Over the years, the AMA has run dozens of example questions from Kaplan Medical. If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 3 exam, you might want to know which questions are most often missed by test-prep takers. We’ve compiled four cases from Kaplan Medical involving senior patients. Each question comes with an expert explanation of the answer. You can check out all posts in this series.

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  1. 102-year-old with pneumonia refuses IV

    A 102-year-old widower is brought to the clinic from his apartment by a neighbor because of a cough productive of green sputum. He had a stroke 10 years ago and has residual left arm weakness. He takes no medications. Vital signs are temperature 38.8º C (101.8º F), blood pressure 100/50 mm Hg, pulse 110 beats per minute. On physical examination rhonchi are found in the right lower lung field. Chest X-ray reveals an infiltrate in the right lower and middle lobes. The patient has a score of 30/30 on a Mini Mental Status exam. The patient says, "I've lived a good life and I don't want to end up in the hospital." What is the best next step in management?

  2. Respiratory failure in Alzheimer’s patient

    An 82-year-old woman with a history of Alzheimer dementia is brought to the emergency department by her family. Her home health attendant found her collapsed on the floor of her apartment. The patient gradually becomes more alert and conversant after administration of intravenous normal saline for two days. Attempts to feed her orally are unsuccessful, as she has evidence of defective swallowing. The decision is made to place a percutaneous gastrostomy tube to ensure proper nutrition and protect against aspiration. Which is the most likely electrolyte abnormality in this patient?

  3. Patient with diabetes has nausea, vomiting

    A 74-year-old man with insulin-dependent diabetes mellitus and chronic renal failure comes to the emergency department because he has been nauseated and vomiting for 24 hours. He denies any chest or abdominal pain. He underwent his routine hemodialysis yesterday without any complications. Which is the best next step in the management of this patient?

  4. Man presents with right leg pain

    A 79-year-old man with a medical history of colon cancer presents to the emergency department because of right leg pain below the knee for the past four hours. He has never had pain like this before and rates the pain as nine out of 10 in intensity below the knee. The patient denies shortness of breath. Physical examination is significant for absent dorsalis pedis and posterior tibial pulses in the right lower extremity. What is the most appropriate next step in the management of this patient?

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For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.

The AMA selected Kaplan as a preferred provider to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. AMA members can save 30% on access to additional study resources, such as Kaplan’s Qbank and High-yield courses. Learn more.

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