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2025 NBME Final Exam And Practice Exam
with 200 accurate questions and verified
answers covering clinical knowledge,
diagnostic reasoning, pathology,
pharmacology, and medical decision-
making.
A 63-year-old man comes to the physician because of progressive
shortness of breath and a persistent morning cough. He has smoked
one pack of cigarettes daily for the past 40 years and had a myocardial
infarction 5 years ago. Temperature is 36.7°C (98°F), pulse is 90/min,
blood pressure is 126/80 mmHg, and oxygen saturation is 85% on room
air while at rest. There are bilateral wheezes on expiration with an
inspiratory:expiratory ratio of 1:3 on pulmonary examination. X-rays of
the chest are shown.
Which of the following additional findings is most likely in this patient?
increased serum EPO levels
COPD is an obstructive lung disease that presents with dyspnea,
chronic cough, wheezing, and lung hyperinflation.
In COPD, hypoxia develops from loss of surface area for gas exchange.
Chronic hypoxia is associated with increased erythropoietin production and
secondary erythrocytosis.
Auer rods
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They appear primarily in acute myeloid leukemias, especially in acute
promyelocytic leukemia, and are made of fused lysosomes. A painful rash is
not a typical manifestation of acute promyelocytic leukemia.
A 48-year-old man with a transplanted kidney comes to the hospital
because of body aches, low-grade fever, and reduced urine volume for
the past 4 days. He underwent uncomplicated cadaveric kidney
transplant 3 weeks ago. Urinalysis shows no bacteria or crystals. His
serum creatinine is 2.8 mg/dL, increased from 1.7 mg/dL in the
immediate postoperative period. A biopsy of the transplanted kidney is
shown.
Which of the following markers is most likely to be found on the surface
of the cells that are causing the depicted damage to tubular cells?
Acute rejection is seen most often in the first 3 months
after transplantation due to human leukocyte antigen discrepancies.
Acute transplant rejection is predominantly mediated by cytotoxic T cells
(CD8), leading to cytotoxic graft cell death and release of proinflammatory
cytokines.
CD20
B cell marker
hyper acute rejection
humoral acute rejection
CD27
plasma cell marker
hyperacute rejection
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CD34
fibrocyte marker, chronic rejection
CD14
protein made by macrophage
innate immunity
A three-year-old boy is admitted to the pediatric intensive care unit for
pneumonia due to atypical non-tuberculous acid-fast bacilli. His
identical twin has had similar hospital admissions and has also had
mucocutaneous Candida infections and severe Salmonella enteritis.
Both parents are healthy, as is his four-year-old brother. Complete
blood cell count shows normal numbers of B cells, T-cell subsets, and
natural killer cells, and immunoglobulin levels of all antibody classes
are normal.
Which of the following conditions is most likely contributing to this
patient’s pneumonia?
IL12 and IFN-γ receptor mutations may lead to
severe M tuberculosis infections. An absence or functional defect in
macrophages and T cells leads to an increased risk for infection with
intracellular organisms. IL-12 receptor deficiency is autosomal recessive.
ADA Deficiency
Adenosine deaminase (ADA) deficiency causes a type of severe combined
immunodeficiency, which presents early in life with viral, bacterial, and fungal
infections. ADA deficiency causes the buildup of toxic metabolites that result
from purine degradation during DNA synthesis. This causes the absence of
, 4|Page
all lymphocytes. This patient has normal lymphocyte subsets
and immunoglobulinlevels, making this diagnosis unlikely.
A 40-year-old woman is hospitalized for aspiration pneumonia and
treated with ceftriaxone and clindamycin. On the fourth day of
hospitalization, her breathing has improved, but she develops crampy
abdominal pain and loose stools. Her temperature is 39.8°C (103.8°F),
pulse is 106/min, respirations are 12/min, and blood pressure is 118/78
mm Hg. The patient's lungs are clear on auscultation bilaterally. Her
abdomen is distended, and auscultation discloses hyperactive bowel
sounds.
A complete blood cell count shows:
WBCs: 34,900/mm3
Neutrophils: 82%
Lymphocytes: 10%
Monocytes: 6%
Basophils: 1%
Eosinophils: 1%
Hemoglobin: 13.4 g/dL
Platelet count: 250,000/mm3
Which of the following best describes the mechanism of action of the
toxin most likely causing the patient's symptoms?
2025 NBME Final Exam And Practice Exam
with 200 accurate questions and verified
answers covering clinical knowledge,
diagnostic reasoning, pathology,
pharmacology, and medical decision-
making.
A 63-year-old man comes to the physician because of progressive
shortness of breath and a persistent morning cough. He has smoked
one pack of cigarettes daily for the past 40 years and had a myocardial
infarction 5 years ago. Temperature is 36.7°C (98°F), pulse is 90/min,
blood pressure is 126/80 mmHg, and oxygen saturation is 85% on room
air while at rest. There are bilateral wheezes on expiration with an
inspiratory:expiratory ratio of 1:3 on pulmonary examination. X-rays of
the chest are shown.
Which of the following additional findings is most likely in this patient?
increased serum EPO levels
COPD is an obstructive lung disease that presents with dyspnea,
chronic cough, wheezing, and lung hyperinflation.
In COPD, hypoxia develops from loss of surface area for gas exchange.
Chronic hypoxia is associated with increased erythropoietin production and
secondary erythrocytosis.
Auer rods
,2|Page
They appear primarily in acute myeloid leukemias, especially in acute
promyelocytic leukemia, and are made of fused lysosomes. A painful rash is
not a typical manifestation of acute promyelocytic leukemia.
A 48-year-old man with a transplanted kidney comes to the hospital
because of body aches, low-grade fever, and reduced urine volume for
the past 4 days. He underwent uncomplicated cadaveric kidney
transplant 3 weeks ago. Urinalysis shows no bacteria or crystals. His
serum creatinine is 2.8 mg/dL, increased from 1.7 mg/dL in the
immediate postoperative period. A biopsy of the transplanted kidney is
shown.
Which of the following markers is most likely to be found on the surface
of the cells that are causing the depicted damage to tubular cells?
Acute rejection is seen most often in the first 3 months
after transplantation due to human leukocyte antigen discrepancies.
Acute transplant rejection is predominantly mediated by cytotoxic T cells
(CD8), leading to cytotoxic graft cell death and release of proinflammatory
cytokines.
CD20
B cell marker
hyper acute rejection
humoral acute rejection
CD27
plasma cell marker
hyperacute rejection
,3|Page
CD34
fibrocyte marker, chronic rejection
CD14
protein made by macrophage
innate immunity
A three-year-old boy is admitted to the pediatric intensive care unit for
pneumonia due to atypical non-tuberculous acid-fast bacilli. His
identical twin has had similar hospital admissions and has also had
mucocutaneous Candida infections and severe Salmonella enteritis.
Both parents are healthy, as is his four-year-old brother. Complete
blood cell count shows normal numbers of B cells, T-cell subsets, and
natural killer cells, and immunoglobulin levels of all antibody classes
are normal.
Which of the following conditions is most likely contributing to this
patient’s pneumonia?
IL12 and IFN-γ receptor mutations may lead to
severe M tuberculosis infections. An absence or functional defect in
macrophages and T cells leads to an increased risk for infection with
intracellular organisms. IL-12 receptor deficiency is autosomal recessive.
ADA Deficiency
Adenosine deaminase (ADA) deficiency causes a type of severe combined
immunodeficiency, which presents early in life with viral, bacterial, and fungal
infections. ADA deficiency causes the buildup of toxic metabolites that result
from purine degradation during DNA synthesis. This causes the absence of
, 4|Page
all lymphocytes. This patient has normal lymphocyte subsets
and immunoglobulinlevels, making this diagnosis unlikely.
A 40-year-old woman is hospitalized for aspiration pneumonia and
treated with ceftriaxone and clindamycin. On the fourth day of
hospitalization, her breathing has improved, but she develops crampy
abdominal pain and loose stools. Her temperature is 39.8°C (103.8°F),
pulse is 106/min, respirations are 12/min, and blood pressure is 118/78
mm Hg. The patient's lungs are clear on auscultation bilaterally. Her
abdomen is distended, and auscultation discloses hyperactive bowel
sounds.
A complete blood cell count shows:
WBCs: 34,900/mm3
Neutrophils: 82%
Lymphocytes: 10%
Monocytes: 6%
Basophils: 1%
Eosinophils: 1%
Hemoglobin: 13.4 g/dL
Platelet count: 250,000/mm3
Which of the following best describes the mechanism of action of the
toxin most likely causing the patient's symptoms?
