USMLE Step 3 CCS Practice Cases

Chief complaint: Shortness of Breath

67-year-old man with 2 weeks of progressive dyspnea, orthopnea, PND, and bilateral leg swelling.

Chief complaint: Chest Pain

58-year-old man with 2 hours of crushing substernal chest pressure radiating to left arm and jaw, diaphoresis, and near-syncope.

Chief complaint: Palpitations

71-year-old woman with new atrial fibrillation and rapid ventricular response, hypotensive and confused, on a background of two days of dysuria, flank pain, and fevers from urosepsis.

Chief complaint: Chest Pain

64-year-old woman with diabetes presents with 3 days of exertional chest pressure now constant at rest; ST depression and T-wave inversions on ECG with rising troponin.

Chief complaint: Shortness of Breath

68-year-old woman presents with sudden-onset severe shortness of breath; management of flash pulmonary edema in the setting of hypertensive emergency.

Chief complaint: Chest Pain

Young adult presents with sharp pleuritic chest pain, positional worsening, and a friction rub; diagnosis and management of acute pericarditis.

Chief complaint: Cough and Fever

72-year-old man with 5 days of productive cough, fever, dyspnea, and mild confusion.

Chief complaint: Shortness of Breath

64-year-old man with worsening dyspnea, productive cough, and wheezing after running out of inhalers.

Chief complaint: Cough and Weight Loss

34-year-old man with 6-week productive cough, hemoptysis, drenching night sweats, and 15-pound weight loss.

Chief complaint: Shortness of Breath

32-year-old woman with asthma, progressive dyspnea after a 6-hour flight, left calf pain, and pleuritic chest pain.

Chief complaint: Wheezing

34-year-old woman with persistent asthma in moderate-severe exacerbation after a viral URI; tripoding, accessory muscle use, peak flow ~41% predicted.

Chief complaint: Chest Pain

24-year-old man with sudden severe right-sided chest pain and dyspnea; absent breath sounds, hyperresonance, tracheal deviation, and hemodynamic compromise requiring immediate needle decompression.

Chief complaint: Cough and Vision Changes

36-year-old woman presents with months of dry cough, fatigue, and new blurry vision; workup for pulmonary sarcoidosis with ocular involvement.

Chief complaint: Shortness of Breath and Near-Syncope

58-year-old man presents 7 days post knee arthroplasty with obstructive shock from a massive saddle PE; systemic thrombolytics are contraindicated.

Chief complaint: Abdominal Pain

38-year-old woman with severe RUQ pain, fever, and vomiting after a fatty meal.

Chief complaint: Vomiting Blood

52-year-old man with hematemesis, melena, and stigmata of chronic liver disease.

Chief complaint: Heartburn

34-year-old woman with postprandial burning epigastric pain, regurgitation, and sour taste.

Chief complaint: Abdominal Pain

44-year-old construction foreman with 10 hours of severe epigastric pain radiating to the back, vomiting, and heavy daily alcohol use.

Chief complaint: Abdominal Pain

22-year-old woman with 18 hours of periumbilical pain migrating to the RLQ, anorexia, and low-grade fever.

Chief complaint: Abdominal Pain and Vomiting

58-year-old woman with prior open appendectomy presents with two days of crampy abdominal pain, distention, bilious vomiting, and obstipation.

Chief complaint: Abdominal Pain and Confusion

54-year-old man with decompensated cirrhosis presents with worsening abdominal pain and new confusion; diagnostic paracentesis and empiric antibiotic management.

Chief complaint: Abdominal Pain and Jaundice

Middle-aged patient presents with right upper quadrant pain, fever, and jaundice; recognize Charcot's triad and manage gallstone pancreatitis with acute cholangitis.

Chief complaint: Headache

48-year-old woman with sudden thunderclap headache — 'worst headache of my life' — while straining at the gym.

Chief complaint: Weakness and Slurred Speech

68-year-old woman brought in by her husband after sudden right-sided weakness and slurred speech, last seen well 2 hours ago.

Chief complaint: Seizure

32-year-old man with epilepsy in active convulsive status after running out of levetiracetam 8 days ago; brought in by EMS still seizing 25 minutes into the event.

Chief complaint: Headache and Fever

22-year-old college student with 2 days of severe headache, high fever, neck stiffness, and new confusion.

Chief complaint: Fever and Flank Pain

72-year-old woman with 3 days of flank pain, dysuria, and fever; now hypotensive and confused.

Chief complaint: Fever and Chest Pain

32-year-old man who injects heroin presents with five days of fevers, pleuritic chest pain, and dyspnea; cavitary pulmonary nodules and a new tricuspid murmur.

Chief complaint: Fever and Confusion

Elderly immunocompromised patient presents with fever, nuchal rigidity, and altered mental status; empiric coverage for Listeria meningitis.

Chief complaint: Confusion

78-year-old woman found confused with 4 days of diarrhea, vomiting, and minimal oral intake.

Chief complaint: Weakness and Palpitations

58-year-old man with end-stage renal disease on hemodialysis presents Saturday after missing Friday's session; K+ 7.2 with bradycardia, peaked T waves, and wide QRS.

Chief complaint: Nausea and Vomiting

28-year-old man with nausea, vomiting, and abdominal pain after running out of insulin 3 days ago.

Chief complaint: Foot Wound

62-year-old woman with poorly controlled diabetes presents with a non-healing right toe ulcer; evaluation for deep tissue infection and underlying osteomyelitis.

Chief complaint: Fatigue and Weight Gain

42-year-old woman presents with 4 months of fatigue, weight gain, and feeling cold all the time; evaluation for primary hypothyroidism and Hashimoto thyroiditis.

Chief complaint: Altered Mental Status

Elderly patient found confused at home with severe hyperglycemia, hyperosmolality, and UTI as precipitant; aggressive fluid resuscitation and careful insulin timing.

Chief complaint: Chest Pain

62-year-old man with sudden tearing chest pain and BP differential between arms.

Chief complaint: Leg Pain

55-year-old truck driver with bilateral calf claudication and absent right DP pulse.

Chief complaint: Abdominal Pain After Trauma

24-year-old unrestrained driver after high-speed MVC with left upper quadrant pain and hypotension.

Chief complaint: Unresponsive

19-year-old woman found unresponsive with empty amitriptyline bottle and suicide note.

Chief complaint: Intentional Overdose

19-year-old woman presents 4 hours after intentional ingestion of a large amount of acetaminophen; management with Rumack-Matthew nomogram and N-acetylcysteine.

Chief complaint: Pelvic Pain

21-year-old woman with lower abdominal pain, vaginal discharge, and fever — office presentation requiring ED transfer.

Chief complaint: Pelvic Pain and Vaginal Bleeding

28-year-old woman presents with 2 days of right-sided pelvic pain and vaginal spotting; workup for ectopic pregnancy with serum hCG and transvaginal ultrasound.

Chief complaint: Vaginal Discharge and Painful Urination

24-year-old woman presents with 5 days of vaginal discharge and dysuria; diagnosis and treatment of uncomplicated gonorrhea cervicitis with partner notification.

Chief complaint: Headache and Vision Changes

36-year-old primigravida at 32 weeks with severe headache, blurred vision, and BP 172/112.

Chief complaint: Diarrhea and Vomiting

18-month-old boy with 3 days of watery diarrhea, vomiting, and decreased oral intake.

Chief complaint: Shortness of Breath

8-year-old boy with persistent asthma, a lapsed controller inhaler, and a viral-triggered moderate-severe exacerbation.

Chief complaint: Tremor and Agitation

48-year-old man with 15 years of heavy daily drinking presents 40 hours after his last drink in severe withdrawal: tremor, diaphoresis, tachycardia, anxiety, and emerging visual hallucinations.

Chief complaint: Hives and Swelling

32-year-old woman with known shellfish allergy in severe anaphylaxis after restaurant exposure to hidden shrimp paste; hypotensive, urticaria, lip and tongue swelling, bronchospasm.

Chief complaint: Joint Pain and Swelling

58-year-old man with poorly controlled diabetes and gout presents with one day of severe right knee pain, swelling, warmth, and inability to bear weight.

Chief complaint: Big Toe Pain and Swelling

54-year-old man with hypertension and CKD stage 3a presents with sudden severe right first MTP pain, erythema, and swelling after increased beer and high-purine food intake.