1|Page
NBME CBSE ACTUAL EXAM PREP 2026 ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ALREADY A
GRADED WITH EXPERT FEEDBACK |NEW
AND REVISED
1. A 68-year-old man with a history of hypertension presents with
sudden onset of severe, tearing chest pain radiating to the back. His
blood pressure is 180/100 mmHg in the right arm and 100/60 mmHg in
the left arm. A chest x-ray shows a widened mediastinum. Which of the
following is the most likely diagnosis?
A. Acute myocardial infarction
B. Acute aortic dissection
C. Pulmonary embolism
D. Pericarditis
Rationale: The history of hypertension, sudden tearing chest pain,
pulse differential, and widened mediastinum are classic for acute
aortic dissection. Myocardial infarction (A) typically presents with
substernal chest pressure without pulse differential. Pulmonary
embolism (C) causes pleuritic chest pain and hypoxia. Pericarditis (D)
presents with positional chest pain and friction rub. Option B is
correct.
2. A 25-year-old woman presents with a 2-week history of fatigue,
low-grade fever, and a non-productive cough. On examination, she has
bilateral hilar lymphadenopathy on chest x-ray. Biopsy of a lymph node
shows non-caseating granulomas. Which of the following is the most
likely diagnosis?
A. Tuberculosis
,2|Page
B. Sarcoidosis
C. Hodgkin lymphoma
D. Coccidioidomycosis
Rationale: Bilateral hilar lymphadenopathy with non-caseating
granulomas is characteristic of sarcoidosis. Tuberculosis (A) typically
shows caseating granulomas. Hodgkin lymphoma (C) often presents
with mediastinal lymphadenopathy but not granulomas.
Coccidioidomycosis (D) can cause granulomas but is less common in
this presentation. Option B is correct.
3. A 45-year-old man with chronic alcoholism presents with abdominal
pain, jaundice, and ascites. Laboratory studies show AST 180 U/L, ALT
100 U/L, GGT 250 U/L, with AST/ALT ratio >1.5. Which of the
following is the most likely underlying liver histopathology?
A. Macrovesicular steatosis
B. Micronodular cirrhosis with Mallory-Denk bodies
C. Bridging necrosis
D. Hepatocellular carcinoma
Rationale: Alcoholic liver disease characteristically shows
micronodular cirrhosis and Mallory-Denk bodies (eosinophilic
cytoplasmic inclusions). Macrovesicular steatosis (A) occurs in early
alcoholic liver disease but not with cirrhosis. Bridging necrosis (C) is
seen in viral hepatitis. Hepatocellular carcinoma (D) may arise in
cirrhosis but is not the underlying histopathology in this presentation.
Option B is correct.
4. A 30-year-old man presents with recurrent episodes of abdominal
pain, diarrhea, and oral ulcers. Colonoscopy shows skip lesions with
cobblestone mucosa and deep fissuring ulcers. Which of the following
histologic findings is most characteristic of this condition?
A. Transmural inflammation with non-caseating granulomas
B. Transmural inflammation with non-caseating granulomas
C. Crypt abscesses
,3|Page
D. Mucosal atrophy
Rationale: The description is Crohn disease. Characteristic histology
is transmural inflammation and non-caseating granulomas. Crypt
abscesses (C) are typical of ulcerative colitis. Option A is correct.
5. A 72-year-old woman with osteoporosis is found to have a T-score of
-3.0 at the femoral neck. She has no prior fractures. Which of the
following medications is first-line for reducing fracture risk?
A. Raloxifene
B. Alendronate
C. Teriparatide
D. Calcitonin
Rationale: Bisphosphonates (alendronate, risedronate) are first-line
for osteoporosis. Raloxifene (A) is for vertebral fracture prevention in
younger women. Teriparatide (C) is anabolic for severe osteoporosis.
Calcitonin (D) is rarely used. Option B is correct.
6. A 55-year-old man with type 2 diabetes and hypertension presents
with a non-healing ulcer on his right heel. The dorsalis pedis pulse is
absent. Which of the following pathophysiologic mechanisms is
primarily responsible for this ulcer?
A. Venous insufficiency
B. Peripheral arterial disease
C. Diabetic neuropathy
D. Pressure injury
Rationale: Absent pulse indicates arterial insufficiency. Peripheral
arterial disease (PAD) is common in diabetes and hypertension and
leads to ischemic ulcers. Neuropathy (C) contributes but does not
explain absent pulse. Venous insufficiency (A) presents with edema
and stasis changes. Option B is correct.
7. A 20-year-old man is involved in a motor vehicle collision and
sustains a fracture of the mid-shaft of the femur. Which of the following
nerves is most at risk for injury with this fracture?
, 4|Page
A. Sciatic nerve
B. Femoral nerve
C. Obturator nerve
D. Superior gluteal nerve
Rationale: The femoral nerve runs along the psoas muscle and is
vulnerable to injury from displaced femoral shaft fractures. The sciatic
nerve (A) is more associated with posterior hip dislocations. Obturator
nerve (C) is injured with pelvic fractures. Superior gluteal nerve (D) is
injured with hip surgery or posterior dislocation. Option B is correct.
8. A 45-year-old woman presents with a 3-month history of fatigue,
weight gain, and constipation. On examination, she has bradycardia (52
bpm), a non-tender goiter, and delayed relaxation of deep tendon
reflexes. Laboratory studies show TSH 25 μIU/mL (normal 0.4-4.0) and
free T4 0.5 ng/dL (normal 0.8-1.8). Which of the following is the most
likely cause of her hypothyroidism?
A. Graves disease
B. Hashimoto thyroiditis
C. Subacute thyroiditis
D. Central hypothyroidism
Rationale: Primary hypothyroidism with a goiter and positive
anti-TPO antibodies (likely) is typical of Hashimoto thyroiditis. Graves
(A) causes hyperthyroidism. Subacute thyroiditis (C) presents with
painful thyroid and transient hyperthyroidism. Central hypothyroidism
(D) would have low or inappropriately normal TSH. Option B is
correct.
9. A 35-year-old man presents with a 1-day history of severe, colicky
right flank pain radiating to the groin, nausea, and hematuria. Urinalysis
shows microscopic hematuria. Non-contrast CT shows a 5 mm stone in
the proximal ureter. Which of the following is the most appropriate
initial management?
A. Extracorporeal shock wave lithotripsy (ESWL)
NBME CBSE ACTUAL EXAM PREP 2026 ALL
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ALREADY A
GRADED WITH EXPERT FEEDBACK |NEW
AND REVISED
1. A 68-year-old man with a history of hypertension presents with
sudden onset of severe, tearing chest pain radiating to the back. His
blood pressure is 180/100 mmHg in the right arm and 100/60 mmHg in
the left arm. A chest x-ray shows a widened mediastinum. Which of the
following is the most likely diagnosis?
A. Acute myocardial infarction
B. Acute aortic dissection
C. Pulmonary embolism
D. Pericarditis
Rationale: The history of hypertension, sudden tearing chest pain,
pulse differential, and widened mediastinum are classic for acute
aortic dissection. Myocardial infarction (A) typically presents with
substernal chest pressure without pulse differential. Pulmonary
embolism (C) causes pleuritic chest pain and hypoxia. Pericarditis (D)
presents with positional chest pain and friction rub. Option B is
correct.
2. A 25-year-old woman presents with a 2-week history of fatigue,
low-grade fever, and a non-productive cough. On examination, she has
bilateral hilar lymphadenopathy on chest x-ray. Biopsy of a lymph node
shows non-caseating granulomas. Which of the following is the most
likely diagnosis?
A. Tuberculosis
,2|Page
B. Sarcoidosis
C. Hodgkin lymphoma
D. Coccidioidomycosis
Rationale: Bilateral hilar lymphadenopathy with non-caseating
granulomas is characteristic of sarcoidosis. Tuberculosis (A) typically
shows caseating granulomas. Hodgkin lymphoma (C) often presents
with mediastinal lymphadenopathy but not granulomas.
Coccidioidomycosis (D) can cause granulomas but is less common in
this presentation. Option B is correct.
3. A 45-year-old man with chronic alcoholism presents with abdominal
pain, jaundice, and ascites. Laboratory studies show AST 180 U/L, ALT
100 U/L, GGT 250 U/L, with AST/ALT ratio >1.5. Which of the
following is the most likely underlying liver histopathology?
A. Macrovesicular steatosis
B. Micronodular cirrhosis with Mallory-Denk bodies
C. Bridging necrosis
D. Hepatocellular carcinoma
Rationale: Alcoholic liver disease characteristically shows
micronodular cirrhosis and Mallory-Denk bodies (eosinophilic
cytoplasmic inclusions). Macrovesicular steatosis (A) occurs in early
alcoholic liver disease but not with cirrhosis. Bridging necrosis (C) is
seen in viral hepatitis. Hepatocellular carcinoma (D) may arise in
cirrhosis but is not the underlying histopathology in this presentation.
Option B is correct.
4. A 30-year-old man presents with recurrent episodes of abdominal
pain, diarrhea, and oral ulcers. Colonoscopy shows skip lesions with
cobblestone mucosa and deep fissuring ulcers. Which of the following
histologic findings is most characteristic of this condition?
A. Transmural inflammation with non-caseating granulomas
B. Transmural inflammation with non-caseating granulomas
C. Crypt abscesses
,3|Page
D. Mucosal atrophy
Rationale: The description is Crohn disease. Characteristic histology
is transmural inflammation and non-caseating granulomas. Crypt
abscesses (C) are typical of ulcerative colitis. Option A is correct.
5. A 72-year-old woman with osteoporosis is found to have a T-score of
-3.0 at the femoral neck. She has no prior fractures. Which of the
following medications is first-line for reducing fracture risk?
A. Raloxifene
B. Alendronate
C. Teriparatide
D. Calcitonin
Rationale: Bisphosphonates (alendronate, risedronate) are first-line
for osteoporosis. Raloxifene (A) is for vertebral fracture prevention in
younger women. Teriparatide (C) is anabolic for severe osteoporosis.
Calcitonin (D) is rarely used. Option B is correct.
6. A 55-year-old man with type 2 diabetes and hypertension presents
with a non-healing ulcer on his right heel. The dorsalis pedis pulse is
absent. Which of the following pathophysiologic mechanisms is
primarily responsible for this ulcer?
A. Venous insufficiency
B. Peripheral arterial disease
C. Diabetic neuropathy
D. Pressure injury
Rationale: Absent pulse indicates arterial insufficiency. Peripheral
arterial disease (PAD) is common in diabetes and hypertension and
leads to ischemic ulcers. Neuropathy (C) contributes but does not
explain absent pulse. Venous insufficiency (A) presents with edema
and stasis changes. Option B is correct.
7. A 20-year-old man is involved in a motor vehicle collision and
sustains a fracture of the mid-shaft of the femur. Which of the following
nerves is most at risk for injury with this fracture?
, 4|Page
A. Sciatic nerve
B. Femoral nerve
C. Obturator nerve
D. Superior gluteal nerve
Rationale: The femoral nerve runs along the psoas muscle and is
vulnerable to injury from displaced femoral shaft fractures. The sciatic
nerve (A) is more associated with posterior hip dislocations. Obturator
nerve (C) is injured with pelvic fractures. Superior gluteal nerve (D) is
injured with hip surgery or posterior dislocation. Option B is correct.
8. A 45-year-old woman presents with a 3-month history of fatigue,
weight gain, and constipation. On examination, she has bradycardia (52
bpm), a non-tender goiter, and delayed relaxation of deep tendon
reflexes. Laboratory studies show TSH 25 μIU/mL (normal 0.4-4.0) and
free T4 0.5 ng/dL (normal 0.8-1.8). Which of the following is the most
likely cause of her hypothyroidism?
A. Graves disease
B. Hashimoto thyroiditis
C. Subacute thyroiditis
D. Central hypothyroidism
Rationale: Primary hypothyroidism with a goiter and positive
anti-TPO antibodies (likely) is typical of Hashimoto thyroiditis. Graves
(A) causes hyperthyroidism. Subacute thyroiditis (C) presents with
painful thyroid and transient hyperthyroidism. Central hypothyroidism
(D) would have low or inappropriately normal TSH. Option B is
correct.
9. A 35-year-old man presents with a 1-day history of severe, colicky
right flank pain radiating to the groin, nausea, and hematuria. Urinalysis
shows microscopic hematuria. Non-contrast CT shows a 5 mm stone in
the proximal ureter. Which of the following is the most appropriate
initial management?
A. Extracorporeal shock wave lithotripsy (ESWL)
