NBME 10 EXAM LATEST ACTUAL 2026/2027 | 200 Questions
and Correct Answers | Clinical Science Examination | Verified
Solutions | Pass Guaranteed - A+ Graded
Section 1: Internal Medicine (80 Questions)
Cardiology
Q1: A 58-year-old man presents to the emergency department with crushing substernal
chest pain radiating to his left arm for the past 45 minutes. He is diaphoretic and
nauseated. Vital signs: BP 92/58 mmHg, HR 110 bpm, RR 24/min, O2 sat 94% on room
air. ECG shows ST-segment elevation in leads V1-V4. Troponin I is pending. Which is the
next best step in management?
A. Administer aspirin, clopidogrel, and heparin, then transfer for cardiac catheterization
within 120 minutes
B. Administer aspirin, clopidogrel, heparin, and tenecteplase immediately
C. Administer aspirin and morphine only, await troponin results before further
intervention
D. Administer aspirin, clopidogrel, heparin, and metoprolol, then transfer for
catheterization within 24 hours
E. Administer aspirin, clopidogrel, heparin, and nitroglycerin, then observe in ICU for 48
hours
Correct Answer: A
,Rationale: This patient presents with an acute anterior ST-elevation myocardial
infarction (STEMI) based on characteristic symptoms and ECG findings (ST elevation in
V1-V4 indicating anterior wall involvement). The patient is hemodynamically unstable
with hypotension (SBP <100 mmHg), making primary percutaneous coronary
intervention (PCI) the preferred reperfusion strategy. According to ACC/AHA guidelines,
primary PCI should be performed within 90 minutes of first medical contact
(door-to-balloon time), or within 120 minutes if transfer is required.
Why A is correct: Dual antiplatelet therapy (aspirin + P2Y12 inhibitor like clopidogrel)
plus anticoagulation (heparin) followed by urgent PCI is the standard of care for STEMI,
especially in hemodynamically unstable patients. This approach achieves superior
outcomes compared to fibrinolysis.
Why B is incorrect: Fibrinolysis (tenecteplase) is reserved for situations where PCI
cannot be performed within 120 minutes of first medical contact. Given the patient's
instability and the availability of catheterization, primary PCI is preferred.
Why C is incorrect: Awaiting troponin results delays definitive reperfusion therapy. In
STEMI, ECG changes are sufficient for diagnosis and immediate intervention.
Why D is incorrect: While beta-blockers are indicated in STEMI, they should be avoided
in acute heart failure, hypotension, or signs of shock. This patient's hypotension (92/58
mmHg) contraindicates immediate metoprolol administration. Additionally, PCI should
occur within 90-120 minutes, not 24 hours.
Why E is incorrect: Observation without reperfusion therapy is inappropriate for STEMI
and would result in unacceptable morbidity and mortality.
,Q2: A 72-year-old woman with a history of hypertension and diabetes presents with
progressive dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea over 6
months. Physical examination reveals an elevated jugular venous pressure, bibasilar
crackles, and bilateral pitting edema. An S3 gallop is heard. Echocardiogram shows an
ejection fraction of 35% with global hypokinesis. Which medication has been shown to
provide the greatest mortality benefit in this patient's condition?
A. Digoxin
B. Furosemide
C. Lisinopril
D. Hydralazine-isosorbide dinitrate
E. Diltiazem
Correct Answer: C
Rationale: This patient has heart failure with reduced ejection fraction (HFrEF, EF 35%).
The cornerstone of HFrEF management includes ACE inhibitors/ARBs/ARNIs,
beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, all of which
have demonstrated mortality benefit in clinical trials.
Why C is correct: ACE inhibitors (like lisinopril) were the first class of medications
proven to reduce mortality in HFrEF (CONSENSUS and SOLVD trials). They inhibit the
renin-angiotensin-aldosterone system, reducing afterload, preload, and adverse cardiac
remodeling. Unless contraindicated, every patient with HFrEF should receive an ACE
inhibitor, ARB, or ARNI.
, Why A is incorrect: Digoxin improves symptoms and reduces hospitalizations but does
not provide mortality benefit in heart failure (DIG trial). It is used for symptom control
and rate control in atrial fibrillation.
Why B is incorrect: Loop diuretics (furosemide) provide symptomatic relief by reducing
volume overload but have not been shown to improve survival in heart failure. They are
used for congestion management.
Why D is incorrect: Hydralazine-isosorbide dinitrate reduces mortality in Black patients
with HFrEF (A-HeFT trial) and is used in patients who cannot tolerate ACE
inhibitors/ARBs or as adjunctive therapy in persistent symptomatic patients. However,
ACE inhibitors remain first-line for all patients regardless of race.
Why E is incorrect: Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
are contraindicated in HFrEF due to negative inotropic effects that can worsen heart
failure. Dihydropyridines (amlodipine) are neutral but do not provide mortality benefit.
Q3: A 45-year-old man presents with palpitations and lightheadedness. He has no
significant medical history. Vital signs: BP 110/70 mmHg, HR 180 bpm, regular rhythm.
ECG shows a narrow-complex regular tachycardia at 180 bpm with no discernible P
waves. Carotid sinus massage fails to terminate the rhythm. Adenosine 6 mg IV is
administered, resulting in transient AV block followed by resumption of the same
tachycardia. What is the most likely diagnosis?
A. Atrial fibrillation with rapid ventricular response
B. Atrial flutter with 2:1 conduction
and Correct Answers | Clinical Science Examination | Verified
Solutions | Pass Guaranteed - A+ Graded
Section 1: Internal Medicine (80 Questions)
Cardiology
Q1: A 58-year-old man presents to the emergency department with crushing substernal
chest pain radiating to his left arm for the past 45 minutes. He is diaphoretic and
nauseated. Vital signs: BP 92/58 mmHg, HR 110 bpm, RR 24/min, O2 sat 94% on room
air. ECG shows ST-segment elevation in leads V1-V4. Troponin I is pending. Which is the
next best step in management?
A. Administer aspirin, clopidogrel, and heparin, then transfer for cardiac catheterization
within 120 minutes
B. Administer aspirin, clopidogrel, heparin, and tenecteplase immediately
C. Administer aspirin and morphine only, await troponin results before further
intervention
D. Administer aspirin, clopidogrel, heparin, and metoprolol, then transfer for
catheterization within 24 hours
E. Administer aspirin, clopidogrel, heparin, and nitroglycerin, then observe in ICU for 48
hours
Correct Answer: A
,Rationale: This patient presents with an acute anterior ST-elevation myocardial
infarction (STEMI) based on characteristic symptoms and ECG findings (ST elevation in
V1-V4 indicating anterior wall involvement). The patient is hemodynamically unstable
with hypotension (SBP <100 mmHg), making primary percutaneous coronary
intervention (PCI) the preferred reperfusion strategy. According to ACC/AHA guidelines,
primary PCI should be performed within 90 minutes of first medical contact
(door-to-balloon time), or within 120 minutes if transfer is required.
Why A is correct: Dual antiplatelet therapy (aspirin + P2Y12 inhibitor like clopidogrel)
plus anticoagulation (heparin) followed by urgent PCI is the standard of care for STEMI,
especially in hemodynamically unstable patients. This approach achieves superior
outcomes compared to fibrinolysis.
Why B is incorrect: Fibrinolysis (tenecteplase) is reserved for situations where PCI
cannot be performed within 120 minutes of first medical contact. Given the patient's
instability and the availability of catheterization, primary PCI is preferred.
Why C is incorrect: Awaiting troponin results delays definitive reperfusion therapy. In
STEMI, ECG changes are sufficient for diagnosis and immediate intervention.
Why D is incorrect: While beta-blockers are indicated in STEMI, they should be avoided
in acute heart failure, hypotension, or signs of shock. This patient's hypotension (92/58
mmHg) contraindicates immediate metoprolol administration. Additionally, PCI should
occur within 90-120 minutes, not 24 hours.
Why E is incorrect: Observation without reperfusion therapy is inappropriate for STEMI
and would result in unacceptable morbidity and mortality.
,Q2: A 72-year-old woman with a history of hypertension and diabetes presents with
progressive dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea over 6
months. Physical examination reveals an elevated jugular venous pressure, bibasilar
crackles, and bilateral pitting edema. An S3 gallop is heard. Echocardiogram shows an
ejection fraction of 35% with global hypokinesis. Which medication has been shown to
provide the greatest mortality benefit in this patient's condition?
A. Digoxin
B. Furosemide
C. Lisinopril
D. Hydralazine-isosorbide dinitrate
E. Diltiazem
Correct Answer: C
Rationale: This patient has heart failure with reduced ejection fraction (HFrEF, EF 35%).
The cornerstone of HFrEF management includes ACE inhibitors/ARBs/ARNIs,
beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors, all of which
have demonstrated mortality benefit in clinical trials.
Why C is correct: ACE inhibitors (like lisinopril) were the first class of medications
proven to reduce mortality in HFrEF (CONSENSUS and SOLVD trials). They inhibit the
renin-angiotensin-aldosterone system, reducing afterload, preload, and adverse cardiac
remodeling. Unless contraindicated, every patient with HFrEF should receive an ACE
inhibitor, ARB, or ARNI.
, Why A is incorrect: Digoxin improves symptoms and reduces hospitalizations but does
not provide mortality benefit in heart failure (DIG trial). It is used for symptom control
and rate control in atrial fibrillation.
Why B is incorrect: Loop diuretics (furosemide) provide symptomatic relief by reducing
volume overload but have not been shown to improve survival in heart failure. They are
used for congestion management.
Why D is incorrect: Hydralazine-isosorbide dinitrate reduces mortality in Black patients
with HFrEF (A-HeFT trial) and is used in patients who cannot tolerate ACE
inhibitors/ARBs or as adjunctive therapy in persistent symptomatic patients. However,
ACE inhibitors remain first-line for all patients regardless of race.
Why E is incorrect: Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
are contraindicated in HFrEF due to negative inotropic effects that can worsen heart
failure. Dihydropyridines (amlodipine) are neutral but do not provide mortality benefit.
Q3: A 45-year-old man presents with palpitations and lightheadedness. He has no
significant medical history. Vital signs: BP 110/70 mmHg, HR 180 bpm, regular rhythm.
ECG shows a narrow-complex regular tachycardia at 180 bpm with no discernible P
waves. Carotid sinus massage fails to terminate the rhythm. Adenosine 6 mg IV is
administered, resulting in transient AV block followed by resumption of the same
tachycardia. What is the most likely diagnosis?
A. Atrial fibrillation with rapid ventricular response
B. Atrial flutter with 2:1 conduction
