Verified Q&As with Detailed Rationales
(Test Bank Bundle - 91 Questions)
NBME 28 | A+ Guaranteed. 2026/2027
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*QUESTION 1:*
A 45-year-old man with hypertension and type 2 diabetes presents with gradually worsening vision.
Funduscopy reveals cotton wool spots and flame hemorrhages. What is the most likely diagnosis?
A) Hypertensive retinopathy
B) Diabetic retinopathy
C) Central retinal vein occlusion
D) Age-related macular degeneration
> 🎯 *CORRECT ANSWER:* B) Diabetic retinopathy
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Classic non-proliferative diabetic retinopathy findings in a diabetic patient.
> * *Why Distractors Fail:* Hypertension causes AV nicking; CRVO causes sudden, severe vision loss;
AMD occurs in elderly.
> * *Core Takeaway:* Cotton wool spots + hemorrhages = diabetic retinopathy.
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*QUESTION 2:*
A 68-year-old woman with a history of osteoarthritis presents with acute onset of severe, tearing chest
pain radiating to her back. Her blood pressure is 100/60 mmHg. Which imaging study is most
appropriate?
,A) CT angiography of the chest
B) Transthoracic echocardiogram
C) Ventilation-perfusion scan
D) Coronary angiography
> 🎯 *CORRECT ANSWER:* A) CT angiography of the chest
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Gold standard for diagnosing aortic dissection.
> * *Why Distractors Fail:* Echo is less sensitive; V/Q is for PE; coronary angio assesses coronaries.
> * *Core Takeaway:* Aortic dissection = CT angiography.
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*QUESTION 3:*
A 25-year-old woman with three episodes of syncope, a heart murmur that increases with Valsalva, and
a family history of sudden cardiac death. What is the most likely diagnosis?
A) Hypertrophic cardiomyopathy
B) Aortic stenosis
C) Mitral valve prolapse
D) Dilated cardiomyopathy
> 🎯 *CORRECT ANSWER:* A) Hypertrophic cardiomyopathy
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Syncope, murmur intensified by Valsalva, and positive family history are classic.
> * *Why Distractors Fail:* Aortic stenosis murmur radiates to carotids; MVP has mid-systolic click; DCM
is dilated.
> * *Core Takeaway:* HCM = syncope + murmur + Valsalva + FH.
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,*QUESTION 4:*
A 55-year-old man with a 30-pack-year smoking history presents with a new cough and hemoptysis. A
chest X-ray shows a solitary pulmonary nodule. What is the most appropriate next step?
A) CT-guided biopsy
B) Positron emission tomography (PET) scan
C) Bronchoscopy
D) Observation with repeat CT in 3 months
> 🎯 *CORRECT ANSWER:* C) Bronchoscopy
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Central lesion evaluation.
> * *Why Distractors Fail:* Biopsy/PET are later steps; observation is inappropriate for high-risk.
> * *Core Takeaway:* Central lung nodule = bronchoscopy.
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*QUESTION 5:*
A 32-year-old woman presents with fatigue, weight gain, and constipation. Laboratory studies show TSH
of 12 µIU/mL and free T4 of 0.6 ng/dL. Which of the following is the most likely cause?
A) Hashimoto thyroiditis
B) Graves' disease
C) Toxic multinodular goiter
D) Pituitary adenoma
> 🎯 *CORRECT ANSWER:* A) Hashimoto thyroiditis
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Primary hypothyroidism with elevated TSH and low T4.
> * *Why Distractors Fail:* Graves' is hyperthyroid (low TSH); TNG causes hyper; pituitary adenoma
causes secondary hypothyroidism (low/low).
, > * *Core Takeaway:* High TSH + low T4 = primary hypothyroidism.
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*QUESTION 6:*
A 60-year-old man is found to have a serum sodium of 120 mEq/L. He takes hydrochlorothiazide for
hypertension. Which laboratory finding would best differentiate SIADH from cerebral salt wasting?
A) Serum osmolality
B) Urine sodium
C) Serum uric acid
D) Urine osmolality
> 🎯 *CORRECT ANSWER:* C) Serum uric acid
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Low uric acid in SIADH, normal/high in CSW.
> * *Why Distractors Fail:* Both have low osmolality and high urine sodium; urine osmolality is high in
both.
> * *Core Takeaway:* Uric acid differentiates SIADH vs. CSW.
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*QUESTION 7:*
A 50-year-old woman presents with acute, colicky right upper quadrant pain radiating to her back,
worse after meals. Ultrasound shows a thickened gallbladder wall and pericholecystic fluid. What is the
next best step?
A) Laparoscopic cholecystectomy
B) ERCP
C) Ursodeoxycholic acid
D) Observation
> 🎯 *CORRECT ANSWER:* A) Laparoscopic cholecystectomy
(Test Bank Bundle - 91 Questions)
NBME 28 | A+ Guaranteed. 2026/2027
–
---
*QUESTION 1:*
A 45-year-old man with hypertension and type 2 diabetes presents with gradually worsening vision.
Funduscopy reveals cotton wool spots and flame hemorrhages. What is the most likely diagnosis?
A) Hypertensive retinopathy
B) Diabetic retinopathy
C) Central retinal vein occlusion
D) Age-related macular degeneration
> 🎯 *CORRECT ANSWER:* B) Diabetic retinopathy
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Classic non-proliferative diabetic retinopathy findings in a diabetic patient.
> * *Why Distractors Fail:* Hypertension causes AV nicking; CRVO causes sudden, severe vision loss;
AMD occurs in elderly.
> * *Core Takeaway:* Cotton wool spots + hemorrhages = diabetic retinopathy.
---
*QUESTION 2:*
A 68-year-old woman with a history of osteoarthritis presents with acute onset of severe, tearing chest
pain radiating to her back. Her blood pressure is 100/60 mmHg. Which imaging study is most
appropriate?
,A) CT angiography of the chest
B) Transthoracic echocardiogram
C) Ventilation-perfusion scan
D) Coronary angiography
> 🎯 *CORRECT ANSWER:* A) CT angiography of the chest
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Gold standard for diagnosing aortic dissection.
> * *Why Distractors Fail:* Echo is less sensitive; V/Q is for PE; coronary angio assesses coronaries.
> * *Core Takeaway:* Aortic dissection = CT angiography.
---
*QUESTION 3:*
A 25-year-old woman with three episodes of syncope, a heart murmur that increases with Valsalva, and
a family history of sudden cardiac death. What is the most likely diagnosis?
A) Hypertrophic cardiomyopathy
B) Aortic stenosis
C) Mitral valve prolapse
D) Dilated cardiomyopathy
> 🎯 *CORRECT ANSWER:* A) Hypertrophic cardiomyopathy
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Syncope, murmur intensified by Valsalva, and positive family history are classic.
> * *Why Distractors Fail:* Aortic stenosis murmur radiates to carotids; MVP has mid-systolic click; DCM
is dilated.
> * *Core Takeaway:* HCM = syncope + murmur + Valsalva + FH.
---
,*QUESTION 4:*
A 55-year-old man with a 30-pack-year smoking history presents with a new cough and hemoptysis. A
chest X-ray shows a solitary pulmonary nodule. What is the most appropriate next step?
A) CT-guided biopsy
B) Positron emission tomography (PET) scan
C) Bronchoscopy
D) Observation with repeat CT in 3 months
> 🎯 *CORRECT ANSWER:* C) Bronchoscopy
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Central lesion evaluation.
> * *Why Distractors Fail:* Biopsy/PET are later steps; observation is inappropriate for high-risk.
> * *Core Takeaway:* Central lung nodule = bronchoscopy.
---
*QUESTION 5:*
A 32-year-old woman presents with fatigue, weight gain, and constipation. Laboratory studies show TSH
of 12 µIU/mL and free T4 of 0.6 ng/dL. Which of the following is the most likely cause?
A) Hashimoto thyroiditis
B) Graves' disease
C) Toxic multinodular goiter
D) Pituitary adenoma
> 🎯 *CORRECT ANSWER:* A) Hashimoto thyroiditis
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Primary hypothyroidism with elevated TSH and low T4.
> * *Why Distractors Fail:* Graves' is hyperthyroid (low TSH); TNG causes hyper; pituitary adenoma
causes secondary hypothyroidism (low/low).
, > * *Core Takeaway:* High TSH + low T4 = primary hypothyroidism.
---
*QUESTION 6:*
A 60-year-old man is found to have a serum sodium of 120 mEq/L. He takes hydrochlorothiazide for
hypertension. Which laboratory finding would best differentiate SIADH from cerebral salt wasting?
A) Serum osmolality
B) Urine sodium
C) Serum uric acid
D) Urine osmolality
> 🎯 *CORRECT ANSWER:* C) Serum uric acid
> 💡 *CLINICAL RATIONALE:*
> * *Why It's Right:* Low uric acid in SIADH, normal/high in CSW.
> * *Why Distractors Fail:* Both have low osmolality and high urine sodium; urine osmolality is high in
both.
> * *Core Takeaway:* Uric acid differentiates SIADH vs. CSW.
---
*QUESTION 7:*
A 50-year-old woman presents with acute, colicky right upper quadrant pain radiating to her back,
worse after meals. Ultrasound shows a thickened gallbladder wall and pericholecystic fluid. What is the
next best step?
A) Laparoscopic cholecystectomy
B) ERCP
C) Ursodeoxycholic acid
D) Observation
> 🎯 *CORRECT ANSWER:* A) Laparoscopic cholecystectomy
