Just like the actual exam

Aligned with the National Board of Medical Examiners format. Authored & peer-reviewed by faculty, clinicians, and clerkship directors.

Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.

  • Must address important content
  • Must be well structured


A 50-year-old man presents to his primary care physician with intermittent episodes of tachycardia, hypertension, sweats, and headache. An extensive workup reveals increased 24-hour urinary fractionated metanephrines. A 3 cm adrenal mass consistent with a pheochromocytoma without malignant features is visualized on CT scan. After surgical consultation, a laparoscopic adrenalectomy is planned in 10 days. He has no significant past medical history and does not take any medications. Which of the following is the most appropriate next step in management?

A Initiate both metoprolol and phenoxybenzamine now
B Initiate metoprolol now and phenoxybenzamine 3 days prior to surgery
C Initiate phenoxybenzamine now and metoprolol 3 days prior to surgery
D No medication therapy is necessary

The most appropriate next step is to initiate phenoxybenzamine now and metoprolol 3 days prior to surgery. A pheochromocytoma is a neuroendocrine tumor originating from the chromaffin cells of the adrenal medulla. Pheochromocytomas are rare tumors that can arise sporadically from a de novo mutation or can be associated with a familial syndrome, such as von Hippel-Lindau syndrome or multiple endocrine neoplasia type 2. Pheochromocytomas produce at least one catecholamine (epinephrine, norepinephrine, or dopamine). Classic presentation involves intermittent tachycardia, sweats, headaches, and episodic or persistent hypertension. Radiologic evaluation with CT or MRI should be performed in patients whose biochemical testing with either plasma metanephrines or 24-hour urinary metanephrines is indicative of a pheochromocytoma. Patients with pheochromocytomas should undergo surgical resection, with laparoscopic adrenalectomy preferred for patients with single, small intra-adrenal tumors without malignant features. Preoperative medical therapy is necessary to manage tachycardia and hypertension (preventing a hypertensive crisis in surgery) and to expand volume prior to surgery. An alpha-adrenergic blocker, such as phenoxybenzamine, is recommended for 7–10 days prior to surgery. A beta-blocker, such as metoprolol, is started 2–3 days prior to surgery, but only after alpha-adrenergic blockade has been established to prevent unopposed alpha-adrenergic receptor stimulation.

Initiate both metoprolol and phenoxybenzamine now (A), initiate metoprolol now and phenoxybenzamine 3 days prior to surgery (B), and no medication therapy is necessary (D) are incorrect. This patient requires medical therapy prior to surgery. Preoperative beta-blockers should not be administered until alpha-adrenergic blockade has been achieved. Worsening hypertension can develop if vasodilatory peripheral beta-adrenergic receptors are blocked while there is unopposed alpha-adrenergic receptor stimulation.


Written with a purpose

Understanding why an answer choice is incorrect is just as important as knowing why one is correct. That’s why every Rosh Review question includes detailed explanations for the correct and incorrect answer choices. These comprehensive summaries link the most important components of a topic—from risk factors to diagnostics and treatment—giving you the context to build relationships between them.

  • Created for optimal learning and recall
  • Help reinforce your knowledge
  • Focus on the essential information


Created to enhance learning

Custom illustrations and tables help further clarify the core concepts. When information is presented visually, you can focus on meaning, easily reorganize and group similar ideas, and make better use of your memory.


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Deep insights to determine your strengths and weaknesses so you can spend your time on the subjects that matter.

Compare with your peers (chart)

Compare with your peers

Discover how your answer choices align with those selected by learners across the country.

Find out your probability of passing

Using data generated by previous users, your Qbank gives a prediction of how likely you are to pass your exam.

One Step Further

Taking your learning to the next level

After each explanation is a straightforward question with a simple, memorizable answer that reinforces the corresponding topic.

  • Strengthens your knowledge
  • Stands alone from the main explanation so you’re not rereading content

Q: What are metanephrines?

Reveal Answer

A: Metabolic products from catecholamine breakdown (metanephrine and normetanephrine).


  • Patients may report headaches, diaphoresis, tremors, and vision changes
  • PE will show hypertension
  • Diagnosis is made by assay of urinary catecholamines and metanephrines, and plasma metanephrine levels
  • Most commonly caused by catecholamine-secreting tumor located in the adrenal glands
  • Treatment is surgery, alpha-blocker (i.e., phentolamine, phenoxybenzamine) prior to beta-blockade to prevent unopposed alpha-agonism

Rapid Review

Keeping things simple

These bulleted reviews focus on condensed, high-yield concepts about the main topic, from patient presentation to preferred management.

  • Cover the fundamentals in one list
  • Allow you to quickly scan the must-know information
I needed to score well on my shelf exam, so I looked for a resource with high-yield content. Rosh Review was it. I ended up scoring the highest shelf score for the rotation.


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You can access free practice questions with a free trial for a Shelf Exam Qbank—no billing information required. The free trial includes practice questions that align with topics found on the shelf exam and include comprehensive answer explanations and beautiful teaching images.

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