NBME SUBJECT EXAM – SURGERY EXAM | ALL
QUESTIONS AND ANSWERS | A+ GRADED |
COMPREHENSIVE EXAM GUIDE 2026/2027
1. A 68-year-old man presents with sudden, severe abdominal pain that began 2 hours ago.
He has atrial fibrillation and is not taking anticoagulation. Examination reveals diffuse
abdominal tenderness that is less severe than expected from the intensity of his pain. Serum
lactate is elevated. Which of the following is the most likely diagnosis?
A. Acute pancreatitis
B. Acute mesenteric ischemia
C. Perforated peptic ulcer
D. Acute cholecystitis
Answer: B
Rationale: Acute mesenteric ischemia from arterial embolism is strongly associated with
atrial fibrillation and classically causes severe abdominal pain that is initially disproportionate
to physical examination findings.
2. A 24-year-old woman presents with right lower quadrant abdominal pain, nausea, and
anorexia. Her temperature is 38.1°C, and examination reveals localized tenderness at
McBurney point. Which of the following is the most appropriate initial imaging study in a
nonpregnant adult?
A. CT scan of the abdomen and pelvis
B. Plain abdominal radiograph
C. HIDA scan
D. MRI of the pelvis
Answer: A
Rationale: CT of the abdomen and pelvis is commonly used to evaluate suspected appendicitis
in nonpregnant adults because it provides high diagnostic accuracy and can identify
complications or alternative diagnoses.
3. A 45-year-old man develops severe epigastric pain radiating to the back after heavy
alcohol consumption. Serum lipase is markedly elevated. Which of the following is the most
important initial management?
A. Immediate laparotomy
B. Emergent ERCP in every patient
C. Aggressive intravenous fluid resuscitation and supportive care
D. Prophylactic total parenteral nutrition
Answer: C
,Rationale: Most cases of acute pancreatitis are initially managed with supportive treatment,
particularly adequate intravenous fluids, analgesia, monitoring, and early enteral nutrition
when tolerated.
4. A 72-year-old woman develops fever, jaundice, and right upper quadrant pain.
Laboratory studies show elevated bilirubin and alkaline phosphatase. Imaging
demonstrates a dilated common bile duct containing a stone. Which intervention is most
appropriate if she has evidence of ascending cholangitis?
A. Elective cholecystectomy only
B. Observation with oral antibiotics
C. Colonoscopy
D. Urgent biliary decompression with ERCP
Answer: D
Rationale: Acute ascending cholangitis requires antibiotics and urgent biliary drainage,
typically by ERCP, to control the infected obstructed biliary system.
5. A 19-year-old man is brought to the emergency department after a motor vehicle
collision. He is hypotensive and has a rigid abdomen. Which of the following is the most
appropriate next step?
A. Immediate exploratory laparotomy
B. Colonoscopy
C. Oral contrast CT
D. Diagnostic endoscopy
Answer: A
Rationale: A hemodynamically unstable trauma patient with findings suggesting intra-
abdominal hemorrhage requires immediate operative evaluation rather than delaying
treatment for extensive imaging.
6. A 58-year-old woman presents with a painful, erythematous mass in the axilla.
Examination reveals fluctuance and surrounding cellulitis. Which treatment is most
appropriate?
A. Topical corticosteroid
B. Incision and drainage
C. Observation alone
D. Compression therapy
Answer: B
Rationale: A fluctuant abscess generally requires incision and drainage because antibiotics
alone do not adequately evacuate the purulent collection.
,7. A 61-year-old man with a history of smoking presents with painless gross hematuria.
Which diagnosis must be considered most strongly?
A. Renal colic
B. Acute cystitis
C. Urothelial carcinoma
D. Benign prostatic hyperplasia
Answer: C
Rationale: Painless gross hematuria is a classic warning sign of urinary tract malignancy,
particularly urothelial carcinoma in an older smoker.
8. A 34-year-old woman develops severe right upper quadrant pain after eating a fatty
meal. Ultrasound shows gallstones and gallbladder wall thickening. Which diagnosis is
most likely?
A. Acute pancreatitis
B. Acute appendicitis
C. Choledocholithiasis without inflammation
D. Acute cholecystitis
Answer: D
Rationale: Persistent right upper quadrant pain with gallstones and gallbladder wall
thickening is characteristic of acute cholecystitis.
9. A 66-year-old man presents with progressive dysphagia that initially occurred with solid
foods and now occurs with liquids. He has experienced significant unintentional weight
loss. Which diagnosis is most concerning?
A. Esophageal carcinoma
B. Achalasia
C. Gastroesophageal reflux disease
D. Esophageal web
Answer: A
Rationale: Progressive dysphagia beginning with solids and progressing to liquids, especially
with weight loss, strongly suggests a mechanical obstruction such as esophageal malignancy.
10. A 27-year-old woman presents with sudden severe lower abdominal pain and vomiting.
Pregnancy testing is negative. Examination reveals marked unilateral adnexal tenderness.
Which diagnosis should be considered urgently?
A. Endometriosis
B. Ovarian torsion
C. Pelvic inflammatory disease
D. Functional constipation
, Answer: B
Rationale: Sudden unilateral pelvic pain with vomiting and adnexal tenderness is highly
concerning for ovarian torsion, which requires urgent evaluation and treatment to preserve
ovarian viability.
11. A 52-year-old man presents with fever, left lower quadrant abdominal pain, and
leukocytosis. CT shows sigmoid diverticulitis with a localized abscess. Which management
is most appropriate?
A. Immediate appendectomy
B. High-fiber diet alone
C. Antibiotics with appropriate drainage when indicated
D. Colonoscopy during the acute inflammatory episode
Answer: C
Rationale: Complicated diverticulitis with an abscess requires antimicrobial therapy and,
depending on abscess size and clinical circumstances, image-guided drainage.
12. A patient develops increasing abdominal distension, vomiting, and inability to pass stool
or flatus. Imaging demonstrates multiple dilated small-bowel loops with air-fluid levels.
Which diagnosis is most likely?
A. Mechanical small-bowel obstruction
B. Acute hepatitis
C. Gastritis
D. Acute pancreatitis
Answer: A
Rationale: Vomiting, obstipation, distension, and dilated small-bowel loops with air-fluid
levels are classic findings of mechanical intestinal obstruction.
13. A 70-year-old woman develops abdominal distension several days after major surgery.
She has nausea and vomiting but no evidence of a transition point on imaging. Which
condition is most likely?
A. Incarcerated hernia
B. Volvulus
C. Postoperative ileus
D. Intussusception
Answer: C
Rationale: Postoperative ileus is characterized by temporary impairment of intestinal motility
without a mechanical obstruction and commonly occurs after abdominal surgery.
QUESTIONS AND ANSWERS | A+ GRADED |
COMPREHENSIVE EXAM GUIDE 2026/2027
1. A 68-year-old man presents with sudden, severe abdominal pain that began 2 hours ago.
He has atrial fibrillation and is not taking anticoagulation. Examination reveals diffuse
abdominal tenderness that is less severe than expected from the intensity of his pain. Serum
lactate is elevated. Which of the following is the most likely diagnosis?
A. Acute pancreatitis
B. Acute mesenteric ischemia
C. Perforated peptic ulcer
D. Acute cholecystitis
Answer: B
Rationale: Acute mesenteric ischemia from arterial embolism is strongly associated with
atrial fibrillation and classically causes severe abdominal pain that is initially disproportionate
to physical examination findings.
2. A 24-year-old woman presents with right lower quadrant abdominal pain, nausea, and
anorexia. Her temperature is 38.1°C, and examination reveals localized tenderness at
McBurney point. Which of the following is the most appropriate initial imaging study in a
nonpregnant adult?
A. CT scan of the abdomen and pelvis
B. Plain abdominal radiograph
C. HIDA scan
D. MRI of the pelvis
Answer: A
Rationale: CT of the abdomen and pelvis is commonly used to evaluate suspected appendicitis
in nonpregnant adults because it provides high diagnostic accuracy and can identify
complications or alternative diagnoses.
3. A 45-year-old man develops severe epigastric pain radiating to the back after heavy
alcohol consumption. Serum lipase is markedly elevated. Which of the following is the most
important initial management?
A. Immediate laparotomy
B. Emergent ERCP in every patient
C. Aggressive intravenous fluid resuscitation and supportive care
D. Prophylactic total parenteral nutrition
Answer: C
,Rationale: Most cases of acute pancreatitis are initially managed with supportive treatment,
particularly adequate intravenous fluids, analgesia, monitoring, and early enteral nutrition
when tolerated.
4. A 72-year-old woman develops fever, jaundice, and right upper quadrant pain.
Laboratory studies show elevated bilirubin and alkaline phosphatase. Imaging
demonstrates a dilated common bile duct containing a stone. Which intervention is most
appropriate if she has evidence of ascending cholangitis?
A. Elective cholecystectomy only
B. Observation with oral antibiotics
C. Colonoscopy
D. Urgent biliary decompression with ERCP
Answer: D
Rationale: Acute ascending cholangitis requires antibiotics and urgent biliary drainage,
typically by ERCP, to control the infected obstructed biliary system.
5. A 19-year-old man is brought to the emergency department after a motor vehicle
collision. He is hypotensive and has a rigid abdomen. Which of the following is the most
appropriate next step?
A. Immediate exploratory laparotomy
B. Colonoscopy
C. Oral contrast CT
D. Diagnostic endoscopy
Answer: A
Rationale: A hemodynamically unstable trauma patient with findings suggesting intra-
abdominal hemorrhage requires immediate operative evaluation rather than delaying
treatment for extensive imaging.
6. A 58-year-old woman presents with a painful, erythematous mass in the axilla.
Examination reveals fluctuance and surrounding cellulitis. Which treatment is most
appropriate?
A. Topical corticosteroid
B. Incision and drainage
C. Observation alone
D. Compression therapy
Answer: B
Rationale: A fluctuant abscess generally requires incision and drainage because antibiotics
alone do not adequately evacuate the purulent collection.
,7. A 61-year-old man with a history of smoking presents with painless gross hematuria.
Which diagnosis must be considered most strongly?
A. Renal colic
B. Acute cystitis
C. Urothelial carcinoma
D. Benign prostatic hyperplasia
Answer: C
Rationale: Painless gross hematuria is a classic warning sign of urinary tract malignancy,
particularly urothelial carcinoma in an older smoker.
8. A 34-year-old woman develops severe right upper quadrant pain after eating a fatty
meal. Ultrasound shows gallstones and gallbladder wall thickening. Which diagnosis is
most likely?
A. Acute pancreatitis
B. Acute appendicitis
C. Choledocholithiasis without inflammation
D. Acute cholecystitis
Answer: D
Rationale: Persistent right upper quadrant pain with gallstones and gallbladder wall
thickening is characteristic of acute cholecystitis.
9. A 66-year-old man presents with progressive dysphagia that initially occurred with solid
foods and now occurs with liquids. He has experienced significant unintentional weight
loss. Which diagnosis is most concerning?
A. Esophageal carcinoma
B. Achalasia
C. Gastroesophageal reflux disease
D. Esophageal web
Answer: A
Rationale: Progressive dysphagia beginning with solids and progressing to liquids, especially
with weight loss, strongly suggests a mechanical obstruction such as esophageal malignancy.
10. A 27-year-old woman presents with sudden severe lower abdominal pain and vomiting.
Pregnancy testing is negative. Examination reveals marked unilateral adnexal tenderness.
Which diagnosis should be considered urgently?
A. Endometriosis
B. Ovarian torsion
C. Pelvic inflammatory disease
D. Functional constipation
, Answer: B
Rationale: Sudden unilateral pelvic pain with vomiting and adnexal tenderness is highly
concerning for ovarian torsion, which requires urgent evaluation and treatment to preserve
ovarian viability.
11. A 52-year-old man presents with fever, left lower quadrant abdominal pain, and
leukocytosis. CT shows sigmoid diverticulitis with a localized abscess. Which management
is most appropriate?
A. Immediate appendectomy
B. High-fiber diet alone
C. Antibiotics with appropriate drainage when indicated
D. Colonoscopy during the acute inflammatory episode
Answer: C
Rationale: Complicated diverticulitis with an abscess requires antimicrobial therapy and,
depending on abscess size and clinical circumstances, image-guided drainage.
12. A patient develops increasing abdominal distension, vomiting, and inability to pass stool
or flatus. Imaging demonstrates multiple dilated small-bowel loops with air-fluid levels.
Which diagnosis is most likely?
A. Mechanical small-bowel obstruction
B. Acute hepatitis
C. Gastritis
D. Acute pancreatitis
Answer: A
Rationale: Vomiting, obstipation, distension, and dilated small-bowel loops with air-fluid
levels are classic findings of mechanical intestinal obstruction.
13. A 70-year-old woman develops abdominal distension several days after major surgery.
She has nausea and vomiting but no evidence of a transition point on imaging. Which
condition is most likely?
A. Incarcerated hernia
B. Volvulus
C. Postoperative ileus
D. Intussusception
Answer: C
Rationale: Postoperative ileus is characterized by temporary impairment of intestinal motility
without a mechanical obstruction and commonly occurs after abdominal surgery.
