.

Pkuo 03.12.24 Reply

Dear Dr. Ben,
I’m planning to take my step 3 exam in 2 weeks time and was really hoping you can do the updated 2023 version of step 3. Your explanations keeps me motivated and knowing my thinking process is on the right track! :) You got me through step 1 and 2ck! Hope you can keep doing what you do, I am truly grateful.
PS. I’ve match :)

Chris 05.08.24 Reply

Thanks so much for this awesome resource! When are you going to a post a guide for the answer key for the new Free 137? We all appreciate you so much!

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