MCQs and Quiz section

Question 1 A four-month old girl is recovering after a truncus arteriosus repair. She is previously known to have a left-sided liver and right-sided stomach. Currently, she is tolerating oral feeds without difficulty and is passing stools normally. What is the next best step in management for this child’s likely intestinal rotational anomaly? A upper gastrointestinal series B diagnostic laparoscopy C prophylactic Ladd procedure D observation alone

Question 1 An otherwise healthy and normal appearing 11 year-old girl presents with sudden lower abdominal pain. She is tender in the LLQ to palpation. US shows an 8 cm complex cyst on the left ovary with a small amount of free fluid in the pelvis. There is decreased flow to the left ovary. The cyst shows septations with a 3 cm solid component. Tumor markers are pending. At laparoscopy, there is torsion of the left ovary and a few small lesions on the liver capsule. There are no peritoneal or omental implants. Peritoneal fluid is sent for cytology and the liver lesions are biopsied. After detorsion of the left ovary, what is the most appropriate step in management? A Clo…

Question 1 A 13-year-old is referred to your clinic by their primary pediatrician for a left forearm skin lesion that has recently increased in size and appears asymmetric and ulcerated. Physical exam, including a complete skin and lymph node exam, is unremarkable except for the left forearm skin lesion. You perform an excisional punch biopsy in clinic using local anesthetic. The pathology is reviewed by a dermatopathologist with expertise in Spitzoid tumors and malignant melanoma and the diagnosis is confirmed as a benign spitz nevus with close (less than 1 mm) but negative margins. What is the best next step for this patient? a re-excision of the scar b re-excision of t…

Question 1 A 13-year old girl presents with mild epigastric pain. Laboratory studies include an AST 135 IU/L, ALT 173 IU/L, total bilirubin 1.9 mg/dL, direct bilirubin 1.4 mg/dL, amylase of 400 u/L, lipase of 500 u/L. Right upper quadrant ultrasound shows small stones in the gallbladder with a 7-mm diameter common bile duct, but no stone was noted in the common duct. The following day, direct bilirubin is 0.7 mg/dL, amylase is 100 u/L, and lipase is 75u/L. The best next step in this child’s management is a MRCP b IV antibiotics c Laparoscopic cholecystectomy with IOC when amylase and lipase normalize d ERCP e Laparoscopic cholecystectomy with intraoperative cholangiogram…

Question 1 An otherwise healthy 38-week-gestation, three-kg newborn with gastroschisis undergoes bedside closure using an umbilical flap (i.e. sutureless closure). On the second day of life the baby is making adequate urine. Nasogastric tube output is 20 mL/kg/day. The current total fluid requirement per day for this infant following gastroschisis closure is A 60 mL/kg B 80 mL/kg C 100 mL/kg D 120 mL/kg E 150 mL/kg

Question 1 You are asked to see a four-week old female with direct hyperbilirubinemia. Ultrasound suggests a small collapsed gallbladder and HIDA study shows hepatic uptake without secretion. Studies for metabolic and infectious diseases were sent off today and final results should be back in 7-10 days. What is the best next step in managing this child with jaundice? A wait for metabolic and infection studies. B ERCP and stent placement C cholangiogram and liver biopsy D liver transplant E MRCP

Question 1 A newborn infant presents with this right knee lesion at birth. What is the best next step in his management? a Observation b Propranolol c Sirolimus d Radiation therapy e Wide excision

Question 1 A 5-year-old child is undergoing umbilical hernia repair. Which of the following would you expect to be most successful in limiting perioperative opioid administration? A Transversus abdominus plane block prior to the incision B Rectus sheath block prior to the incision C Rectus sheath block at the end of the operation D Local wound administration at the end of the operation

Question 1 A 5-week old infant presents with a six-day history of projectile nonbilious emesis. He is awake and responsive. His mother has noticed only one wet diaper in the last 24 hours. On exam the anterior fontanel is sunken. Electrolytes are sodium 136, potassium of 3.5, chloride 92, CO2 32. Following a normal saline bolus of 20 mL/kg, the most appropriate maintenance fluid for this patient with possible hypertrophic pyloric stenosis is: A D10 W with 20 mEq/L potassium chloride B D10 0.2% saline C D5 0.9% (normal) saline D D5 0.45% sodium chloride with 20 mEq/L of potassium chloride

Question 1 You are called by the emergency department to consult on a ten-day old full term male infant with bilious vomiting. The baby is hemodynamically stable and the abdominal exam is unremarkable. An abdominal ultrasound obtained by the emergency physician suggests that the superior mesenteric artery lies to the right of the vein and that there might be “swirl sign”. Your plan in this patient with bilious vomiting should be immediate A repeat the ultrasound with graded compression B upper gastrointestinal series. C contrast enema. D computerized tomography of the abdomen. E laparotomy.

Question 1 A three-year old female presents with large abdominal masses and the computerized tomography (CT) scan shown below. The next best step in management of this child with bilateral renal masses is A systemic chemotherapy B needle biopsy C open wedge biopsy D unilateral nephrectomy E bilateral nephrectomy

Question 1 A 9-month-old child undergoes removal of a central abdominal neuroblastoma. Postoperatively, she develops accumulation of fluid in her abdomen. The fluid has 90% lymphocytes and high chylomicron levels. She undergoes abdominal drain placement due to respiratory compromise. She receives octreotide infusion and TPN administration. Six weeks later, the patient continues to have 40-50 ml/kg/day of chylous ascites, persistent lymphopenia, and hypoalbuminemia. The best option to manage persistent chylous ascites is A abdominal exploration with direct ligation of lymphatic vessels B percutaneous lymphatic duct embolization C percutaneous retroperitoneal injection of …

Question 1 A three-year-old boy presents with refractory constipation following an uncomplicated Yancey-Soave endorectal pull-through for Hirschsprung disease. The most common condition requiring redo pull through operation is A twisted pull through. B tight muscular cuff. C anastomotic stricture. D motility disorder. E aganglionosis.

Question 1 A ten-year-old girl presents to the emergency department with bilious emesis and groin pain six hours prior to arrival. She is mildly distended with a visible mass in the right inguinal region. The mass cannot be reduced. At laparoscopy the right internal ring appears closed. However, an inferomedial defect is identified consistent with a femoral hernia. The recommended operative repair for this child is? A Inversion of the hernia sac with closure of the external oblique aponeurosis B Placement of preperitoneal mesh C High ligation of the hernia sac D Approximation of the transversalis fascia to Cooper’s ligament E Approximating the transversalis fascia to the…

Question 1 A 3-day-old, full-term boy is POD 2 from duodenoduodenostomy for annular pancreas and duodenal atresia. He has a history of truncus arteriosus on preoperative echocardiogram. He has worsening acidemia, requires epinephrine and dopamine, and a distended abdomen. Abdominal x-rays show free air. What is the best next step in management? a Pulmonary artery banding b Repair of truncus arteriosus c Image guided percutaneous drain placement d Exploration with pyloric exclusion and g-tube placement e Exploration and revision of duodenoduodenostomy

Question 1 A 20 week old fetus is diagnosed with macrocystic CPAM (dominant cyst) with CVR of 1.2. The screening ultrasound did not show any evidence of fetal hydrops or polyhydramnios. At 24 weeks, CVR was calculated at 1.8 and there is evidence of ascites, pleural effusion, and pericardial effusion. The best next step for this fetus with CPAM is A Immediate induction to natural delivery B Placement of thoracoamniotic shunt C Immediate EXIT procedure D Repeat ultrasound at 28 weeks E Administration of maternal steroids

Question 1 A 15 month-old boy presents with a cough. A chest x-ray and subsequent CT scan demonstrate a cystic mass in the right lower lobe. Two prenatal ultrasounds showed no evidence of a lung lesion. The most appropriate management is: A Bronchoscopy B Repeat chest x-ray in three months C Right lower lobectomy D Thoracoscopic wedge resection of cyst E Cyst aspiration and sclerosis

Question 1 A five-year old male presents to his pediatrician’s office with a fever and cough. A community acquired pneumonia is diagnosed on chest radiograph. He is treated as an outpatient with oral antibiotics but returns three days later with worsening dyspnea and a large left pleural effusion on repeat chest radiograph. They are admitted and started on broad spectrum IV antibiotics with persistent fevers and an increasing oxygen requirement. A CT scan is obtained which shows a loculated pleural effusion. What is the best next step in management of this patient? a Chest tube alone b Continued IV antibiotic therapy c Chest tube/Fibrinolysis d VATS and decortication

Question 1 A 1-year old girl presents with intermittent drainage near the angle of the mandible. She also has a history of intermittent otorrhea. On exam, there is a small opening near the angle of her mandible and mucus expressed with manual pressure. The rest of her exam is normal. What is the best next step in the management of this patient? A Oral antibiotics B Excision of the entire lesion C Aspiration of the fluid D Incision and drainage E IV antibiotics

Question 1 An infant girl is discovered to have vaginal agenesis. The most frequently anomaly associated with vaginal agenesis is A tethered spinal cord B unilateral renal agenesis C tracheoesophageal fistula D sacral agenesis E ventricular septal defect

Question 1 A 2-year-old boy is referred to your clinic with scrotal asymmetry and a suspected diagnosis of undescended testicle. His mother reports that he was born with a swollen, firm right hemiscrotum that resolved completely after several weeks, and scrotal asymmetry has been present since then. Physical examination confirms a normal left testicle. The right hemiscrotum is comparatively small, however a 3-4 mm “nubbin” is palpable. An inguinoscrotal ultrasound confirms a slightly hypertrophied left testicle and an atrophic right testicular remnant within the scrotum. The best next step in care should be: A Laparoscopy to exclude intraabdominal testicle B Transscrotal…

Question 1 You are called by a physician at a local urgent care facility about a 12-year-old boy with 8 hours of right scrotal pain. A scrotal ultrasound shows twisting of the right spermatic cord and there is an absence of testicular blood flow on color doppler. The most appropriate plan is to a transfer the patient directly to the operating room at your hospital. b transfer the patient to your hospital’s emergency department for assessment. c ask the urgent care physician to send you the ultrasound images to review with a pediatric radiologist. d ask the urgent care physician to attempt manual detorsion.

Question 1 A 6-month old boy presents with enlarging bilateral hydroceles. A plan for bilateral open inguinal hydrocele repair is decided upon. At the time of surgery, after induction of general anesthesia, a previously unrecognized left-sided abdominal mass is palpated. Compression of the left scrotal hydrocele seems to increase the size of the mass slightly; release of compression causes the hydrocele to feel tense again. At this point the surgeon should A Laparoscopically evaluate in conjunction with an inguinal exploration B Cancel the surgery and obtain a VCUG (voiding cystourethrogram) C Scrotal hydrocelectomy D Open laparotomy for the abdominal mass E Cancel the s…

Question 1 You are asked to assess a former 32 week premature male infant with bilateral inguinal hernias. He is now 60 weeks corrected gestational age. An advantage of laparoscopic inguinal hernia repair compared to the open approach is the decreased: a Need for general anesthetic b Risk of complications c Operative time for bilateral inguinal hernias d Operative time for unilateral inguinal hernias e Rate of recurrence

Question 1 An 11-year-old undergoes a laparoscopic splenectomy for hereditary spherocytosis. She returns with complaints of fever and abdominal pain. A doppler ultrasound is obtained which shows the following finding. The next best step in management of this patient is a Transjugular catheterization with thrombolytic transhepatic mechanical thrombectomy b Thrombectomy c Surgical portosystemic shunt d Initiation of anticoagulation