NRE Step 1 Surgery MCQs
12 sample questions from the 655 Surgery questions in NRE-1 Prep. Choose an answer to see why it is right and why each other option is wrong.
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Sample Surgery questions
1. A 71-year-old has abdominal and back pain, fainted, has BP 88/54 and a pulsatile abdominal mass. What is the best management?
Answer: Vascular surgeon now, permissive hypotension. Suspected ruptured AAA in an unstable patient is a surgical emergency. Keep systolic around 70–90 if conscious.
- CT before calling surgeons: Unstable: theatre decision first.
- Ultrasound in the morning: Too late.
- Large fluid boluses to normal BP: Raises BP and worsens bleeding.
- Analgesia and observation: Fatal delay.
2. Before reducing an anterior shoulder dislocation, which nerve must be checked?
Answer: Axillary nerve. Check and document sensation over the lateral deltoid before and after reduction.
- Radial nerve only: Axillary is most commonly injured.
- Phrenic nerve: No.
- Long thoracic nerve: No.
- Median nerve only: Less common.
3. A man has a swelling at the site of a midline laparotomy scar from 2 years ago, more prominent on coughing. It is reducible. What is it and what is the main risk factor?
Answer: Incisional hernia — wound infection. Incisional hernias complicate ~10–20% of laparotomies. Risk factors: wound infection (biggest), obesity, smoking, diabetes, steroids, malnutrition, emergency surgery, poor closure technique, chest infection/coughing. Repair (mesh) if symptomatic; smaller-bite suture techniques reduce risk. Other hernias: umbilical/paraumbilical, epigastric (linea alba), Spigelian (linea semilunaris), obturator (elderly women, Howship–Romberg sign).
- Lipoma — genetic: A cough impulse suggests hernia.
- Divarication of recti — pregnancy: Midline bulge without a defect, not at a scar.
- Epigastric hernia — congenital: Above the umbilicus, not at a scar.
4. A 72-year-old man collapses with sudden back pain, BP 80/50 and a pulsatile tender abdominal mass. What is the management?
Answer: Emergency repair. Ruptured AAA classic triad: abdominal/back pain, hypotension, pulsatile mass. Call vascular surgeon immediately; use permissive hypotension (SBP ~70–90, conscious patient) to limit bleeding; CT angiography only if stable to plan EVAR. Emergency open repair or EVAR. Elective repair indications: diameter ≥ 5.5 cm, growth > 1 cm/year, or symptomatic. Screening men ≥ 65 (smokers) with ultrasound.
- Fluids to normal BP, then CT: Raising BP to normal worsens bleeding; permissive hypotension is used.
- Admit to ward and observe: Observation on the ward is fatal.
- Elective repair next week: A ruptured AAA needs emergency repair.
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5. A 30-year-old woman from Peshawar has 4 months of right iliac fossa pain, weight loss, low-grade fever and a doughy RIF mass. Colonoscopy shows transverse ulcers at the ileocaecal valve; biopsy shows caseating granulomas. What is the treatment?
Answer: Six months of anti-TB therapy. Abdominal TB (ileocaecal commonest) is common in Pakistan and mimics Crohn’s disease. Features: chronic RIF pain, fever, weight loss, mass, subacute obstruction, ascites. Colonoscopy: transverse ulcers, patulous ileocaecal valve; caseating granulomas, AFB, Xpert/culture. Treat with standard 6 months HRZE/HR; surgery for complications (obstruction, perforation, bleeding). Never start anti-TNF therapy for presumed Crohn’s without excluding TB.
- Right hemicolectomy first: Medical therapy comes first.
- Infliximab: Infliximab is dangerous in TB.
- Mesalazine: Mesalazine does not treat TB.
6. A 28-year-old has a painless hard testicular lump. Ultrasound shows a solid intratesticular mass. AFP is normal and β-hCG mildly raised. What is the next step?
Answer: Inguinal orchidectomy. Any solid intratesticular mass is malignant until proved otherwise. Germ cell tumours: seminoma (30s; AFP normal, hCG may be mildly raised; radiosensitive) and non-seminomatous (20s; raised AFP and/or hCG). Never biopsy through the scrotum (changes lymphatic drainage). Treat with radical inguinal orchidectomy with high ligation of the cord; staging CT; chemotherapy/radiotherapy by stage. Cure rates are high. Risk factor: undescended testis.
- Trans-scrotal needle biopsy: Scrotal biopsy risks seeding the tumour.
- Antibiotics for 2 weeks: This is not orchitis.
- Repeat ultrasound in 6 weeks: A solid testicular mass is malignant until proved otherwise.
7. Ten days after a perforated appendix, a patient has swinging fever, right shoulder-tip pain, hiccups and a right pleural effusion. What is the diagnosis?
Answer: Subphrenic abscess. Subphrenic (subdiaphragmatic) abscess after peritonitis or abdominal surgery: swinging pyrexia, malaise, shoulder-tip pain (diaphragmatic irritation, C3–5), hiccups, basal effusion/atelectasis, raised hemidiaphragm. ‘Pus somewhere, pus nowhere, pus under the diaphragm.’ Diagnose by ultrasound/CT; treat with percutaneous drainage and antibiotics.
- Pneumonia: Pneumonia does not explain shoulder pain and hiccups.
- Pulmonary embolism: PE does not cause a swinging fever.
- Wound infection: Wound infection is superficial.
8. A woman with metastatic breast cancer has a painful lytic lesion occupying 70% of the femoral shaft cortex; pain worsens on weight-bearing. Mirels score is 10. What is recommended?
Answer: Prophylactic IM nailing. Bone metastases (breast, prostate, lung, kidney, thyroid) cause pain, pathological fracture, hypercalcaemia and cord compression. Mirels score (site, pain, lesion type, size) ≥ 9 indicates high fracture risk → prophylactic fixation (IM nail) followed by radiotherapy. Bisphosphonates/denosumab reduce skeletal events. Lytic: breast, lung, kidney, thyroid, myeloma; sclerotic: prostate.
- Radiotherapy alone: Radiotherapy alone leaves a high fracture risk.
- Bed rest for 6 weeks: Bed rest causes complications.
- Fix only if it fractures: Fixing after fracture gives a worse outcome.
9. In septic shock unresponsive to fluids, which vasopressor is first-line?
Answer: Noradrenaline. Noradrenaline (α1 > β1) is first-line in septic and vasodilatory shock. Vasopressin is added to reduce noradrenaline dose. Adrenaline for anaphylaxis/cardiac arrest and as an alternative. Dobutamine (β1 inotrope) for low cardiac output (cardiogenic shock, septic cardiomyopathy) once MAP is adequate. Dopamine is associated with more arrhythmias.
- Dopamine: Dopamine causes more arrhythmias.
- Isoprenaline: Isoprenaline is a vasodilator.
- Dobutamine alone: Dobutamine is an inotrope that may lower BP.
10. An obese 50-year-old woman has a painless reducible swelling just above the umbilicus with a narrow neck that has slowly enlarged. What is recommended?
Answer: Elective mesh repair. Adult paraumbilical hernia: through the linea alba adjacent to the umbilicus; associated with obesity, multiparity, ascites; narrow neck → risk of incarceration/strangulation → elective repair (mesh for defects > 1–2 cm). Infant umbilical hernia: through the umbilical ring, usually closes spontaneously by 3–5 years — repair if persists. Epigastric hernia: linea alba between xiphoid and umbilicus, often contains extraperitoneal fat. Divarication of recti: separation of rectus muscles — not a true hernia, no strangulation risk.
- Observation until 5 years: Adult paraumbilical hernias with a narrow neck risk incarceration.
- Herniotomy without mesh as in children: Adult paraumbilical hernias differ from childhood umbilical hernias.
- Truss: A truss is not used for paraumbilical hernias.
11. A construction worker fell 4 metres landing on his heels; he has bilateral heel swelling and pain. Besides the calcaneal fractures, which injury must be excluded?
Answer: Thoracolumbar fracture. Calcaneal fractures (axial load from fall from height): often bilateral; Böhler angle reduced on lateral X-ray; CT for intra-articular extent. Associated injuries (~10% spinal): thoracolumbar burst/compression fractures, tibial plateau, pelvis, contralateral calcaneus. Management: elevation, compartment monitoring (foot compartment syndrome), non-operative or ORIF; complications: subtalar arthritis, heel pad pain, wound problems.
- Scaphoid waist fracture: The scaphoid is in the hand.
- Midshaft clavicle fracture: The clavicle is in the shoulder.
- Patellar dislocation: Patellar dislocation affects the knee.
12. In a head-on collision, a driver’s chin strikes the steering wheel forcing his neck into hyperextension. CT shows bilateral fractures through the pars interarticularis of C2. What is this injury?
Answer: Hangman fracture. Hangman fracture (traumatic spondylolisthesis of the axis): bilateral pars/pedicle fractures of C2 from hyperextension with axial loading (chin on dashboard, judicial hanging with submental knot) — the canal is widened so cord injury is often absent in survivors; classification by displacement/angulation (Levine–Edwards). Most heal with collar or halo; unstable types need surgery. Always protect the spine and image with CT in significant facial/chin injuries.
- Jefferson fracture: A Jefferson fracture is a C1 burst from axial load.
- Flexion teardrop fracture: A flexion teardrop fracture is an anterior-inferior body fragment.
- Chance fracture: A Chance fracture is a thoracolumbar flexion–distraction injury.
Topics covered
Orthopaedics, Trauma, Perioperative care, Gastrointestinal surgery, Skin & subcutaneous tissues, Kidney, urinary bladder & genital, Paediatric surgery, Vascular surgery, Hepatobiliary, Urology, Breast, Lower GI, Burns, Upper GI, Cauda equina syndrome, Priapism, Epididymo-orchitis, Anorectal surgery, Head & neck surgery, Skin & soft tissue, Basic principles of surgery, Appendicitis, Acute pancreatitis, Head injury, Acute abdominal pain, Bowel obstruction, Renal colic (kidney stones), Hip (neck of femur) fracture, Septic arthritis, Testicular torsion, Compartment syndrome, Open fractures, Spinal cord compression, Urinary retention, Perforated viscus and peritonitis, Gallstone disease: colic, cholecystitis, cholangitis, Ankle and foot injuries, Back pain, Elbow injuries, Fractures and dislocations: the basics
Frequently asked questions
How many NRE Step 1 Surgery questions are in the bank?
There are 655 Surgery questions in NRE-1 Prep, each with an explanation for every option.
Are these past paper questions?
No. Every question is original, written by us and mapped to the published PMDC NRE syllabus.
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