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This study explores an integrated approach to identify enemy items in item bank management in a medical licensure examination. The integrated approach utilizes item bank analysis, natural language processing methods by using Cosine Similarity Index, and content analysis and review by subject matter experts. Preliminary results from an empirical study indicate that the integrated approach is efficient in identifying enemy items. The final results will be available after completing the content review of the flagged enemy item pairs and extension to different item banks.