SURGERY SHELF EXAM: CASE-BASED CLINICAL SCENARIOS | 2026 ROTATIONS
QUESTIONS AND WELL-EXPLAINED ANSWERS 2026/2027
SURGERY SHELF EXAM
Case-Based Clinical Scenarios | 2026 Rotations
NBME-Style | 5 Core Cases | Surgery Topics
CASE INDEX
Case Title Topic Difficulty Answer
01 22-year-old motorcyclist Trauma Medium B
after MVC
02 67-year-old with acute GI / Hard B
abdominal pain Abdomen
03 58-year-old with pulsatile Vascular Easy C
abdominal mass
04 45-year-old with thyroid Endocrine Medium C
incidentaloma
05 34-year-old stabbing Trauma Hard C
victim
CASE 01 22-year-old motorcyclist after MVC Trauma Medium
CLINICAL VIGNETTE
A 22-year-old man is brought to the ED after a high-speed motorcycle
collision. He is diaphoretic and confused. Primary survey reveals
diminished breath sounds on the left, tracheal deviation to the right, and
distended neck veins. His GCS is 12.
, VITAL SIGNS
HR (bpm) BP (mmHg) RR (/min) SpO2 (%) Temp (°C)
128 82/50 28 84% 37.1
QUESTION
What is the most appropriate immediate next step in management?
A Chest X-ray to confirm diagnosis
B Needle decompression of the left chest, 2nd intercostal space,
midclavicular line
C Emergent intubation and mechanical ventilation
D CT chest/abdomen with contrast
E Insert 28Fr chest tube on the right side
Explanation:
This patient has tension pneumothorax — the clinical triad of
hypotension, absent breath sounds (left), and tracheal deviation away
from the affected side is pathognomonic. Immediate needle
decompression at the 2nd ICS, MCL is the life-saving first step. Imaging
is contraindicated when tension PTX is clinically apparent — every
minute delays definitive decompression. A chest tube follows after needle
decompression.
CASE 02 67-year-old with acute abdominal pain GI / Abdomen Hard
CLINICAL VIGNETTE
A 67-year-old woman with a history of atrial fibrillation presents with
sudden onset severe periumbilical pain for 3 hours. She describes the
pain as out of proportion to her exam findings. She is on warfarin. Labs
show WBC 11,000, lactate 3.8 mmol/L, and INR 2.6.
VITAL SIGNS
QUESTIONS AND WELL-EXPLAINED ANSWERS 2026/2027
SURGERY SHELF EXAM
Case-Based Clinical Scenarios | 2026 Rotations
NBME-Style | 5 Core Cases | Surgery Topics
CASE INDEX
Case Title Topic Difficulty Answer
01 22-year-old motorcyclist Trauma Medium B
after MVC
02 67-year-old with acute GI / Hard B
abdominal pain Abdomen
03 58-year-old with pulsatile Vascular Easy C
abdominal mass
04 45-year-old with thyroid Endocrine Medium C
incidentaloma
05 34-year-old stabbing Trauma Hard C
victim
CASE 01 22-year-old motorcyclist after MVC Trauma Medium
CLINICAL VIGNETTE
A 22-year-old man is brought to the ED after a high-speed motorcycle
collision. He is diaphoretic and confused. Primary survey reveals
diminished breath sounds on the left, tracheal deviation to the right, and
distended neck veins. His GCS is 12.
, VITAL SIGNS
HR (bpm) BP (mmHg) RR (/min) SpO2 (%) Temp (°C)
128 82/50 28 84% 37.1
QUESTION
What is the most appropriate immediate next step in management?
A Chest X-ray to confirm diagnosis
B Needle decompression of the left chest, 2nd intercostal space,
midclavicular line
C Emergent intubation and mechanical ventilation
D CT chest/abdomen with contrast
E Insert 28Fr chest tube on the right side
Explanation:
This patient has tension pneumothorax — the clinical triad of
hypotension, absent breath sounds (left), and tracheal deviation away
from the affected side is pathognomonic. Immediate needle
decompression at the 2nd ICS, MCL is the life-saving first step. Imaging
is contraindicated when tension PTX is clinically apparent — every
minute delays definitive decompression. A chest tube follows after needle
decompression.
CASE 02 67-year-old with acute abdominal pain GI / Abdomen Hard
CLINICAL VIGNETTE
A 67-year-old woman with a history of atrial fibrillation presents with
sudden onset severe periumbilical pain for 3 hours. She describes the
pain as out of proportion to her exam findings. She is on warfarin. Labs
show WBC 11,000, lactate 3.8 mmol/L, and INR 2.6.
VITAL SIGNS
