NBME Surgery Shelf Practice Test

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• An elderly man with recurrent vomiting of bright red blood and near-syncope is hemodynamically unstable. What is the initial management step?
• In pancreatitis, colon cutoff sign is seen at which part of the colon?
• For colorectal procedures, which antibiotic combination is typical for prophylaxis?
• A 68-year-old man with a pulsatile abdominal bulge measures 7 cm above the umbilicus. What is the best initial diagnostic test?
• The FAST exam in trauma is primarily used to detect which finding?
• Which imaging modality is most accurate for preoperative localization of a hyperfunctioning parathyroid adenoma?
• Which radiographic sign is most characteristic of sigmoid volvulus?
• Diabetic patient with neuropathy presenting with swelling of the foot, a warm, deformed foot, and radiographs showing osteopenia and fragmentation. What is the most likely diagnosis?
• In a pregnant patient with suspected pheochromocytoma, what is the preferred imaging modality?
• A 62-year-old man with hemoptysis and a long smoking history has hypercalcemia and a coin lesion on chest imaging. The most likely diagnosis is which type of lung cancer?
• For mid- to upper-rectal cancer, what is a common sphincter-preserving option if feasible?
• In suitable patients with potentially curable pancreatic head cancer, the operation of choice is?
• A diabetic patient presents with RUQ pain and ultrasound shows gas within the wall of the gallbladder. What is the likely diagnosis and recommended management?
• A college football player sustains a knee injury and the lower leg sags when the knee is flexed to 90 degrees. What is the most likely diagnosis?
• In a hemodynamically stable elderly patient with brisk lower GI bleeding and colonoscopy showing multiple diverticula but no active bleeding source, what is the next best diagnostic test to localize bleeding?
• In a clavicle fracture with bruit and suspected vascular injury, which imaging study best evaluates the vascular injury?
• A 1-year-old boy with a two-month history of persistent cough, loose stools, and facial flushing accompanied by weight loss. CT shows a tumor in the pancreas. Which pancreatic tumor is most likely?
• In blunt thoracic trauma, which injury is considered a hidden thoracic injury?
• What is a common nonoperative management option for uncomplicated biliary colic?
• A 5-year-old child of a parent with familial adenomatous polyposis (APC gene) is being screened. What is the most appropriate starting test and age?
• How is the diagnosis of traumatic cardiac tamponade established?
• An 11-month-old girl presents with fever and purple current jelly stools; a palpable RUQ mass is noted. What is the next step in management?
• Initial essential step in management of acute esophageal variceal bleeding?
• An 88-year-old female with dementia who recently had CABG develops marked abdominal distension, no bowel sounds, abdominal pain, and no bowel movements for 48 hours following surgery. A plain abdominal radiograph shows massive colonic distension with gas in the rectum. What is the most likely diagnosis?
• A previously healthy 47-year-old man presents with two weeks of progressive abdominal distension. Exam shows shifting dullness; paracentesis yields milky chylous fluid. What is the most likely underlying cause?
• What is the standard operative treatment for localized colon cancer?
• For patients with colorectal cancer presenting with obstruction, what is an immediate intervention to relieve the obstruction?
• For obese patients undergoing bariatric surgery, which perioperative consideration is particularly important?
• Functional status is assessed using metabolic equivalents (METs). What threshold defines adequate functional capacity?
• In NSTI, which antibiotic approach is essential alongside surgical debridement?
• Which condition is typically a contraindication to laparoscopic repair?
• Which statement best defines a surgical emergency?
• Pain in the anatomic snuffbox after FOOSH most strongly suggests fracture of which carpal bone?
• A 45-year-old alcoholic presents with finger swelling described as sausage-shaped with tendon sheath tenderness along the entire length and pain with passive motion. What is the most likely diagnosis?
• Which imaging finding is most reliable for detecting pneumoperitoneum in an unstable patient?
• When assessing breast masses, which biopsy method is generally preferred to differentiate in situ from invasive disease?
• Which laboratory finding is diagnostic for hypercortisolism?
• Following an episode of biliary pancreatitis, what is the preferred strategy to prevent recurrence after stabilization?
• Which statement best describes optimal perioperative electrolyte management?
• A 52-year-old man, 12 hours after pancreatic abscess drainage, is intubated with FiO2 100%, tidal volume 1000 mL, PEEP 2.5 cm H2O; O2 saturation remains low and arterial blood gas shows acidosis. What is the next step in management?
• What is the correct, stepwise sequence of evaluation for a patient with a recent myocardial infarction who requires noncardiac surgery?
• 35-year-old patient with necrolytic erythema and metabolic symptoms is most likely diagnosis?
• What is the role of stress testing in preoperative risk assessment for a patient with recent myocardial infarction?
• What is a primary goal of preoperative coronary evaluation after a recent myocardial infarction?
• What is the most common cause of fever in the first 48 hours after noncardiac surgery?
• An elderly patient after a fall with a shortened, externally rotated leg most likely has which fracture, and what is a possible complication?
• A 62-year-old man presents with buttock pain during evening walks and absent femoral and distal pulses. Likely dx?
• Carotid endarterectomy provides the greatest absolute benefit in which scenario?
• Which of the following is NOT part of the diagnostic criteria for acute pancreatitis?
• An 90-year-old man with Alzheimer's has abdominal distention and pain for 12 hours. X-rays show markedly distended colon with a bent inner tube sign. He is hemodynamically unstable with signs of peritonitis. What is the likely diagnosis and the next step after IV fluids and antibiotics?
• An incidental heavily calcified gallbladder is found on imaging. What is the recommended next step?
• The standard operative approach for localized colon cancer includes removal of the tumor with surrounding colon and what additional step?
• In the ATLS framework, what is the first priority in management?
• A spermatocele is best described as which of the following?
• A bridging strategy for obstructive colorectal cancer is appropriate when?
• In suspected intra-abdominal sepsis, what is the cornerstone of initial management?
• Which condition is a relative contraindication to laparoscopic repair, depending on surgeon experience?
• For resectable pancreatic cancer, what is a key determinant of survival?
• In suspected esophageal rupture after endoscopy, which contrast agent is preferred for radiographic evaluation?
• A patient with subarachnoid hemorrhage develops progressive lethargy and coma; hyponatremia is most likely due to which condition?
• Which test best assesses myocardial perfusion under stress and helps identify ischemia before high-risk surgery?
• Best treatment for metastases in a patient with ER-positive, PR-negative, HER2-negative breast cancer after hormonal therapy failure?
• In suspected pancreatic necrosis, what is the general timing strategy for surgery?
• What is the cornerstone of treatment for venous stasis ulcers due to chronic venous insufficiency?
• After breast-conserving surgery (lumpectomy), the standard adjuvant local therapy is?
• In adults with suspected appendicitis, which imaging modality offers the highest sensitivity and specificity?
• A 50-year-old woman with colonoscopy showing dark discoloration of the entire colon with pale patches in which lymph follicles shine through—most likely etiology?
• The most common cause of postoperative ileus is?
• A pancreatic neuroendocrine tumor presents with watery diarrhea and facial flushing. This description is most consistent with which tumor?
• Which management approach is appropriate for symptomatic primary hyperparathyroidism?
• Which finding is most characteristic of fat embolism syndrome after a long-bone fracture?
• In a patient with back pain and a history of cancer, sensory loss below the nipple and leg weakness localize the lesion to which imaging as the best modality to confirm?
• Two days after a Whipple procedure, the patient has 30 cm of white opaque drainage from the drain. What is the next best step in evaluation?
• In a hemodynamically unstable patient with sigmoid volvulus and signs of peritonitis, what is the most appropriate next step after resuscitation?
• Which patient population has the highest risk of postoperative pulmonary complications?
• What is the typical management approach for rapidly expanding abdominal aortic aneurysm rupture?
• Barrett’s esophagus is associated with an increased risk of which type of esophageal cancer?
• A 37-year-old woman with a neck mass has circulating antibodies against thyroid peroxidase and thyroglobulin. Which diagnosis is most likely?
• For prophylaxis in clean-contaminated GI surgery, antibiotics should be given within how many minutes before incision, and which combination is typical for colorectal procedures?
• Which of the following is the most common cause of a posterior shoulder dislocation?
• If tibial stress fracture is suspected but plain radiographs are negative, which imaging modality is most sensitive?
• Which of the following is NOT among the six hidden injuries of thoracic trauma?
• Phalen's sign is most indicative of which condition?
• What is the main purpose of sentinel lymph node biopsy in breast cancer?
• The initial imaging test of choice for suspected acute cholecystitis?
• A 47-year-old morbidly obese man with panniculitis asks for definitive long-term weight management. Which option is best for long-term management?
• In a 90-year-old man with sigmoid volvulus presenting with peritonitis, what is the next step in management?
• An insidious onset of shin pain in a young athlete after a sudden increase in activity. There is focal tenderness and some surrounding edema. What is the most likely diagnosis and the next step in management?
• A 52-year-old postmenopausal woman presents with two months of progressive abdominal distension and decreased appetite. Exam reveals ascites; CT shows multiple pelvic masses with omental thickening. What is the most likely diagnosis?
• If catheterization shows clinically significant stenosis, what is recommended prior to proceeding with elective noncardiac surgery?
• A 23-year-old presents after blunt trauma with left shoulder pain and abdominal tenderness; Hb 10 g/dL and WBC 11,000. The most likely diagnosis is which organ injury?
• Beck's triad components for cardiac tamponade commonly include hypotension, muffled heart sounds, and which finding?
• In a patient with suspected upper GI bleed who has been stabilized after resuscitation, what is the next step to evaluate the bleed?
• In tension pneumothorax, which statement is true regarding diagnosis and management?
• Pancreatic necrosis management often emphasizes establishing stability before delayed surgery; which imaging-guided step helps achieve this?
• Uncomplicated diverticulitis is typically managed with which approach in stable patients?
• A patient with progressive dysphagia to both liquids and solids and endoscopy showing gastroesophageal junction stricture with Barrett’s esophagus is most likely diagnosed with which condition?
• A patient has persistent abdominal pain, fever, and nausea several days after laparoscopic cholecystectomy. The best next step in management to identify the source of the problem is which imaging study?
• If noninvasive testing is negative but the patient remains high-risk due to persistent symptoms, what is the recommended course of action?
• Which statement best defines a surgical emergency?
• If noninvasive stress testing suggests possible ischemia, what is the appropriate next diagnostic step to delineate coronary anatomy?
• Sentinel lymph node biopsy in breast cancer aims to determine what?
• In ATLS protocol, what is the first priority in management?
• A patient asks for a definition: what is a spermatocele?
• Charcot foot in a diabetic patient is due to which underlying pathology?
• What test is used to localize the involved gland in primary hyperparathyroidism?
• A 13-year-old boy has progressive hip pain with limp, no trauma, passive hip motion elicits pain. What is the most likely diagnosis?
• Which scenario is a contraindication to pharmacologic DVT prophylaxis after surgery?
• An 8 cm left adrenal mass with irregular borders and high attenuation suggesting a lipid-poor lesion: next step in management?
• High-dose dexamethasone suppression test in ACTH differentiation: which statement is true?
• A 42-year-old man swallows a piece of meat lodged in the lower esophagus; the foreign body is removed endoscopically. That evening he develops fever. What is the most appropriate diagnostic study to evaluate for a complication?
• A 45-year-old man with fever, weight loss, pallor, and a diastolic murmur at the apex that changes with position most likely has which diagnosis?
• In a patient with cirrhosis and ascites, which diuretic is commonly used as first-line therapy?
• Beck's triad in tamponade can be supported by which bedside imaging modality?
• For DVT prophylaxis in postoperative patients, what is a commonly used approach?
• Preoperative optimization for a patient with hyperthyroidism to reduce perioperative risk includes which of the following?
• A patient presents with one day of right upper quadrant pain after fatty meals, along with nausea, altered mental status, jaundice, and fever. What is the most likely diagnosis?
• What is the approximate diameter threshold for elective repair of an abdominal aortic aneurysm in men?
• What is the definitive surgical approach for a perforated viscus with generalized peritonitis?
• A patient fell on an outstretched hand and now presents with an externally rotated arm. What is the most likely dx?
• A 28-year-old woman presents with right lower quadrant pain and nausea/vomiting for the past hour. She is tender at McBurney's point and has pain on passive extension of the right hip. Leukocytosis. What is the next step in management?
• In suspected intra-abdominal sepsis, what are the two key elements of initial management?
• Which imaging modality provides more information about the amount and location of a postoperative fluid collection after cholecystectomy?
• An ASX 72-year-old patient with decreased renal function 3 days after a second renal transplant from a 65-year-old donor. The most likely explanation for the decline in function is what?
• In a patient with colorectal cancer and isolated liver metastasis, which approach may be considered?
• Which imaging study is used for workup of suspected developmental dysplasia of the hip?
• Courvoisier's sign, a palpable non-tender gallbladder in a jaundiced patient, is most suggestive of which condition?
• Emphysematous cholecystitis is most commonly seen in which patient population?
• What is the most common cause of postoperative fever after the first postoperative day?
• In Ogilvie's syndrome, which portion of the colon is most at risk for perforation due to distention?
• In asymptomatic patients with mild comorbidity undergoing low-risk surgery, which test is NOT routinely indicated preoperatively?
• A 52-year-old woman with a history of breast cancer presents with back pain. She has sensory loss below the nipple level, hyperreflexia, and weakness in the legs while arms are relatively normal. Where is the lesion?
• An elderly man, 72, was recently hospitalized and has not voided since catheter removal 8 hours ago. He had sigmoid colectomy 2 days ago. He is on IV fluids. He has a temperature of 100.8°F. What is the most likely cause of his inability to void?
• Which sign is characteristic of purulent flexor tenosynovitis (Kanavel signs)?
• Which finding is an established indication for parathyroidectomy in an asymptomatic patient with primary hyperparathyroidism?
• A 42-year-old woman with a 9-year history of scleroderma presents with diffuse abdominal pain, distension, colon dilation, and leukocytosis. What is the next step?
• An asymptomatic 3 cm right adrenal mass on CT: most appropriate next step in management?
• How is pneumoperitoneum most reliably detected in an unstable patient?
• A 24-year-old with 50% total body surface area burns requires fluids. According to the Parkland formula, how much LR is needed in the first 24 hours for a 75 kg patient with 50% burns?
• A child with obesity presents with a limp and dull knee pain. Exam reveals tenderness at the anterior hip and limited internal rotation. Plain radiographs show subluxation of the right femoral head. What is the next step in management?
• What is the initial therapy for hyperkalemia following crush injury?
• Is urgent ERCP beneficial for severe pancreatitis?
• In resectable pancreatic cancer, absence of distant metastasis combined with negative margins indicates potential for what?
• What is the purpose of using prophylactic drains in general surgery?
• In trauma resuscitation, what is the role of prehospital blood products?
• Which radiographic finding is classically associated with acute pancreatitis on an abdominal X-ray?
• In preoperative evaluation of an asymptomatic patient with mild comorbidity undergoing low-risk surgery, which test is not routinely indicated?
• In a patient with warfarin-induced skin necrosis, which is the most likely etiologic factor?
• In a patient with massive lower GI bleed who becomes unstable, which management step is most appropriate?
• When confirming a suspected femoral neck fracture in an elderly patient, which imaging study is most commonly used first?
• In a hemodynamically unstable patient with splenic injury, what is the preferred initial management?
• Splenorrhaphy refers to which intraoperative approach in splenic injury management?
• In malnourished surgical patients, what is a recommended approach to improve outcomes?
• When is nutritional support indicated in the surgical patient?
• After a baseline electrocardiogram, which test is typically next to assess for inducible ischemia in a high-risk patient before noncardiac surgery?
• Which operation preserves the anal sphincter for mid- to upper-rectal cancer if feasible?
• In necrotizing soft tissue infection, the mainstay of treatment is?
• In bariatric surgery, which perioperative approach is emphasized for better outcomes?
• Milky ascitic fluid in a patient with chylous ascites is most likely to show which laboratory finding?
• Which sign is classically associated with splenic rupture and should raise suspicion for referred left shoulder pain (Kehr sign)?
• Which nerve is at risk with a shoulder dislocation?
• Which imaging modality is most helpful for evaluating acute cholecystitis when ultrasound is inconclusive?
• For acute cholecystitis, what is the recommended timing of cholecystectomy in stable patients?
• Which statement best describes a common indication for a temporary stoma in colorectal surgery?
• What is typically the next step in evaluating a solitary thyroid nodule after an abnormal TSH?
• If catheterization identifies multivessel disease amenable to bypass, which intervention should be considered before noncardiac surgery?
• To differentiate ACTH-dependent from ACTH-independent Cushing's syndrome after hypercortisolism is established, which tests are used?
• What is the best initial method to diagnose tension pneumothorax?
• Which test provides direct visualization of coronary anatomy?
• A patient needs noncardiac surgery two months after myocardial infarction. What is the initial preoperative cardiac test to obtain?
• Which abdominal condition is most commonly caused by postoperative adhesions?
• Postoperative infection around a colostomy with crepitus suggests a gas-forming organism. Which organism is most likely responsible?
• Which antibody is most characteristic of Hashimoto thyroiditis?
• In malnourished surgical patients, what is the recommended approach to improve outcomes?
• A 77-year-old man with severe epistaxis not controlled by anterior packing and who spits clots. What is the most likely source of the bleed?
• Standard surgical treatment for symptomatic primary hyperparathyroidism?
• A 25-year-old patient presents after a motor vehicle collision with a fracture of the right clavicle. A bruit is heard over the right upper chest. What is the most appropriate next step in management?
• If coronary catheterization reveals significant coronary disease, what is the next step before elective noncardiac surgery?
• Pigmentation around the medial malleolus with a painless ulcer is most consistent with which underlying vascular problem?
• After recognition of systemic inflammatory response syndrome, what is the first step in management?
• What is the essential element of perioperative electrolyte management?
• Slipped capital femoral epiphysis most commonly occurs in which age range?
• What is the treatment for a nonfunctional adrenal mass?
• Tx for uncomplicated sigmoid volvulus?
• In evaluating suspected peripheral arterial disease in a patient with intermittent claudication and diminished leg pulses, what is the initial noninvasive test?
• In noncardiac surgery preoperative assessment, which factor best predicts perioperative cardiac risk?
• How to confirm diagnosis of suspected ischemic colitis?
• In trauma resuscitation, what is the role of prehospital blood products?
• Imaging showing omental thickening and adnexal masses in an older woman is most suggestive of which diagnosis?
• Initial imaging for suspected colorectal liver metastases should include which of the following?
• A 55-year-old woman with a hyperextended neck injury presents with spastic paraplegia, loss of pain sensation in the upper extremities, but preserved leg movement and vibratory/light touch sensation in the feet. Most likely diagnosis?
• A 35-year-old woman with a nonhealing ulcer on the medial ankle and surrounding skin pigmentation consistent with lipodermatosclerosis. Best diagnostic test?
• A patient with suspected small bowel obstruction but stable hemodynamics should be managed with which initial steps?
• The decision to use water-soluble enema or stenting as a bridge to definitive surgery depends on which factors?
• Which organism is commonly associated with purulent tenosynovitis after a human bite?
• What is the most sensitive screening test for hyperaldosteronism?
• If norepinephrine fails to achieve target MAP in septic shock, which adjunct vasopressor is commonly used?
• A patient has pain in the anatomic snuffbox after a fall on an outstretched hand. What is the next step in management?
• In a patient with cirrhosis undergoing elective surgery, which perioperative factor most influences risk?
• Which statement best describes when to use a primary anastomosis in colon surgery?
• A previously healthy adolescent with intermittent right anterior thigh pain and limp; 25th percentile height and weight; limited abduction and internal rotation of the hip. What is the most likely diagnosis?
• What stenosis percentage defines high-grade symptomatic carotid disease in the commonly cited threshold?
• What is the best initial treatment for symptomatic hypocalcemia?
• Recommended management of a pyogenic liver abscess?
• A 32-year-old woman presents with gradual onset pain localized to the lateral aspect of the hip. She is afebrile, with tenderness over the greater trochanter when the patient lies on the unaffected side in the lateral decubitus position. What is the most likely diagnosis?
• When evaluating a solitary thyroid nodule, the initial test is measurement of which hormone?
• A 61-year-old man with a history of IV drug use and remote spinal surgery presents with focal back pain and right leg weakness with elevated ESR. What is the best management approach?
• Incidental 2.5 cm carcinoid tumor at the tip of the appendix identified after laparoscopic appendectomy. Next step in management?
• In central cord syndrome, which motor tracts are relatively spared?
• Which radiographic sign is associated with sigmoid volvulus?
• Twelve hours after rod stabilization of a femoral fracture, a 27-year-old homeless patient develops combativeness and disorientation with petechiae on the axilla. What is the most likely cause?
• What is the primary goal of source control in an abdominal sepsis scenario?
• In gallstone pancreatitis without organ failure, when should cholecystectomy be performed?
• In cirrhotic patients with ascites, what is first-line medical management?
• Why is the timing of noncardiac surgery after myocardial infarction considered critical?
• For chronic hypocalcemia, which therapy is recommended?
• After a head-on motor vehicle collision at high speed, a patient has a widened mediastinum but is asymptomatic. What is the next best diagnostic test to evaluate for a potential aortic injury?
• Screening mammography shows six stippled microcalcifications in a cluster in the upper outer quadrant of the left breast, with no discrete lump. What is the next diagnostic step?
• Porcelain gallbladder is associated with an increased risk of which condition?
• Fat embolism syndrome typically presents within what time frame after a long-bone fracture?
• In this testing plan, what is the step immediately after diagnostic testing if significant coronary disease is present and revascularization is indicated?
• A former smoker presents with painless jaundice and a non-tender palpable RUQ mass. What is most likely diagnosis?
• In the setting of sigmoid volvulus, which scenario most clearly requires surgical intervention rather than endoscopic decompression?
• A 30-year-old man with claudication and a long smoking history. Which disease is most likely and what is the cornerstone of therapy?
• Which factor most strongly predicts poor wound healing besides smoking?
• In cirrhosis, portal hypertension and hepatic dysfunction contribute to perioperative bleeding risk primarily through what mechanism?
• In burn resuscitation using Parkland formula, what is the time frame for administering the second half of the calculated lactated Ringer’s solution?
• What is the preferred initial imaging modality to evaluate suspected colorectal liver metastases?
• In suspected acute stroke, what is the initial step to differentiate ischemic from hemorrhagic etiologies?
• A 53-year-old woman presents with unilateral bloody nipple discharge. Mammography is normal. What is the most definitive next step to establish histology?
• Suspected slipped capital femoral epiphysis in an adolescent requires which immediate management?
• Phalen's sign tests compression of which nerve?
• What imaging modality is preferred on admission to evaluate the cause of acute pancreatitis?
• Leriche syndrome results from occlusion of which vessels?
• 1st step in management of septic shock?
• During a pancreaticoduodenectomy (Whipple procedure), which structures are typically removed?
• Which test is the definitive method to visualize the coronary arteries?
• Which of the following is NOT one of the listed colon cancer screening options?
• Which factor most strongly increases the risk of a postoperative wound infection?
• Which of the following is an absolute contraindication to surgery?
• Which histologic type of breast cancer is often difficult to detect on mammography due to a diffuse growth pattern?
• A 37-year-old man presents with isolated thrombocytopenia: normal Hb, WBC; platelets 45k with high bleeding time and normal PT. Bone marrow shows increased megakaryocytes. What is the most likely diagnosis?
• Which feature most strongly suggests a malignant adrenal mass?
• After initial fluids, what is the recommended vasopressor first-line for septic shock?
• Endoscopic finding most consistent with ischemic colitis?
• A 51-year-old woman has a left breast mass; mammogram and ultrasound are normal; biopsy shows cancer. What is the most likely histologic type?
• Which imaging modality is NOT useful in evaluating nipple discharge?
• On day 3 of admission for severe acute pancreatitis after hemodynamic stability, a patient develops tachypnea and hypoxia with bilateral infiltrates. ABG shows respiratory alkalosis. What is the most likely diagnosis?
• Which cancer surgery commonly requires consideration of adjuvant chemotherapy based on nodal involvement?
• In acute limb ischemia, what is the immediate management step?
• Which triad is classically associated with Leriche syndrome?
• Gallbladder polyps: which statement accurately reflects indications for cholecystectomy?<br>Which statement is true about polyps?
• An incidental 12 mm polyp is found in the gallbladder. What is the next step?