NBME 28 | A+ GUARANTEED COMPREHENSIVE
PRACTICE EXAMINATION QUESTIONS WITH
VERIFIED ANSWERS AND DETAILED
RATIONALES
1. A 45-year-old woman presents with acute-onset shortness of breath,
pleuritic chest pain, and hemoptysis. She recently returned from a 12-hour
international flight. Her pulse is 110/min, respirations are 22/min, and blood
pressure is 130/85 mm Hg. Oxygen saturation is 92% on room air. Which of
the following is the most likely diagnosis?
A) Pulmonary embolism
B) Myocardial infarction
C) Pneumothorax
D) Pneumonia
Answer: A) Pulmonary embolism
Rationale: This patient has classic risk factors for venous thromboembolism
(prolonged immobilization during international travel) and presents with the
classic triad of dyspnea, pleuritic chest pain, and hemoptysis. Tachycardia and
hypoxemia further support the diagnosis. Pulmonary embolism occurs when a
thrombus from the deep venous system lodges in the pulmonary vasculature,
causing ventilation-perfusion mismatch and increased dead space ventilation.
Incorrect Answers:
• Myocardial infarction (B) would present with substernal chest pain
radiating to the jaw or left arm, not typically associated with hemoptysis.
• Pneumothorax (C) would present with sudden sharp chest pain and
decreased breath sounds on the affected side, without the risk factor of
recent travel.
• Pneumonia (D) would present with fever, productive cough, and crackles
on auscultation, which are not described in this case.
,2. A 58-year-old man with a history of hypertension and type 2 diabetes
presents with progressive shortness of breath and bilateral lower extremity
edema. On examination, jugular venous pressure is elevated at 14 cm H₂O,
and crackles are heard at the lung bases. Echocardiography reveals an
ejection fraction of 35%. Which of the following is the most appropriate initial
pharmacological therapy to reduce mortality?
A) Digoxin
B) Furosemide
C) Metoprolol succinate
D) Spironolactone
Answer: C) Metoprolol succinate
Rationale: This patient has heart failure with reduced ejection fraction (HFrEF).
Beta-blockers such as metoprolol succinate, carvedilol, and bisoprolol are
cornerstone therapies that significantly reduce mortality in HFrEF. They work by
antagonizing the detrimental effects of chronic sympathetic activation, reducing
heart rate, and preventing arrhythmias. The benefits are seen regardless of the
underlying etiology.
Incorrect Answers:
• Digoxin (A) improves symptoms and reduces hospitalizations but has no
mortality benefit in heart failure.
• Furosemide (B) provides symptomatic relief of volume overload but does
not reduce mortality.
• Spironolactone (D) is a mineralocorticoid receptor antagonist that reduces
mortality in NYHA Class III-IV heart failure but is not the initial first-line
therapy.
3. A 32-year-old woman who is 28 weeks pregnant presents with a 2-day
history of headache, blurred vision, and epigastric pain. Her blood pressure is
160/105 mm Hg, and urinalysis shows 3+ protein. Laboratory studies reveal
platelets of 85,000/μL, AST of 85 U/L, and ALT of 92 U/L. Which of the
following is the most appropriate definitive management?
,A) Intravenous labetalol
B) Magnesium sulfate infusion
C) Delivery of the fetus
D) Oral nifedipine
Answer: C) Delivery of the fetus
Rationale: This patient has HELLP syndrome (Hemolysis, Elevated Liver enzymes,
Low Platelets), which is a severe form of preeclampsia. The definitive treatment
for HELLP syndrome is delivery of the fetus, regardless of gestational age. HELLP
syndrome can rapidly progress to life-threatening complications including hepatic
rupture, acute renal failure, and intracranial hemorrhage. While antihypertensive
therapy and magnesium sulfate for seizure prophylaxis are important adjunctive
measures, they do not address the underlying pathophysiology.
Incorrect Answers:
• Intravenous labetalol (A) is appropriate for acute blood pressure control
but does not treat the underlying syndrome.
• Magnesium sulfate (B) is indicated for seizure prophylaxis in preeclampsia
but is not definitive treatment.
• Oral nifedipine (D) is used for chronic blood pressure management but
does not treat HELLP syndrome.
4. A 67-year-old man with a 40-pack-year smoking history presents with a 3-
month history of hoarseness and a non-healing ulcer on his lower lip. He
reports significant weight loss and difficulty swallowing. On examination,
there is an enlarged, firm lymph node in the left supraclavicular region.
Biopsy of the lip lesion reveals squamous cell carcinoma. Which of the
following is the most likely origin of the supraclavicular lymphadenopathy?
A) Direct extension from the lip lesion
B) Hematogenous spread from the lip lesion
C) Lymphatic spread from the lip lesion
D) A second primary malignancy
Answer: C) Lymphatic spread from the lip lesion
, Rationale: Squamous cell carcinoma of the lip typically spreads via the lymphatic
system to regional lymph nodes. The left supraclavicular lymph node (Virchow's
node) receives lymphatic drainage from the head and neck region. In this patient
with known lip squamous cell carcinoma, the supraclavicular lymphadenopathy
most likely represents metastatic disease from the primary lesion. The lymphatic
system is the most common route of spread for squamous cell carcinomas of the
head and neck.
Incorrect Answers:
• Direct extension (A) occurs through contiguous spread to adjacent
structures rather than to distant lymph nodes.
• Hematogenous spread (B) is less common in squamous cell carcinoma of
the lip and typically occurs later in the disease course.
• A second primary malignancy (D) is possible but less likely given the
patient's known diagnosis of lip squamous cell carcinoma and the typical
pattern of lymphatic spread.
5. A 28-year-old woman presents with a 6-month history of fatigue, joint pain,
and a facial rash that worsens with sun exposure. She also reports episodes of
chest pain with deep breathing. Laboratory studies show ANA positive at
1:640, anti-dsDNA positive, and anti-Smith antibody positive. Which of the
following is the most common cause of mortality in patients with this
condition?
A) Malignancy
B) Myocardial infarction
C) Renal failure
D) Infection
Answer: C) Renal failure
Rationale: This patient has systemic lupus erythematosus (SLE) based on the
presence of malar rash, arthritis, serositis (pleuritic chest pain), and positive ANA
with anti-dsDNA and anti-Smith antibodies. While cardiovascular disease is now
the leading cause of overall mortality, renal involvement (lupus nephritis) remains
a major cause of morbidity and mortality in SLE, particularly in the first decade of
PRACTICE EXAMINATION QUESTIONS WITH
VERIFIED ANSWERS AND DETAILED
RATIONALES
1. A 45-year-old woman presents with acute-onset shortness of breath,
pleuritic chest pain, and hemoptysis. She recently returned from a 12-hour
international flight. Her pulse is 110/min, respirations are 22/min, and blood
pressure is 130/85 mm Hg. Oxygen saturation is 92% on room air. Which of
the following is the most likely diagnosis?
A) Pulmonary embolism
B) Myocardial infarction
C) Pneumothorax
D) Pneumonia
Answer: A) Pulmonary embolism
Rationale: This patient has classic risk factors for venous thromboembolism
(prolonged immobilization during international travel) and presents with the
classic triad of dyspnea, pleuritic chest pain, and hemoptysis. Tachycardia and
hypoxemia further support the diagnosis. Pulmonary embolism occurs when a
thrombus from the deep venous system lodges in the pulmonary vasculature,
causing ventilation-perfusion mismatch and increased dead space ventilation.
Incorrect Answers:
• Myocardial infarction (B) would present with substernal chest pain
radiating to the jaw or left arm, not typically associated with hemoptysis.
• Pneumothorax (C) would present with sudden sharp chest pain and
decreased breath sounds on the affected side, without the risk factor of
recent travel.
• Pneumonia (D) would present with fever, productive cough, and crackles
on auscultation, which are not described in this case.
,2. A 58-year-old man with a history of hypertension and type 2 diabetes
presents with progressive shortness of breath and bilateral lower extremity
edema. On examination, jugular venous pressure is elevated at 14 cm H₂O,
and crackles are heard at the lung bases. Echocardiography reveals an
ejection fraction of 35%. Which of the following is the most appropriate initial
pharmacological therapy to reduce mortality?
A) Digoxin
B) Furosemide
C) Metoprolol succinate
D) Spironolactone
Answer: C) Metoprolol succinate
Rationale: This patient has heart failure with reduced ejection fraction (HFrEF).
Beta-blockers such as metoprolol succinate, carvedilol, and bisoprolol are
cornerstone therapies that significantly reduce mortality in HFrEF. They work by
antagonizing the detrimental effects of chronic sympathetic activation, reducing
heart rate, and preventing arrhythmias. The benefits are seen regardless of the
underlying etiology.
Incorrect Answers:
• Digoxin (A) improves symptoms and reduces hospitalizations but has no
mortality benefit in heart failure.
• Furosemide (B) provides symptomatic relief of volume overload but does
not reduce mortality.
• Spironolactone (D) is a mineralocorticoid receptor antagonist that reduces
mortality in NYHA Class III-IV heart failure but is not the initial first-line
therapy.
3. A 32-year-old woman who is 28 weeks pregnant presents with a 2-day
history of headache, blurred vision, and epigastric pain. Her blood pressure is
160/105 mm Hg, and urinalysis shows 3+ protein. Laboratory studies reveal
platelets of 85,000/μL, AST of 85 U/L, and ALT of 92 U/L. Which of the
following is the most appropriate definitive management?
,A) Intravenous labetalol
B) Magnesium sulfate infusion
C) Delivery of the fetus
D) Oral nifedipine
Answer: C) Delivery of the fetus
Rationale: This patient has HELLP syndrome (Hemolysis, Elevated Liver enzymes,
Low Platelets), which is a severe form of preeclampsia. The definitive treatment
for HELLP syndrome is delivery of the fetus, regardless of gestational age. HELLP
syndrome can rapidly progress to life-threatening complications including hepatic
rupture, acute renal failure, and intracranial hemorrhage. While antihypertensive
therapy and magnesium sulfate for seizure prophylaxis are important adjunctive
measures, they do not address the underlying pathophysiology.
Incorrect Answers:
• Intravenous labetalol (A) is appropriate for acute blood pressure control
but does not treat the underlying syndrome.
• Magnesium sulfate (B) is indicated for seizure prophylaxis in preeclampsia
but is not definitive treatment.
• Oral nifedipine (D) is used for chronic blood pressure management but
does not treat HELLP syndrome.
4. A 67-year-old man with a 40-pack-year smoking history presents with a 3-
month history of hoarseness and a non-healing ulcer on his lower lip. He
reports significant weight loss and difficulty swallowing. On examination,
there is an enlarged, firm lymph node in the left supraclavicular region.
Biopsy of the lip lesion reveals squamous cell carcinoma. Which of the
following is the most likely origin of the supraclavicular lymphadenopathy?
A) Direct extension from the lip lesion
B) Hematogenous spread from the lip lesion
C) Lymphatic spread from the lip lesion
D) A second primary malignancy
Answer: C) Lymphatic spread from the lip lesion
, Rationale: Squamous cell carcinoma of the lip typically spreads via the lymphatic
system to regional lymph nodes. The left supraclavicular lymph node (Virchow's
node) receives lymphatic drainage from the head and neck region. In this patient
with known lip squamous cell carcinoma, the supraclavicular lymphadenopathy
most likely represents metastatic disease from the primary lesion. The lymphatic
system is the most common route of spread for squamous cell carcinomas of the
head and neck.
Incorrect Answers:
• Direct extension (A) occurs through contiguous spread to adjacent
structures rather than to distant lymph nodes.
• Hematogenous spread (B) is less common in squamous cell carcinoma of
the lip and typically occurs later in the disease course.
• A second primary malignancy (D) is possible but less likely given the
patient's known diagnosis of lip squamous cell carcinoma and the typical
pattern of lymphatic spread.
5. A 28-year-old woman presents with a 6-month history of fatigue, joint pain,
and a facial rash that worsens with sun exposure. She also reports episodes of
chest pain with deep breathing. Laboratory studies show ANA positive at
1:640, anti-dsDNA positive, and anti-Smith antibody positive. Which of the
following is the most common cause of mortality in patients with this
condition?
A) Malignancy
B) Myocardial infarction
C) Renal failure
D) Infection
Answer: C) Renal failure
Rationale: This patient has systemic lupus erythematosus (SLE) based on the
presence of malar rash, arthritis, serositis (pleuritic chest pain), and positive ANA
with anti-dsDNA and anti-Smith antibodies. While cardiovascular disease is now
the leading cause of overall mortality, renal involvement (lupus nephritis) remains
a major cause of morbidity and mortality in SLE, particularly in the first decade of
