HIGH YIELD IMAGES

NBME 25-30
 NBME 25

Given Brain biopsy; RCC – metastasis to brain –

Paraneoplastic – polycythemia & hypercalcemia

Old Age – Osteoporosis – Imbalance between Osteoblast &

Osteoclasts – Increase in IL-1 (Osteoclast Activating Factor)
Acoustic Neuroma compressing on which part of brainstem –
A – Inferior cerebellar peduncle
C and D: Medial longitudinal fasciculus
E and F: Pyramidal tract decussation

Patient undergoing Chemo -Immunocompromised – narrow

based budding – Cryptococcus Neoformans – bright red
capsules stained with mucicarmine stain or Acid-Schiff stain
Medial Border of Direct Inguinal Hernia is formed by – Rectus
Abdominis muscle

HIV affected person - Immunocompromised - Pneumonia

symptoms - CMV infection ( Owl's Eye appearance ) - similar
to Hodgkin's Lymphoma
Where will allopurinol act ? - Ans: G

Young boy - microcytic anemia - TARGET CELLS - Molecular

cause of defect - Beta thalassemia major -beta globin
mutation
Young female - hypertensive - Renal artery aneurysm - Most
common cause - Ans: Fibromuscular dysplasia (also a repeat
from NBME 23)

Patient with Chronic Hep B - Mixed cryoglobulinemia (triad of

Arthralgias, Palpable purpura & peripheral neuropathy) -
Increased amt of cryoglobulin C
History of Staph infection - Taking TMP-SMX - adverse drug
reaction - not itchy- morbilliform rash

Acute viral hepatitis/yellow fever - apoptosis of hepatocytes -

via Extrinsic apoptotic pathway -Ballooning hepatocytes &
Councilman bodies seen on histology
Malaria infection treated with Chloroquine +Primaquine -
what is the use of Primaquine ? - kills exoerythrocytic phase
of disease (Hypnozoites) (Vivax & ovale)
Patient with loss of motor & sensory sensation from Left
lower extremities - location of lesion ? - G
Pregnant woman -UTI spreading retrograde to Kidney - Dx.
Acute Pyelonephritis - histology lymphocytic infiltrates seen
inside tubules.

White matter hyperintensities with Periventricular lesions -

Dx. Multiple sclerosis

History of high grade fever,rash & Proximal Coronary artery

dilation - Dx. Kawasaki disease(Mucocutaneous lymph node
syndrome)
Patient with crohn's disease -treated with Monoclonal
antibody -targeted against TNF-alpha - Causing Reactivation
TB
Zenker diverticulum - present between defect in which
muscles ? - Cricopharyngeal & Inferior pharyngeal
constrictor muscle

Old age women with proteinuria - long standing

hyperglycemia - DM - Diabetic nephropathy
Lady with AAA repaired - 48hrs later needle shaped crystal
deposition in small arteries - Cholesterol embolism

Young boy with Duplex Collecting system - ureter

obstruction as complication - recurrent UTI
Cerebral infarction -location on left (Myelin stains black) -
Upper motor symptoms on right side(contralateral) - spastic
hemiparesis on right side

Inferior thoracic part of esophagus blood supply- directly

from Aorta thru esophageal branches -must be ligated during
esophagectomy. (learn blood supply of esophagus)
Patient with a variety of analgesic abuse - changes in urine
after administering ADH ? Dx.Renal papillary necrosis -
damaged CT - No effect on urine osmolality & volume

Patient with inoculated mass on left psoas muscle -

Dx.Psoas abscess - difficulty in flexion
 NBME 26

Why is X feathery compared to Y?

A: Greater mucosal surface area - jejunum has prominent plicae circulares

65 yo pt w CLL + sudden onset fatigue/SOB. Labs = low Hb, high leukocytes, high
reticulocytes, and high total bilirubin.
A: Autoimmune hemolysis (warm AIHA a/w CLL bc autoantibodies)
Pt w postpartum hemorrhage, previous C section. Hysterectomy performed.
Cause?
A: placenta accreta

Pt w hx of RA. Prussian blue stained bone marrow aspirate. What is cause of

anemia?
A: Anemia of chronic disease (see increased iron stores)
Prison pt, PPD shows 14mm induration. IFN-y + which other cytokine are
activated?
A: IL-12 (secreted by macrophages, acts on NK + CD8+ cells which then causes
IFN-y release.)

56yo dies 1 mo after onset of sx (short term memory loss + anxiety). PMH =
resection of small cell carcinoma 1y ago. Where are degenerative changes going
to occur?
A: C = limbic system is located in mesial temporal lobe + is commonly damaged by
radiation/chemo
Pt w worsening pain in left thigh. INcreased focal areas of calcification. Several
cysts
A: Chondrosarcoma

Where should you enter to access neural canal in surgery?

A: D = lamina
A: follicular epidermal hyperproliferation w XS sebum production

Pt post kidney transplant on immunosuppressant therapy

A: CMV pneumonitis w diffuse alveolar damage
spleen rupture from motor vehicle collision

Pt w progressive SOB on exertion + recurrent nosebleeds. Albuterol doesn’t help

A: Caused by pulmonary arteriovenous shunting (hereditary hemorrhagic
telangiectasia)
Calcified congenital bicuspid valve - can lead to sudden cardiac death

Lesion = Inability to abduct ipsilateral eye (CN 6)

3 mo history of fevers, weakness, night sweats. Biopsy of enlarged axillary lymph
nodes, negative acid fast stain
A: type 4 delayed hypersensitivity rxn (sarcoidosis)

Autoimmune disorder w proximal muscle weakness of lower extremities

A: myasthenic lambert eaton syndrome (anti vgCa2+ channels on presynaptic
neuron)
Malassezia furfur

Fracture of distal radius

Hb = 18.5 in 57yo man
A: COPD (causes polycythemia)

ARDS pt, which cell would undergo hyperplasia during recovery?

A: Type 2 pneumocyte
Hydronephrosis

Numbness of fingers of left hand, loss of touch graphesthesia, loss of

2 point discrimination in left hand
A: B - right anterolateral parietal lobe (sensory cortex in postcentral
gyrus)
Ptosis of left eyelid + miosis of pupil. Diminished flushing + sweating
on left half of face.
A: B - lesion caused Horner syndrome

Findings caused by perforation of what structure?

A: Duodenum (2nd-4th segments bc retroperitoneal)
Old man comes in w 7y history of red, dry, itchy skin - corticosteroids
don’t help. Labs show eosinophilia + increased IgA + IgE.
Which other cell type is involved?
A: T lymphocytes - mycosis fungoides cutaneous T cell lymphoma
 NBME 27

Left thrombotic (ischemic) stroke: Global aphasia

Cellulitis: Streptococcus pyogenes (group A)

 A. Gastric mucous neck cells
B. Parietal cells
C. Chief cells
D. Vascular endothelial cell
E. Perivascular fibroblast

Atrophic cerebellar vermis (Gait ataxia)

 A. Aortic valve
B. Pulmonic valve
C. Tricuspid valve (most common affected valve in Endocarditis from IVDU)
D. Mitral valve

Round oocysts on the colonic epithelial surface, consistent with cryptosporidiosis

(Cryptosporidium parvum), an AIDS defining illness.

Staghorn calculi (Proteus mirabilis)

Occlusion of the Posterior Cerebral Artery (PCA), causing Contralateral visual
field deficit
Visual symptoms include: Cortical blindness, contralateral homonymous
hemianopsia with macular sparing, visual agnosia, and prosopagnosia.

Roseola (Human herpesvirus 6)

Crest syndrome. Calcinosis cutis; Decreased esophageal motility, decreased LES
tone (Esophageal dysmotility)

Scabies (Sarcoptes scabiei). Transmitted through skin to skin contact.

"Does anyone else in the family have an itchy rash like this?"

\
Urothelial carcinoma. Smoking is the biggest risk factor. (Picture repeated on
almost every NBME)

Actinic keratosis
Testosterone and estrogen regulate the rate of physeal growth, ossification, and
closure. Closure occurs in adolescence and is marked by ossification of the
radiolucent physis on x-rays.

Hemochromatosis
Immune thrombocytopenic purpura. Bone marrow biopsy (below) will
demonstrate increased megakaryocytes.

Pituitary adenoma. Can cause visual field deficit (bitemporal hemianopsia)

Giardia lamblia. Can cause intestinal malabsorption

Musculocutaneous nerve (C5-C7)

The endometrium goes through three stages each menstrual cycle:
proliferative, secretory, and menses. The secretory endometrium
(below) is characterized by dilated, tortuous endometrial glands with
large intracytoplasmic vacuoles containing secretory material

Pneumothorax. Visceral pleura (arrow)

Hemolytic Uremic Syndrome (HUS). MAHA
NBME 28

What sensory information is

compromised by lesion to X?
A: Unconscious proprioception
(anterior lobe of cerebellum)

Aphthous ulcers. Exacerbated

by spicy, salty, and acidic
food and drinks
 Patient w difficulty swallowing
and history of regurgitation of
gastric contents. Biopsy from
lower ⅓ of esophagus.
A: Barrett esophagus
(intestinal metaplasia of
squamous epithelium)

What is the most likely diagnosis?

Image of liver w multiple metastases
A: Colonic carcinoma
 X-ray of esophagus. Patient choking on
both solids and liquids.
A: Achalasia (MOA: inflammatory
degeneration of esophageal neurons)

21-year-old woman with shortness of breath. Widely split S2 and

holosystolic murmur on left lower sternal border.
Essentially has increased right heart volume and atrial septal defect.
ECG shows right bundle branch block (deep S-wave on V6 and
double-R wave on V1 that looks like an M with the second R being
large).
Answer: Dysfunction of atrial septum
 Patient has weakness of the
right lower two thirds of the
face. Where is the lesion? A: C
(pre-central gyrus)

Patient is in an MVC. Soft-tissue injury of

face that restricts her ability to drink
water from a glass. Attempting to purse
lips in photo. What nerve is injured? A:
Buccal branch of the facial nerve
Man with erectile dysfunction. Sildenafil corrects the
dysfunction by acting at which of the corresponding
structures? A: D (corpora cavernosa; inhibits PDE-5
and increases NO)

Woman has carcinoma of the breast.

Q stem mentions that an X-ray shows
tumor next to right side of heart.
Q stem mentions that THIS CT SCAN
with the tumor invading the
PERICADIUM is shown.
Question: What structure is most
likely involved? A: right phrenic nerve
Repeat from older NBME. Q mentions that patient
had been undergoing eval for occult blood in the
stool. What is the most likely diagnosis? A:
Tubular adenoma

Patient undergoes root canal before she had

taken a dose of amoxicillin.
Has a blowing murmur under left axilla.
Organism shows alpha-hemolysis.
What is organism? A: Strep mitis
 Woman has rectal pain made more severe by defecation.
Occasional blood on toilet tissue. Diagnosis? A: Anal
fissure

3-year-old boy comes in with 1 month history of pale skin. Parents of

European descent. Physical exam shows pallor. Genetic testing
would show what? A: Heterozygous mutation of ankyrin gene
(hereditary spherocytosis)
 Patient with decreased pain and
temp in left lower extremity.
Lesion? A: E (spinothalamic tract)

Trauma to what vascular structures would cause this?

A: Dural bridging veins (subdural hematoma)
Might be a better quality image from an older NBME.
Pregnant woman with 4-day history of fever and
back pain (emphasizes that she has been crying
frequently). High temp and CVA tenderness. What
mechanism is likely cause? A: Obstructive
uropathy. Image shows pyelonephritis from
ascending UTI. Pregnant patients at high risk.

From old NBME. Newborn born at 36 weeks

gestation dies 3 days later. What is the most likely
underlying disease? A: Hemolytic disease of the
newborn. Shows kernicterus.
 Man dies of renal failure. Labs
show positive Bence Jones
protein. What is the most likely
diagnosis? A: Amyloidosis. (from
multiple myeloma)

From old NBME. Sexually active 20-year-old woman has erythematous, vesicular
lesions on the vulva. Scraping of base of one of the vesicles is shown.
Diagnosis? A: Genital herpes
US of male fetal scrotum. Testes are indicated by the arrows. What is the
underlying cause of this finding? A: Patent processus vaginalis (hydrocele;
testes surrounded by fluid in US)

Old NBME image. Neisseria gonorrhoeae

Old NBME image. Renal biopsy. A: Renal cell
carcinoma.

70-year-old woman brought to ER 30 minutes

after being found unresponsive at home.
Arrowheads indicate abnormalities.
Q: Which of the following would be present 2
months later?
A: Inability to learn and recall new facts.
(arrowheads pointing at hippocampal cortex
which is vulnerable to ischemic damage in
anoxic brain injury)
Patient comes to ED with severe shoulder and abdominal pain. Has high temp
and shows signs of acute peritonitis. What is the most likely cause of these
findings? A: Perforated viscus (x-ray shows air under diaphragm)

From old NBME. Vignette describes little girl who gets this rash after a summer
vacation in Maine (Lyme disease). Q: The likely cause of this patient's infection is
taxonomically and morphologically most similar to the infectious agent of which
of the following conditions? A: Leptospirosis (because it’s a spirochete)
 Photograph of silver-stained
specimen. P. jirovecii

Giardia
Patient had 30-pack-year smoking history. Cough productive of blood-tinged
sputum. Had hypercalcemia. Essentially has squamous cell carcinoma of the
lung. Q: How is hypercalcemia treated in this patient? A: Treated with drug that
inhibits osteoclasts (aka bisphosphonates)

Young woman with 1-week history of fatigue, muscle pain, and weakness. Unable
to climb stairs. 1 month history of rash shown in the photographs. Diagnosis?
A: Dermatomyositis
 NBME 29

Q- Pt with increased leukocyte count

A : AML
Clue- Auer rods in the image

Q- Kid with proteinuria, hypoalbuminemia

and periorbital edema
A- Minimal change disease
Clue- Normal glomerulus on microscopy
 Q- Middle aged woman with easy
bruising after a viral infection
A- Peripheral destruction of platelets
Clue- Increased megakaryocytes on
biopsy (ITP)

Q- Kid with nasal polyps and bronchospasms after taking a drug

A- B (aspirin)
Q- What is X?
A- Tubocurarine

Q- Joint pain. What is found in the joint?

A- Sodium monourate
A- Trichotillomania
(repeat from old NBME)

Q- Presents a pt with
parkinson's (classic TRAPS).
What is the arrow composed of?
A- Alpha synuclein
Q- Present a pt with SLE. What
other condition has similar
hypersensitivity?
A- Serum sickness
Type III HS

Q- Elderly female with

anemia. Cause?
A : GI blood loss (iron
deficiency anemia)
Q- Alkaline urine. Cause?
A- Proteus

Q- Alcoholic with classic signs of

cirrhosis. Arrow indicates a mass. Which
vein will have high pressure?
So basically portal HTN leads to back up
where?
A- Short gastric
Other options- Hepatic, phrenic, renal,
suprarenal
Q- Young adult male with abdominal pain and distension. What developmental
anomaly?
A- Malrotation
Clue- First image shows air-fluid levels due to obstruction (caused by volvulus).
Second image shows small intestine only on right side

Q- Young female took antibiotics for acne and now presents with white vaginal
discharge. Biopsy shown (candida).
MOA of the oral agent used to treat?
A- Inhibition of CYT P450 demethylation reaction (fluconazole)
Q- Tense blisters. Function of the structure that is targeted by the antibody?
A- Attach keratinocyte to ECM
Bullous pemphigoid; antibody against hemidesmosomes

Q- Middle aged male with bloody diarrhea

and crampy abdominal pain?
A- Ulcerative colitis
Q- Fluent speech but problems with grammar and understanding
verbal comments.
A- H

Q- Recurrent painful blister. What transport established latent infection?

A- Retrograde transport
Herpes
Q- Young male with left sided chest pain. What respiratory exam
finding?
A- Decreased breath sounds on the left
Tension pneumothorax

Q- Teenager with interstitial pneumonia. Bone marrow transplant 2 months ago.

Decreased function of what predisposed to this condition?
A- T-lymphocyte
Clue- Basophilic nuclear inclusion bodies (CMV pneumonia)
Q- Long stem describing
prolactinoma. Location?
A:D

Q- Reason for the

spillage of contrast
(arrow)?
A : Spillage, Normal
Q- Describe systemic sclerosis. What pulmonary finding?
A- Interstitial fibrosis

Q- Enlarged lymph node. Dx?

A- Follicular lymphoma
 Q- Young boy, lytic bone
lesions. Dx?
A : Langerhans cell histiocytosis

Q- Episodic headaches and hypertension (pheochromocytoma). Location of

problem (arrow)?
A- Adrenal

Q- Itchy rash
A- Pityriasis rosea
 NBME 30

Photomicrograph of lung tissue from a patient with Chronic Granulomatous

Disease

Esophageal varices d/t portal HTN :

- Gross image = dilated esophagus
- Histo image = dilated submucosal venous plexus
Also seen on another NBME → MENINGIOMA - most common adult brain tumor -
tumor is well circumscribed, extra axial + compress the parenchyma

Coccidioides immitis → silver stain shows large spherules containing endospores

HIV encephalopathy. Image shows microglial nodules with multinucleated giant cells.
Contrast with PML (bc HIV encephalopathy is more rapid)

Rheumatic heart diseased/t acute rheumatic fever caused by recurrent Group A Strep
infection - present w mid diastolic murmur
- Inflammation causing fibrosis & calcification of heart valves (mitral)
Squamous cell carcinoma
- Gross → central cavitation
- Histo → polygonal cells with intercellular bridges, eosinophilic cytoplasm &
keratin pearls & extensive necrosis

Repeat from another NBME → Peutz-Jeghers syndrome

Perforated duodenal ulcer → air under diaphragm (pneumoperitoneum)

Lead poisoning ( inhibition of ferrochelatase ) → basophilic stippling on blood smear &

ringed sideroblast within bone marrow.

Hepatitis → apoptosis, can see councilman bodies ( eosinophilic cytoplasm in lower

left quadrant of slide) which represents hepatocytes in a state of apoptosis or necrosis.
Posterior cruciate ligament → option E
A = subcutaneous fat
B = anterior aspect of medial femoral condyle
C = patellar ligament
D = anterior cruciate ligament

Protease inhibitor deficiency → alpha-1 antitrypsin deficiency, inherited mutations in

SERPINA1 gene
Aortic valve
Another nbme has tricuspid but image is different so compare/contrast & don’t mix them
up!

Malassezia furfur
Immune thrombocytopenic Purpura

Testicular carcinoma → q asked where does it drain → para aortic (lumbar) lymph
nodes
 Papillary transitional cell carcinoma → common
tumor of urinary tract, can develop in renal
collecting tubules,pelvis, calyxes,urethra, or
bladder bc they all have the same embryolgical
origin & same epithelium. Smoking is the biggest
risk factor
Other carcinogens associated = phenacetin,
cyclophosphamide & 2-napthylamine (answer to
this q)

Cafe au lait spot. When by itself usually benign.

Repeat from another NBME. Bullet in spleen

Community acquired bacterial pneumonia, asked whats causing hypoxemia →
pulmonary arterial blood traversing poorly aerated alveoli

Osteoporosis
Leukemoid reaction

Infamous NBME repeat - external hemorrhoid

Actinomyces israelii Gram positive branching filamentous rod,
resembles fungi but is not, is a component of oral flora
Hope this saves a lot of us a few free points & minutes
on exam day. Thank you for your contribution to those
who helped put this together.

GOOD LUCK EVERYONE!

- @DedicatedDarkHole