USMLE Step 3 USMLE Step 3 Practice Test 2025
This is the official USMLE Step 3 USMLE Step 3 question paper for 2025, as set in the Model questions examination. It carries 480 full marks and a time allowance of 960 minutes, across 10 questions. On Kekkei you can attempt this USMLE Step 3 past paper online with a timer, get instant AI feedback and step-by-step solutions, and track the topics where you lose marks — completely free. Whether you are revising for your USMLE Step 3 USMLE Step 3 exam or solving previous years' question papers, this 2025 paper is a great way to practise under real exam conditions.
| Level | USMLE Step 3 |
|---|---|
| Subject | USMLE Step 3 |
| Year | 2025 BS |
| Exam session | Model questions |
| Full marks | 480 |
| Time allowed | 960 minutes |
| Questions | 10, all with step-by-step solutions |
Clinical Practice
Select the single best answer.
A 72-year-old man with heart failure (EF 30%), type 2 diabetes, and chronic kidney disease (eGFR 35 mL/min/1.73 m²) is admitted for an acute exacerbation of heart failure. He has been stabilized with IV diuretics and is now euvolemic. His current medications include lisinopril 20 mg daily, carvedilol 25 mg twice daily, and furosemide 40 mg daily. Blood pressure is 118/72 mmHg, heart rate 64 bpm, potassium 4.8 mEq/L. Which of the following medication additions has the strongest evidence for reducing mortality in this patient?
Dapagliflozin 10 mg daily
In heart failure with reduced ejection fraction (HFrEF), the four-pillar medication regimen includes an ACE inhibitor/ARB/ARNI, beta-blocker, mineralocorticoid receptor antagonist (MRA), and SGLT2 inhibitor. This patient is already on an ACEi and beta-blocker. An SGLT2 inhibitor (dapagliflozin or empagliflozin) has been shown to reduce cardiovascular death and HF hospitalization regardless of diabetes status, and is safe in CKD with eGFR ≥20. Adding spironolactone would be appropriate but the potassium of 4.8 with CKD raises concern for hyperkalemia.
A 55-year-old woman presents to your outpatient clinic for management of newly diagnosed type 2 diabetes mellitus. Her HbA1c is 8.2%. BMI is 34 kg/m². She has a history of atherosclerotic cardiovascular disease (prior MI 2 years ago). She has no history of pancreatitis. eGFR is 72 mL/min/1.73 m². Which of the following is the most appropriate initial pharmacotherapy?
Metformin plus a GLP-1 receptor agonist with proven cardiovascular benefit
For patients with type 2 diabetes and established ASCVD, current ADA guidelines recommend metformin as first-line therapy combined with a GLP-1 receptor agonist (liraglutide, semaglutide) or SGLT2 inhibitor that has demonstrated cardiovascular benefit. Metformin plus a GLP-1 RA is the best initial combination given her ASCVD history, as GLP-1 RAs have shown reduction in major adverse cardiovascular events and also promote weight loss.
A 28-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is unresponsive with a GCS of 6. Blood pressure is 70/40 mmHg, heart rate 130 bpm, respiratory rate 8 breaths/min, and oxygen saturation 82% on room air. There are no breath sounds on the left side and the trachea is deviated to the right. Neck veins are distended. Which of the following is the most appropriate immediate intervention?
Immediate needle decompression of the left chest
This patient has classic signs of a tension pneumothorax: hypotension, tachycardia, absent breath sounds unilaterally, tracheal deviation away from the affected side, and distended neck veins. Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression (large-bore needle in the 2nd intercostal space, midclavicular line) followed by tube thoracostomy. This takes priority over imaging.
A 65-year-old woman with atrial fibrillation (CHA₂DS₂-VASc score of 4) is currently on warfarin with a therapeutic INR of 2.5. She presents to the emergency department after a fall with a large scalp laceration that is actively bleeding. Her INR on arrival is 5.8. CT head shows no intracranial hemorrhage. She is hemodynamically stable. Which of the following is the most appropriate management of her coagulopathy?
Hold warfarin and administer IV vitamin K 5 mg
This patient has a supratherapeutic INR of 5.8 with active non-life-threatening bleeding. For warfarin-associated bleeding with elevated INR, guidelines recommend holding warfarin and administering IV vitamin K (2.5–5 mg). Four-factor prothrombin complex concentrate (4F-PCC) is reserved for life-threatening or intracranial bleeding. Fresh frozen plasma is slower and less effective than PCC for urgent reversal.
A 78-year-old woman with advanced Alzheimer’s disease is admitted with aspiration pneumonia. Her son is the designated healthcare proxy. The medical team recommends a percutaneous endoscopic gastrostomy (PEG) tube for long-term feeding. The patient’s advance directive, written when she was competent, clearly states she does not want artificial nutrition or hydration in the setting of advanced dementia. Her son insists on PEG tube placement, stating he “cannot let his mother starve.” Which of the following is the most appropriate course of action?
Follow the advance directive and provide comfort care without PEG placement
When an advance directive (created when the patient was competent) conflicts with the healthcare proxy’s wishes, the advance directive takes precedence because it represents the patient’s own autonomous wishes. The healthcare proxy’s role is to make decisions consistent with the patient’s known wishes, not to substitute their own preferences. The appropriate course is to follow the advance directive while providing compassionate counseling to the family.
A 45-year-old woman with systemic lupus erythematosus on chronic prednisone 15 mg daily and hydroxychloroquine presents with fever (39.2°C), productive cough, and dyspnea for 3 days. Chest X-ray shows bilateral interstitial infiltrates. Oxygen saturation is 88% on room air. Sputum Gram stain shows yeast forms. CD4 count is 180 cells/µL. LDH is elevated at 520 U/L. Which of the following is the most appropriate empiric treatment?
IV trimethoprim-sulfamethoxazole with adjunctive corticosteroids
This immunosuppressed patient with bilateral interstitial infiltrates, hypoxemia, elevated LDH, low CD4 count, and yeast forms on sputum is highly concerning for Pneumocystis jirovecii pneumonia (PJP). First-line treatment for moderate-to-severe PJP (PaO2 <70 mmHg or A-a gradient >35) is IV trimethoprim-sulfamethoxazole (TMP-SMX) plus adjunctive corticosteroids.
A 48-year-old man presents to your office for a routine physical. He is asymptomatic. Family history is significant for his father having a myocardial infarction at age 50. Lipid panel: total cholesterol 265 mg/dL, LDL 185 mg/dL, HDL 38 mg/dL, triglycerides 210 mg/dL. Blood pressure 128/82 mmHg. Fasting glucose 102 mg/dL. Non-smoker. 10-year ASCVD risk score is 14%. According to current ACC/AHA guidelines, which of the following is the most appropriate lipid-lowering therapy?
High-intensity statin therapy
According to ACC/AHA guidelines, patients with LDL ≥190 mg/dL should be started on high-intensity statin therapy regardless of ASCVD risk score, as this qualifies as severe hypercholesterolemia. This patient also has intermediate risk (7.5–20%) with risk-enhancing factors (family history of premature ASCVD, elevated triglycerides). High-intensity statins include atorvastatin 40–80 mg or rosuvastatin 20–40 mg.
A 19-year-old woman is brought to the emergency department after ingesting an unknown quantity of acetaminophen approximately 4 hours ago in a suicide attempt. She is alert and oriented but complains of nausea. Vital signs are stable. Serum acetaminophen level drawn at 4 hours post-ingestion is 210 µg/mL. AST and ALT are currently within normal limits. According to the Rumack-Matthew nomogram, her level falls above the treatment line. Which of the following is the most appropriate next step?
Initiate IV N-acetylcysteine (NAC)
An acetaminophen level above the treatment line on the Rumack-Matthew nomogram at 4 hours post-ingestion (the treatment line starts at 150 µg/mL at 4 hours) indicates risk of hepatotoxicity and is an indication to start N-acetylcysteine (NAC). NAC is most effective when given within 8 hours of ingestion but can be beneficial even later.
A 60-year-old man with chronic hepatitis C cirrhosis (Child-Pugh class B) presents with his first episode of hematemesis. Upper endoscopy reveals large esophageal varices with active bleeding. Endoscopic variceal band ligation is performed successfully. His hemoglobin stabilizes at 8.5 g/dL after transfusion. Which of the following is the most appropriate pharmacologic therapy for secondary prophylaxis of variceal bleeding?
Propranolol with repeat endoscopic band ligation
After successful endoscopic treatment of acute variceal bleeding, secondary prophylaxis combines endoscopic band ligation (repeated every 1–2 weeks until variceal obliteration) with a non-selective beta-blocker (NSBB) such as propranolol or nadolol. NSBBs reduce portal pressure by decreasing cardiac output (β1 blockade) and causing splanchnic vasoconstriction (β2 blockade).
A 35-year-old man is diagnosed with active pulmonary tuberculosis. He is started on four-drug therapy but after 2 weeks states he wants to stop all medications because he feels better and does not believe he is still contagious. He works as a school teacher. He is competent and understands the risks explained to him. Which of the following is the most appropriate next step?
Report to public health authorities and arrange directly observed therapy
While patient autonomy is fundamental, public health law allows for limitations on individual autonomy when there is significant risk of harm to others. Active pulmonary TB is a reportable communicable disease, and public health authorities have the legal authority to mandate treatment and, if necessary, isolate non-compliant patients. The physician should report to the public health department for directly observed therapy (DOT). The duty to protect third parties overrides the individual’s right to refuse treatment in this case.
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- Yes. Every question on this USMLE Step 3 past paper includes a step-by-step solution, plus instant AI feedback when you attempt it on Kekkei.
- How many marks is the USMLE Step 3 USMLE Step 3 2025 paper?
- The USMLE Step 3 USMLE Step 3 2025 paper carries 480 full marks and is meant to be completed in 960 minutes, across 10 questions.
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