Module 2. Pediatric surgery
Tests questions
1. Thirty-six hours after delivery, an otherwise healthy term infant has not yet passed meconium (has not yet had a bowel movement). Which one of these modalities would not be an appropriate step in the child’s workup?
A. Suction rectal biopsy
B. Contrast enema
C. Chromosomes for delta F-508
D. Plain abdominal radiography
E. *Colonoscopy
2. All of the following radiologic abdominal plain film findings are consistent with mechanical bowel obstruction except:
A. a “step ladder” pattern
B. dilated small bowel loops
C. absence of gas in large bowel
D. rows of small gas accumulations in valvulae conniventes (i.e. “string of pearls”)
E. *air-fluid levels at uniform height in same bowel loop
3. Which of the following signs and symptoms warrant surgical intervention for patients with small bowel obstruction?
A. abdominal tenderness
B. air-fluid levels on abdominal x-ray
C. feculent vomitus
D. air in the colon and rectum on abdominal x-ray
E. *worsening abdominal pain
4. Which of the following does not cause bilious vomiting in an infant or child?
A. Intestinal malrotation and volvulus
B. Duodenal atresia
C. Small bowel obstruction
D. Ulcerative colitis with colonic obstruction
E. *Pyloric stenosis
5. All of the following radiologic abdominal plain film findings are consistent with mechanical bowel obstruction except:
A. a “step ladder” pattern
B. dilated small bowel loops
C. absence of gas in large bowel
D. rows of small gas accumulations in valvulae conniventes (i.e. “string of pearls”)
E. *air-fluid levels at uniform height in same bowel loop
6. Which of the following signs and symptoms warrant surgical intervention for patients with small bowel obstruction?
A. abdominal tenderness
B. air-fluid levels on abdominal x-ray
C. feculent vomitus
D. air in the colon and rectum on abdominal x-ray
E. *worsening abdominal pain
7. Complete mechanical small bowel obstruction can cause dehydration by:
A. Interfering with oral intake of water.
B. Inducing vomiting.
C. Decreasing intestinal absorption of water.
D. Causing secretion of water into the intestinal lumen.
E. *All of the above.
8. History and physical examination permit the diagnosis of intestinal obstruction in most cases. Which of the following are important for the clinical diagnosis of small bowel obstruction?
A. Crampy abdominal pain.
B. Abdominal tenderness.
C. Vomiting.
D. Abdominal distention.
E. *All of the above
9. Patients with established, complete, simple, distal small bowel obstruction usually have the following findings on plain and upright abdominal radiographs:
A. Free air
B. Modest amount of gas in the pelvis.
C. Peripheral, rather than central, distribution of gas.
D. Prominent haustral markings.
E. *Multiple air-fluid levels.
10. For which of the following consequences of radiation injury of the intestine is urgent laparotomy required?
A. Small bowel obstruction.
B. Rectovaginal fistula.
C. Malabsorption and diarrhea.
D. Rectal stenosis.
E. *Colonic perforation.
11. Regarding contrast study for intestinal obstruction:
A. Gastrografin is preferred to barium for studying distal small bowel
B. Gastrografin has no therapeutic potential
C. Gastrografin is less hazardous than barium if aspiration occurs
D. barium can convert partial small bowel obstruction into complete obstruction
E. *Gastrografin can cause serious fluid shift
12. Benign small bowel tumors most commonly present as:
A. gastrointestinal bleeding
B. weight loss
C. incidental finding on laparotomy
D. intestinal perforation
E. *small bowel obstruction
13. Small bowel obstruction in an elderly female without external hernia or previous surgery is most likely caused by:
A. small bowel neoplasm
B. volvulus
C. abdominal abscess
D. obturator hernia
E. *gallstone ileus
14. Of the following, which is the most likely cause of hemodynamically significant lower gastrointestinal bleeding in a 6 month old male child?
A. Infectious diarrheas
B. Henoch-Schonlein purpura
C. Crohn’s colitis
D. Hemolytic uremic syndrome
E. *Intussusception
15. Which of the following signs and symptoms warrant surgical intervention for patients with small bowel obstruction?
A. abdominal tenderness
B. air-fluid levels on abdominal x-ray
C. feculent vomitus
D. air in the colon and rectum on abdominal x-ray
E. *worsening abdominal pain
16. The most common type of intussusception is:
A. ileoileal
B. colocolic
C. ileo-ileocolic
D. Ileocecal
E. *ileocolic
17. Contraindications for non-surgical reduction of an intussusception include all of the following except:
A. shock
B. intestinal perforation
C. peritonitis
D. symptoms until 12 hours
E. *symptoms for longer than 24 hours
18. Which is the most common pathological lead point found with intussusception?
A. neoplasm
B. appendicitis
C. polyps
D. intestinal duplication
E. *Meckel’s diverticulum
19. A pathologic lead point can be identified in approximately what percentage of patients with intussusception?
A. 1%
B. 5%
C. 15%
D. 25%
E. *10%
20. Which element of the “classical triad” of intussusception usually appears first?
A. diarrhea
B. vomiting
C. fever
D. bloody stools
E. *abdominal pain
21. All three of the “classical triad” of symptoms is found in what percentage of patients with intussusception?
A. 9%
B. 50%
C. 70%
D. 90%
E. *21%
22. In case of intussusception if a mass is palpable on physical examination, it is most often found in the:
A. right lower quadrant
B. left upper quadrant
C. left lower quadrant
D. suprupubic region
E. *right upper quadrant
23. Which is the most common pathological lead point found with intussusception?
A. neoplasm
B. appendicitis
C. polyps
D. intestinal duplication
E. *Meckel’s diverticulum
24. A pathologic lead point can be identified in approximately what percentage of patients with intussusception?
A. 1%
B. 5%
C. 15%
D. 25%
E. *10%
25. Which element of the “classical triad” usually appears first?
A. diarrhea
B. vomiting
C. fever
D. bloody stools
E. *abdominal pain
26. Ileocolic intussusception in children:
A. presents with rectal bleeding in 90% of cases
B. is commonly caused by an underlying pathology
C. is ideally treated by operative reduction
D. Hydrostatic reduction without surgery rarely provides successful treatment
E. *is the most common cause of intestinal obstruction before the age of 3 years
27. A 3-day-old boy presents with 12 hours of bilious vomiting, abdominal pain, and abdominal distension. Which of the following is the most appropriate next step in management?
A. Order an abdominal ultrasonography.
B. Order a computerized tomography scan of the abdomen.
C. Order a barium enema.
D. Order a chest radiograph.
E. *Order a upper GI contrast series.
28. Correct statements concerning intussusception in infants include which of the following?
A. Recurrence rates following treatment are high
B. A 1- to 2-wk period of parenteral alimentation should precede surgical reduction when surgery is required
C. Hydrostatic reduction without surgery rarely provides successful treatment
D. The most common type occurs at the junction of the descending colon and sigmoid colon
E. *It is frequently preceded by a gastrointestinal viral illness
29. Which of the following statements about achalasia is/are correct?
A. In most cases in North America the cause is a parasitic infestation by Trypanosoma cruzi.
B. Chest pain and regurgitation are the usual symptoms.
C. Distal-third esophageal adenocarcinomas may occur in as many as 20% of patients within 10 years of diagnosis.
D. Endoscopic botulinum toxin injection of the LES, pneumatic dilatation, and esophagomyotomy provide highly effective curative therapy for achalasia.
E. *Manometry demonstrates failure of LES relaxation on swallowing and absent or weak simultaneous contractions in the esophageal body after swallowing.
30. A 17-year- man is scheduled to undergo sigmoid colectomy for diverticular disease. He denies a history of prolonged bleeding after biting the lip or tongue, bruises without apparent injury, or prolonged bleeding after dental extraction. His preoperative evaluation of hemostasis should include
A. no screening tests
B. prothrombin time (PT) and partial thromboplastin time (PTT)
C. platelet count, blood smear, bleeding time, PT, and PTT
D. platelet count, PT, and PTT
E. *platelet count, blood smear, and PTT
31. Bank blood is appropriate for replacing each of the following EXCEPT
A. factor I (fibrinogen)
B. factor II (prothrombin)
C. factor VII (proconvertin)
D. factor X (Stuart-Prower factor)
E. *factor VIII (antihemophilic factor)
32. Which of the following clotting factors is consumed during coagulation?
A. factor IX (Christmas factor)
B. factor X (Stuart-Prower factor)
C. factor XI (plasma thromboplasma antecedent)
D. factor XII (Hageman factor)
E. *factor I (fibrinogen)
33. All of the following are physiologic events in the hemostatic process EXCEPT
A. fibrinolysis
B. fibrin formation
C. platelet plug formation
D. vascular constriction
E. *rise in circulating epinephrine
34. A prolonged bleeding time may be anticipated in patients with each of the following problems EXCEPT
A. aspirin ingestion in the past week
B. qualitative platelet dysfunction
C. thrombocytopenia
D. von Willebrand’s disease
E. *classic haemophilia
35. If a patient is found to have a normal partial thromboplastin time (PTT) and a prolonged one-stage prothrombin time (PT), there may be a deficiency of factor
A. VIII (antihemophilic factor)
B. IX (plasma thromboplastin component)
C. XI (plasma thromboplastin antecedent)
D. XII (Hageman factor)
E. *V (proaccelerin)
36. Frozen plasma prepared from freshly donated blood is necessary when a patient requires
A. fibrinogen
B. prothrombin
C. Christmas factor
D. Hageman factor
E. *antihemophilic factor
37. Which of the following conditions caot prolong bleeding time to abnormal levels?
A. Thrombocytopenia
B. Qualitative abnormalities of platelets
C. Ingestion of aspirin
D. von Willebrand’s disease
E. *Hemophilia
38. Which of the following is NOT a cause of major lower gastrointestinal hemorrhage?
A. angiodysplasia
B. aortoenteric fistula
C. none of the above
D. all of the above
E. *Diverticulitis
39. A one year-old female presents with vaginal bleeding. Vaginal inspection reveals the presence of a multicystic grape-like lesion. The most likely diagnosis is?
A. sexual abuse
B. DES syndrome
C. clear cell Adenocarcinoma
D. exposure to exogenous estrogen
E. *sarcoma botyroides
40. A 2-year-old child has got intestinal dysbacteriosis, which results in hemorrhagic syndrome. What is the most likely cause of hemorrhage of the child?
A. PP hypovitaminosis
B. Fibrinogen deficiency
C. Hypocalcemia
D. Activation of tissue thromboplastin
E. *Vitamin K insufficiency
41. An 8-year-old boy presents with acute onset of cramping abdominal pain and vomiting. He has multiple maculopapular rash spots on his lower extremities. Which of the following is the most likely diagnosis?
A. Acute appendicitis
B. Kawasaki disease
C. Crohn disease
D. Sickle cell crisis
E. *Henoch-Schenlein purpura
42. The diagnostic test of choice for suspected acute sigmoid diverticulitis is:
A. barium enema
B. Gastrografin enema
C. abdominal ultrasound
D. colonoscopy
E. *computed tomography scan of the abdomen and pelvis
43. Stored blood is deficient in:
A. factor II
B. factor VII
C. factor IX
D. factor XI
E. *factor VIII
44. An 18-month-old female child presents with blood-streaked stool.The stool is grossly positive on Hemoccult testing. Which of the following diagnoses is most likely?
A. peptic ulcer disease
B. Mallory-Weiss tear
C. inflammatory bowel disease
D. necrotizing enterocolitis
E. *anal fissure
45. A diagnosis of bleeding esophageal varices is made in patient. Appropriate initial therapy would be
A. Intravenous vasopressin
B. Emergency portacaval shunt
C. Emergency esophageal transection
D. Esophageal balloon tamponade
E. *Endoscopic sclerotherapy
46. A previously healthy 9-yearold child comes to the emergency room because of fulminant upper gastrointestinal bleeding. The hemorrhage is most likely to be the result of
A. Mallory-Weiss syndrome
B. Gastritis
C. A gastric ulcer
D. A duodenal ulcer
E. *Esophageal varices
47. Which of the following is the most common type of ectopic tissue found in Meckel diverticulum?
A. Pancreatic
B. Colonic
C. Endometrial
D. Jejunal
E. *Gastric
48. Which of the following is the most common cause of intestinal obstruction in patients with Meckel diverticulum?
A. Volvulus around vitelline duct remnants
B. Volvulus through vitelline duct remnants
C. Leiomyoma
D. Internal hernia
E. *Omphalomesenteric band
49. Meckel’s diverticulum may present with all of the following signs or symptoms. In wich clinical presentation approximate frequency will be the less?
A. Hemorrhage
B. Intussusception
C. Volvulus
D. Right lower quadrant peritoneal findings
E. *Patent omphalomesenteric duct
50. Of the following, which is the most likely cause of hemodynamically significant lower gastrointestinal bleeding in a 6 month old male child?
A. Henoch-Schonlein purpura
B. Infectious diarrheas
C. Crohn’s colitis
D. Hemolytic uremic syndrome
E. *Meckel diverticulum
51. Which of the following statements is true concerning Meckel’s diverticulum?
A. It is found within
B. Ectopic colonic epithelium is found in it.
C. Diagnosis is best made by CT scan.
D. The diverticulum is usually found on the mesenteric border of the bowel.
E. *It represents a remnant of the embryonic vitelline duct.
52. Which of the following is an indication to resect a Meckel’s diverticulum found incidentally during a laparoscopic appendectomy in a 52-year-old male?
A. any Meckel’s diverticulum found incidentally should be removed
B. location within
C. history of rectal bleeding
D. presence of a wide neck
E. *presence of firm tissue at the base of the diverticulum
53. All of the following statements about the embryology of Meckel’s diverticulum are true except:
A. Meckel’s diverticulum usually arises from the ileum within
B. Meckel’s diverticulum results from the failure of the vitelline duct to obliterate.
C. Meckel’s diverticulum is a true diverticulum possessing all layers of the intestinal wall.
D. Gastric mucosa is the most common ectopic tissue found within a Meckel’s diverticulum.
E. *The incidence of Meckel’s diverticulum in the general population is 5%.
54. Meckel’s diverticulum most commonly presents as:
A. Obstruction.
B. Diverticulitis.
C. Intermittent abdominal pain.
D. Perforation
E. *Gastrointestinal bleeding.
55. Meckel’s diverticulum:
A. is a false diverticulum
B. commonly presents as gastrointestinal bleeding in adults
C. commonly presents with intestinal obstruction in children
D. is found in approximately 5% to 10% of people
E. *is asymptomatic in most cases
56. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?
A. Patent urachus
B. Patent omphalomesenteric duct
C. Omphalocele
D. Gastroschisis
E. *Umbilical hernia
57. A colon polyp with the highest malignant potential is:
A. 1cm tubular adenoma
B.
C.
D.
E. *2 cm villous adenoma
58. Which of the following statements about familial adenomatous polyposis (FAP) is true?
A. Inherited in an autosomal-dominant manner, this genetic defect is of variable penetrance, some patients having only a few polyps whereas others develop thousands.
B. The phenotypic expression of the disease depends mostly on the genotype.
C. Panproctocolectomy with ileostomy is not appropriate therapy for this disease.
D. Pharmacologic management of this disease may be appropriate in some instances.
E. *Appropriate surgical therapy includes total abdominal colectomy with ileorectal anastomosis and ileoanal pull-through with rectal mucosectomy.
59. A patient with a history of familial polyposis undergoes a diagnostic polypectomy. Which of the following types of polyps is most likely to be found?
A. Villous adenoma
B. Hyperplastic polyp
C. Retention polyp
D. Pseudopolyp
E. *Adenomatous polyp
60. Which of the following colonic pathologies is thought to have no malignant potential?
A. Ulcerative colitis
B. Villous adenomas
C. Familial polyposis
D. Crohn’s colitis
E. *Peutz-Jeghers syndrome
61. Which of the following complications is known to occur in children or infants with peptic ulcer disease (PUD)?
A. Perforation
B. Hemorrhage
C. Anemia
D. Obstruction
E. *All of the above
62. Which of the following etiologic factors is not associated with an increased risk for developing peptic ulcer disease (PUD)?
A. Use of nonsteroid anti-inflammatory drugs (NSAIDs)
B. Brain injury
C. Helicobacter pylori infection
D. Alcohol intake
E. *Milk intake
63. Which of the following is the most common site for a gastrinoma?
A. gastric antrum
B. duodenum
C. spleen
D. gallbladder
E. *pancreas
64. Gastrin secretion is enhanced by which of the following?
A. antral acidification
B. presence of fat in the antrum
C. sympathetic nerve stimulation
D. duodenal acidification
E. *antral distention
65. Which of these statements is true in regard to GI hormones?
A. Secretin stimulates gastrin.
B. Secretin is released from the antrum of the stomach.
C. Cholecystokinin (CCK) release is stimulated by fat in the duodenum and results in release of insulin by the pancreas.
D. CCK is released by the pancreas and relaxes the sphincter of Oddi.
E. *Vagal activation, antral distension, and antral protein are all stimuli for gastrin release.
66. On your surgery rotation you are assisting in a gastric surgical procedure. The attending surgeon asks you to describe the vascular supply to the stomach. You reply with which of the following?
A. The right gastric artery arises from the celiac axis.
B. The left gastric artery arises from the common hepatic artery.
C. The right gastroepiploic arises from the right hepatic artery.
D. The left gastroepiploic arises from the left gastric artery.
E. *The short gastric arteries arise from the splenic artery.
67. A patient with dyspepsia has a positive serologic test for Helicobacter pylori and is concerned that he could have an ulcer. Which of the following statements about H. pylori and ulcer disease would be most accurate?
A. Gastric ulcers are usually caused by hypersecretion of acid, not bacteria.
B. A positive IgG serology confirms an active infection with H. pylori.
C. Most patients with H. pylori have ulcers.
D. The use of antibiotics alone is successful in eradicating H. pylori.
E. *H. pylori is associated with both gastric and duodenal ulcers.
68. First-line therapy for routine peptic duodenal ulcer disease includes:
A. Vagotomy and antrectomy.
B. Upper endoscopy and biopsy to rule out tumor.
C. Serum gastrin determination.
D. Cream or milk-based “Sippy” diet.
E. *Evaluation for Helicobacter pylori.
69. Appropriate management of severe vomiting associated with gastric outlet obstruction from peptic ulcer disease includes all of the following except:
A. Nasogastric suction.
B. Intravenous hydration.
C. Nutritional assessment; upper endoscopy to rule out malignancy.
D. Intravenous H 2 antagonist.
E. *Oral antacid therapy.
70. All of the following are complications of peptic ulcer surgery except:
A. Duodenal stump blowout.
B. Dumping.
C. Diarrhea.
D. Delayed gastric emptying.
E. *Steatorrhea.
71. The presentation of Zollinger-Ellison syndrome includes all of the following except:
A. Hyperparathyroidism in patients with multiple endocrine neoplasia type 1 (MEN 1) syndrome.
B. Diarrhea.
C. Jejunal ulcers.
D. Duodenal ulcers.
E. *Migratory rash.
72. All are true about the dumping syndrome except:
A. Symptoms can be controlled with a somatostatin analog.
B. Flushing and tachycardia are common features of the syndrome.
C. Separating solids and liquids in the patient’s oral intake alleviates some of the symptoms of the syndrome.
D. Early postoperative dumping after vagotomy often resolves spontaneously.
E. *Diarrhea is always part of the dumping syndrome.
73. In patients with bleeding duodenal ulcers, the endoscopic finding associated with the highest incidence of rebleeding is:
A. Cherry-red spot.
B. Clean ulcer bed.
C. Duodenitis.
D. Shallow, 3-mm. ulcer.
E. *Visible vessel.
74. All of the following are contraindications for highly selective vagotomy except:
A. Peptic ulcer disease causing gastric outlet obstruction.
B. Fundic peptic ulceration.
C. Cigarette chain smoking.
D. Perforated peptic ulcer disease with more than 24 hours’ soilage.
E. *Intractable duodenal ulcer disease.
75. All the following are true of omeprazole except:
A. It is the only drug available that has the potential to achieve pharmacologically induced achlorhydria.
B. It works by blocking the hydrogen-potassium ATPase in the parietal cell.
C. It is parietal cell specific.
D. It has been associated with gastric neoplasm in a rat model.
E. *It has a short half-life (about 90 minutes) when taken orally.
76. All of the following statements about gastrin-releasing peptide (GRP) are true except:
A. In species other than man and dog GRP is commonly referred to as bombesin.
B. GRP serves as a neurotransmitter.
C. GRP stimulates gastric acid secretion when given intravenously.
D. GRP is released in response to cholinergic stimulation of the parietal cells to stimulate release of gastrin.
E. *GRP inhibits pancreatic secretion when given intravenously.
77. All of the following measures have been recommended for control of acid secretion in patients with Zollinger-Ellison syndrome except:
A. Highly selective vagotomy.
B. Total gastrectomy.
C. Vagotomy and pyloroplasty.
D. Medical therapy with Prilosec (omeprazole).
E. *Antrectomy.
78. All of the following contribute to peptic ulcer disease except:
A. Cigarette smoking.
B. Nonsteroidal anti-inflammatory drugs.
C. Helicobacter pylori.
D. Gastrinoma.
E. *Spicy foods.
79. The gastroduodenal artery is a branch of the:
A. celiac axis
B. right gastric artery
C. right hepatic artery
D. left hepatic artery
E. *common hepatic artery
80. The most frequent complication of giant gastric ulcer is:
A. gastric outlet obstruction
B. upper gastrointestinal bleeding
C. gastroenteric fistula
D. penentration
E. *perforation
81. Mallory-Weiss tear is located:
A. in the distal esophagus
B. anteriorly across the gastroesophageal junction
C. posteriorly across the gastroesophageal junction
D. on the greater curve of the cardia
E. *on the lesser curve of the cardia
82. The superior pancreaticoduodenal artery is a branch of:
A. the celiac axis
B. the superior mesenteric artery
C. the hepatic artery
D. the right gastric artery
E. *the gastroduodenal artery
83. Omeprazole has been added to the H2 antagonists as a therapeutic approach to the management of acute gastric and duodenal ulcers. It acts by
A. Blocking breakdown of mucosaldamaging metabolites of NSAIDs
B. Providing a direct cytoprotective effect
C. Buffering gastric acids
D. Inhibiting gastrin release and parietal cell acid production
E. *Inhibiting parietal cell hydrogenpotassium- ATPase
84. Which of the following organisms is most closely associated with gastric and duodenal ulcer disease?
A. Campylobacter
B. Cytomegalovirus
C. Mycobacterium avium-intracellulare
D. Yersinia enterocolitica
E. *Helicobacter
85. When the development of a wound seroma is a potential problem after an appendectomy in an obese patient, the least effective method of wound management is
A. leaving the subcutaneous tissue and skin open to heal by secondary intention
B. closing the wound over a rubber drain
C. closing the wound with multiple sutures in the subcutaneous tissue
D. closing the wound primarily without drainage
E. *closing the wound with a closed suction drain
86. Which of the following are not consistent with primary (spontaneous) bacterial peritonitis?
A. abdominal discomfort and fever
B. ascitic fluid neutrophil count of > 250×106 cells/L
C. ascitic fluid WBC count of >500×106 cells /L
D. nausea and vomiting
E. *multiple organisms on culture and sensitivity of ascitic fluid
87. A 17 year-old patient was diagnosed with appendicitis and was hospitalized. The surgical operation on ablating appendix vermiformis is to be performed. What artery must be fixed to stop bleeding during the surgical operation?
A. The iliac
B. The colica sinistra
C. The colica dextra
D. The colica media
E. *The ileocolic artery
88. Diarrhea has been defined as a probable albeit not constant feature of acute appendicitis. In which of the following cases is this sign likely to be evident?
A. In the first day of illness
B. In patients with a very high temperature
C. Retroperitoneal position of the vermiform appendix
D. In prolonged illness
E. *Pelvic position of the vermiform appendix
89. A child of 2 and a half presented with abdominal pains, emesis and a high temperature of 37.6C. The physical signs elicited did not point to a diagnosis of acute appendicitis. What should be the physician’s course of action?
A. Repeat the examination in 12 hrs
B. Repeat the examination in 24 hrs
C. Discharge the patient
D. Prescribe an analgesic and antibiotics
E. *Immediate hospitalization and continuous monitoring
90. In which position of the vermiform appendix is the rectal examination most informative?
A. Retrocecal
B. Postileal
C. Medial
D. Paracecal
E. *Pelvic
91. Which of the following signs is the most useful in diagnosis of acute appendicitis in a febrile child of 8 presented with abdominal pains and emesis?
A. Local tenderness in the right iliac fossa
B. Local tenderness and muscular rigidity in the mesogastrium
C. Tenderness in all the regions of the abdomen
D. Rigidity around the umbilicus
E. *Local tenderness and muscular rigidity in the right iliac fossa
92. A boy of 12 presented with abdominal pains and a fever lasting for the past 3 days. On examination an abdominal mass was suspected. Which of the following would be most effective in verifying this diagnosis?
A. Plain abdominal radiograph
B. Endoscopy
C. Contrast abdominal radiography
D. Rectomanoscopy
E. *Ultrasonography
93. What should be the surgeon’s course of action in an intra-operative finding of an appendix mass while operating on a child of 12 for acute destructive appendicitis?
A. Continue the appendectomy as usual
B. Complete closure of the peritoneal cavity without appendectomy
C. Remove the mass
D. Appendectomy with subsequent drainage of the peritoneal cavity
E. *Drainage of the peritoneal cavity without an appendectomy
94. Which of the following is not a direct complication of acute appendicitis
A. An appendix mass
B. Appendiceal abscess
C. Local peritonitis
D. Diffuse peritonitis
E. *Diverticulitis
95. At the patient of 34 years of age you suspect an abscess of Douglas spaces. What method of research is preferable to diagnostics:
A. Rectoromanoscopy
B. Laparoscopy
C. Percusion and auscultation of a stomach
D. R-scopy of abdominal cavity
E. *Digital research of rectum
96. The most common cause of pyogenic liver abscess in children today is which of the following?
A. Perforated appendicitis
B. Blunt liver injury
C. Immunocompromised host
D. Omphalitis
E. *Percutaneous liver biopsy
97. All of the following are associated with an increased incidence of abdominal wound dehiscence EXCEPT
A. bringing a stoma through the incision
B. presence of ascites
C. presence of jaundice
D. use of braided sutures
E. *closure of the wound with a continuous suture
98. An 8-year-old boy presents with acute onset of cramping abdominal pain and vomiting. He has multiple maculopapular rash spots on his lower extremities. Which of the following is the most likely diagnosis?
A. Acute appendicitis
B. Kawasaki disease
C. Crohn disease
D. Sickle cell crisis
E. *Henoch-Schenlein purpura
99. Which of the following is the correct classification of peritonitis based on clinical manifestations?
A. Infectious and non-infectious
B. Bilious, calculous and urinary
C. Serous, fibrous and purulent
D. Localized and diffuse
E. *Acute and chronic
100. A boy of 12 presented with abdominal pains and a fever lasting for the past 3 days. On examination an abdominal mass was suspected. Which of the following would be most effective in verifying this diagnosis?
A. Plain abdominal radiograph
B. Endoscopy
C. Contrast abdominal radiography
D. Rectomanoscopy
E. *Ultrasonography
101. A patient presents with a 24-hour history of periumbilical pain, now localized to the right lower quadrant. Which of the following is considered a physical sign often associated with this diagnosis?
A. concave and empty right lower quadrant
B. pain on flexion of the right hip
C. flank bruising
D. inspiratory arrest while palpating under the right costal margin
E. *pain in right lower quadrant with palpation in left lower quadrant
102. At an operation for appendicitis, the appendix is found to be normal and the fallopian tube is found to be thickened with surrounding purulent exudate. The operative management should be:
A. appendectomy and salpingectomy
B. salpingectomy
C. no operative intervention
D. conservative treatment
E. *appendectomy
103. Which of the following is not true of diverticular disease:
A. It is more common in the United States and Western Europe than in Asia and Africa.
B. A low-fiber diet may predispose to development of diverticulosis.
C. It involves sigmoid colon in more than 90% of patients.
D. It is the most common cause of massive lower gastrointestinal hemorrhage.
E. *Sixty per cent develop diverticulitis sometime during their lifetime.
104. The most common indication for surgery secondary to acute diverticulitis is:
A. Colonic obstruction.
B. Colovesical fistula.
C. Free perforation.
D. Hemorrhage.
E. *Abscess.
105. A 4-year-old girl has a fever of
A. Antigen test for Epstein-Barr virus (“Monospot”)
B. Lateral neck radiograph
C. Abdominal ultrasound
D. Complete blood count
E. *Streptococcal antigen test (“rapid strep test”)
106. A 9-year-old boy has 24 hours of persistent abdominal pain and vomiting. His physical examination reveals abdominal guarding and right lower quadrant rebound tenderness. Which of the following is the most likely diagnosis?
A. Gastroenteritis
B. Gastroesophageal reflux
C. Intussusception
D. Pyloric stenosis
E. *Appendicitis
107. During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Frozen section reveals this lesion to be a carcinoid tumor. Which of the following statements is true?
A. No further surgery is indicated
B. There is about a 50% chance that this patient will develop the carcinoid syndrome
C. Carcinoid tumors arise from islet cells
D. Carcinoid syndrome can occur only in the presence of liver metastases
E. *A right hemicolectomy should be performed
108. What is the likely cause of the gallstones in this patient?
A. hypocholesterolemia
B. chronic cholecystitis
C. primary sclerosing cholangitis (PSC)
D. tobacco use
E. *failure of enterohepatic bile salt Circulation
109. The common bile duct:
A. is posterior to the hepatic artery
B. lies to the right of the portal vein
C. is posterior to the portal vein
D. lies to the left of the hepatic artery
E. *lies to the right of the hepatic artery
110. Hypotension develops after pneumoperitoneum and trocar placement for laparoscopic cholecystectomy. The next action is to:
A. convert to open cholecystectomy
B. give intravenous fluids
C. place the patient in head down position
D. check for bowel injury
E. *deflate the abdomen
111. Which of the following statements about the segmental anatomy of the liver are not true?
A. Segments are subdivisions in both the French and American systems.
B. Segments are determined primarily by the hepatic venous drainage.
C. The French anatomic system is more applicable than the American system to clinical hepatic resection.
D. None of the above
E. *Segments are important to the understanding of the topographic anatomy of the liver.
112. Which of the following anatomic features of the biliary system are important considerations in operative cholangiography?
A. The left hepatic duct comes off farther anterior than the right one.
B. At the confluence there may be more than just a right and a left hepatic duct.
C. Dissection of the triangle of Calot is more important than cholangiography in preventing bile duct injury.
D. Segments V, VII, or VIII sometimes join the biliary system below the confluence.
E. *All of the above
113. Laparoscopic cholecystectomy is indicated for symptomatic gallstones in which of the following conditions?
A. Cirrhosis
B. Prior upper abdominal surgery
C. Suspected carcinoma of the gallbladder
D. Coagulopathy
E. *Morbid obesity
114. The bare area of the liver is in contact with all of the following structures EXCEPT
A. the diaphragm
B. the inferior vena cava
C. the right suprarenal gland
D. the right kidney
E. *the aorta
115. The most common cause of surgery in a patient with Crohn’s disease is which of the following?
A. carcinoma
B. fistula
C. bleeding
D. abscess
E. *obstruction
116. The most common cause of spontaneous intestinal fistula is:
A. radiation injury
B. malignancy
C. ulcerative colitis
D. diverticular disease
E. *Crohn’s disease
117. Crohn’s disease:
A. Is caused by Mycobacterium paratuberculosis.
B. Is more common in Asians than in Jews.
C. Is less frequent in temperate climates than in tropical ones.
D. Is improved by smoking.
E. *Tends to occur in families.
118. Recurrence after operation for Crohn’s disease:
A. Occurs after operations for ileal Crohn’s but not colonic Crohn’s.
B. Rarely requires reoperation.
C. Occurs in 1% of patients at risk per year during the first 10 years after the operation.
D. Is prevented by maintenance therapy with corticosteroids.
E. *Is usually found just proximal to an enteric anastomosis.
119. Excision rather than bypass is preferred for surgical treatment of small intestinal Crohn’s because:
A. Excision is safer.
B. Bypass does not relieve symptoms.
C. Excision cures the patient of Crohn’s disease but bypass does not.
D. Fewer early complications appear with excision.
E. *The risk of small intestine cancer is reduced.
120. The most common indication for operation in Crohn’s disease of the colon is:
A. Obstruction.
B. Bleeding.
C. Perforation.
D. Carcinoma.
E. *Chronic debility.
121. Which of the following statements is true?
A. Ulcerative colitis typically is characterized by rectal sparing.
B. Ulcerative colitis typicalry is characterized by skip lesions.
C. Crohn’s disease typically is characterized by crypt abscesses.
D. Having Crohn’s disease dramatically increases the risk of carcinoma of the colon.
E. *c Crohn’s disease typically is characterized by transmural disease.
122. A 12-year-old boy with Crohn’s disease is admitted with an exacerbation. He is complaining of abdominal pain and diarrhea. The most effective management in this acute setting is which of the following?
A. TNF alpha inhibitor
B. metronidazole
C. sulfasalazine
D. azathioprine
E. *corticosteroids
123. Indications for operation in Crohn’s disease include which of the following?
A. Intestinal obstruction
B. Enterovesical fistula
C. Ileum–ascending colon fistula
D. Enterovaginal fistula
E. *Free perforation
124. An 8-year-old boy presents with acute onset of cramping abdominal pain and vomiting. He has multiple maculopapular rash spots on his lower extremities. Which of the following is the most likely diagnosis?
A. Acute appendicitis
B. Kawasaki disease
C. Crohn disease
D. Sickle cell crisis
E. *Henoch-Schenlein purpura
125. The most common cause of acute pancreatitis in childhood is which of the following?
A. Pancreas divisum
B. Cholelithiasis
C. Valproic acid
D. Annular pancreas
E. *Trauma
126. The most common indication for surgery in chronic pancreatitis is:
A. jaundice
B. pseudocyst
C. gastric outlet obstruction
D. endocrine deficiency
E. *pain
127. Which of the following requires surgical drainage?
A. amebic liver abscess
B. peridiverticular abscess
C. appendiceal abscess
D. subphrenic abscess
E. *pancreatic abscess
128. The optimal treatment for bleeding gastric varices in chronic pancreatitis is:
A. distal pancreatectomy
B. splenorenal shunt
C. portocaval shunt
D. transjugular intrahepatic portosystemic shunt Procedure
E. *splenectomy
129. The main pancreatic duct is formed by which of the following?
A. the prominal part of the dorsal pancreatic duct and the distal portion of the ventral pancreatic duct
B. the entire dorsal pancreatic duct
C. the entire dorsal and ventral pancreatic ducts
D. the proximal parts of both the dorsal and ventral pancreatic ducts
E. *the distal part of the dorsal pancreatic duct and the entire ventral pancreatic duct
130. Ieonates with necrotizing enterocolitis, which of the following findings is an indication of significant bowel ischemia?
A. Increased gastric residuals.
B. Septic shock.
C. Cardiac failure due to a patent ductus arteriosus.
D. Elevated platelet count.
E. *Erythema of the abdominal wall.
131. Neonates with NEC may demonstrate all of the following findings on abdominal films except:
A. Pneumatosis intestinalis.
B. Portal vein air.
C. Pneumoperitoneum.
D. Fixed and thickened bowel loops.
E. *Colovesical fistula.
132. Which of the following does not cause bilious vomiting in an infant or child?
A. Intestinal malrotation and volvulus
B. Duodenal atresia
C. Small bowel obstruction
D. Ulcerative colitis with colonic obstruction
E. *Pyloric stenosis
133. Which of the following has not been suspected as a risk factor for NEC?
A. aggressive enteral feeding
B. maternal infections during delivery
C. umbilical vein catheters
D. all of the above have been considered as risk factors
E. *dopamine administration
134. Which of the following has not been suspected as a risk factor for NEC?
A. aggressive enteral feeding
B. maternal infections during delivery
C. umbilical vein catheters
D. all of the above have been considered as risk factors
E. *dopamine administration
135. An indication for laparotomy ieonatal necrotizing enterocolitis is:
A. distended bowel loops
B. thickened bowel wall
C. pneumatosis intestinalis
D. gas in the portal vein
E. *abdominal wall erythema
136. Which of the following is a clear indication of surgery for necrotizing enterocolitis?
A. generalized gas distension of the intestine
B. bleeding rectum
C. pneumatosis intestinalis
D. gas in the portal vein
E. *pneumoperitoneum
137. Which finding(s) suggest(s) the diagnosis of chronic ulcerative colitis as opposed to Crohn’s colitis?
A. Granulomas on biopsy.
B. Anal fistula.
C. Rectal sparing.
D. Cobblestone appearance on barium enema.
E. *Endoscopic evidence of backwash ileitis.
138. Suppurative cervical lymphadenitis in a 3-year-old child is commonly related to which of the following organisms?
A. Atypical mycobacterial organisms
B. Mycobacterium tuberculosis
C. Lymphoma with secondary pyogenic organisms
D. Cat scratch
E. *Staphylococcus aureus
139. The most common species of bacteria isolated from Type I NF (necrotising fasciitis) is:
A. Staphylococcus
B. Streptococcus
C. Clostridium
D. Campylobacter
E. *Bacteroides
140. The virulence factor which has been found to protect streptococcal species from phagocytosis is:
A. Streptokinase
B. Streptococcal pyrogenic exotoxins
C. Streptolysin O
D. Hyaluronidase
E. *M-protein
141. Type III NF (necrotising fasciitis) is most often caused by:
A. Group A beta-hemolytic streptococcus
B. Bacteroides
C. Campylobacter
D. Staphylococcus
E. *Clostridium perfringens
142. First line treatment for streptococcal NF (necrotising fasciitis) is:
A. Erythromycin
B. Gentamicin
C. Doxycycline
D. ceftriaxon
E. *Penicillin
143. The virulence factor which has been found to protect streptococcal species from phagocytosis is:
A. Streptokinase
B. Streptococcal pyrogenic exotoxins
C. Streptolysin O
D. Hyaluronidase
E. *M-protein
144. The most common cause of pyogenic liver abscess in children today is which of the following?
A. Perforated appendicitis
B. Blunt liver injury
C. Percutaneous liver biopsy
D. Omphalitis
E. *Immunocompromised host
145. Osteomyelitis:
A. Is an infection of the muscle caused by a fungal infection.
B. Is a joint & muscle infection caused by a virus.
C. Is a form of bone cancer that is predominately found in children.
D. Is a joint infection caused by bacteria.
E. *Is a bone infection usually caused by bacteria.
146. Examples of exogenous osteomyelitis would include:
A. dental infections & ear infections.
B. surgical procedures, penetrating wounds, & open fractures.
C. penetrating wounds, surgical procedures, & sinusitis.
D. pathogens which enter the body causing infection to spread from soft tissue into the bone
E. *bites, penetrating wounds, & sickle cell anemia.
147. Endogenous osteomyelitis
A. from pathogens which enter the body causing infection to spread from soft tissue into the bone.
B. is caused by pathogens from penetrating wounds, surgical procedures, & sinusitis.
C. bites, penetrating wounds, & sickle cell anemia.
D. is caused by pathogens from surgical procedures, penetrating wounds, & open fractures.
E. *is caused carried in the blood from sites of infection elsewhere in the body.
148. Inflammation of the bone is characterized by:
A. vascular engorgement, edema, & leukocyte activity.
B. abscess formation.
C. edema, bleeding, & leukocyte activity.
D. B & C
E. *A & B
149. In children, the abscess lifts the periosteum off of the underlying bone resulting in:
A. sequestrum
B. involucrum
C. osteoblast destruction
D. rezorbtion of bone
E. *exudate
150. The most common site(s) for children with osteomyelits include:
A. skull, humerous
B. spine, pelvis
C. scapula
D. calcaneus, and pelvis
E. *femur and tibia
151. Patients with septic arthritis of the hip joint usually present with which position?
A. internal rotation and flexion
B. internal rotation and extension
C. internal rotation and abduction
D. external rotation and abduction
E. *external rotation and flexion
152. Avascular necrosis is most likely to occur in fracture dislocations involving which of the following?
A. the shaft of the femur
B. the shaft of the humerus
C. the scapula
D. the clavicle
E. *the femoral head
153. An 18-year-old male developed chills, fever, and a painful swollen knee. What test would be most appropriate in order to help in making the diagnosis?
A. Lyme disease test
B. MRI
C. serum protein electrophoresis
D. study of crystals in the synovium
E. *culture of joint fluid from the affected knee
154. A 20 year-old man has an 8 x
A. fine-needle aspiration
B. core biopsy
C. local excision
D. enucleation
E. *incisional biopsy
155. A 12-year-old male adolescent presents with a 1-month history of fever, weight loss, fatigue, and pain and localized swelling of the midproximal femur. Which of the following is the most likely diagnosis?
A. osteosarcoma
B. chronic osteomyelitis
C. benign bone tumor
D. eosinophilic granuloma
E. *Ewing’s sarcoma
156. A mother brings to the clinic her 4-year-old son who began complaining of right knee pain 2 weeks ago, is limping slightly, is fatigued, and has had a fever to
A. Antinuclear antibodies
B. Epstein-Barr virus titer
C. Rheumatoid factor
D. Sedimentation rate
E. *Complete blood count (CBC) with differential and platelets
157. Hematogenous osteomyelitis most frequently affects:
A. The diaphysis of long bones.
B. The epiphysis.
C. Flat bones.
D. Cuboidal bones.
E. *The metaphysis of long bones.
158. A 5-year-old child presents with a 2-day history of the atraumatic onset of pain, erythema, and swelling of the right knee joint. The child is febrile with an elevated white blood cell count. The differential diagnosis includes:
A. Acute rheumatic fever.
B. Leukemia.
C. Acute juvenile rheumatoid arthritis.
D. Acute septic arthritis.
E. *All of the above
159. Which of the following diagnostic tests is most likely to reveal osteomyelitis in a child who stepped on a nail 4 days ago?
A. roentgenogram of the foot
B. gallium bone scan
C. CT scan of the foot
D. blood count and sedimentation rate
E. *technetium bone scan
160. Pulmonary function testing performed as long-term follow-up care of pediatric patients treated for parapneumonic effusions reveals which of the following?
A. Persistent restrictive lung defect
B. Hypoxemia
C. Reduced exercise tolerance from restrictive ventilatory limitations
D. None of the above
E. *Mild expiratory flow limitation
161. Which of the following is not included regularly in pediatric management of complicated parapneumonic effusions?
A. Video-assisted thoracoscopic surgery
B. Antibiotic infusion
C. Recombinant tissue plasminogen activator
D. Decortication and debridement
E. *Rib resection with open drainage
162. Tension pneumothorax is best diagnosed with:
A. stat CT scan
B. chest x-ray
C. watch and wait
D. none of the above
E. *clinical exam
163. Which is more often associated with hospital acquired pneumonia than community acquired pneumonia?
A. Streptococcus pneumoniae
B. Hemophilus influenza
C. Chlamydia pneumoniae
D. Mycoplasma pneumoniae
E. *Legionella
164. In order to emergently decompress a tension pneumothorax, one should insert a large bore needle between:
A. the second and third interspace in the midaxillary line
B. the fourth and fifth interspace in the midclavicular line
C. the sixth and seventh interspace in the midclavicular line
D. either a or b
E. *neither a or b
165. Pick the two conditions which you would most likely to encounter a tension pneumothorax:
A. Near drowning patient on blow-by oxygen.
B. Hydrocarbon aspiration.
C. Blunt chest trauma.
D. Stab wound to the mid lateral torso.
E. *NICU ventilator patient for RDS.
166. A “sucking chest wound” refers to what kind of air-leak syndrome?
A. Interstitial emphysema
B. Simple pneumothorax
C. Tension pneumothorax
D. Pneumomediastinum
E. *Communicating pneumothorax
167. What is the most sensitive indicator of pneumonia in a child?
A. tachycardia
B. hypotonia
C. vomiting
D. coughing
E. *tachypnea
168. Spontaneous pneumothorax:
A. is more common in young females
B. is typically postexertional
C. often requires thoracotomy in the first episode
D. is often associated with severe persistent pain
E. *is recurrent in at least 30% of cases
169. Eight hours after esophagogastroduodenoscopy (EGD), a patient complains of severe substernal pain. Chest x-ray film shows left pleural effusion. The next test is:
A. repeated EGD
B. celiotomy
C. computed tomography scan of the chest
D. water-soluble esophagogram
E. *thoracotomy
170. The most likely cause of sudden cardiopulmonary collapse in a patient with blunt thoracic injury is
A. rib fracture
B. hemothorax
C. pulmonary contusion
D. chylothorax
E. *pneumothorax
171. The most frequent cause of spontaneous pneumothorax is
A. carcinoma of the lung
B. tuberculosis
C. pyogenic abscess of the lung
D. emphysema
E. *rupture of small blebs
172. Which one of the following is not a parameter in the definition of SIRS?
A. Tachycardia
B. Tachypnea
C. Leukocytosis
D. Hypothermia
E. *Hypotension
173. Characteristics of the systemic inflammatory response syndrome (SIRS) include all of the following EXCEPT
A. fever
B. hyperventilation
C. leukocytosis
D. tachycardia
E. *delayed wound healing
174. Complications of arterial catheterization for a 96-h period of monitoring include all the following EXCEPT
A. arterial thrombosis
B. infection at the catheter site
C. hemorrhage
D. wound hematoma
E. *septicemia
175. An early sign of systemic sepsis in a patient receiving intravenous hyperalimentation is
A. appearance of shaking cells
B. hypotension
C. rapid drop in arterial pH
D. Tachycardia
E. *sudden development of glucose intolerance
176. The intense pain associated with a felon occurs because of
A. bone involvement
B. digital artery thrombosis
C. nail bed involvement
D. tendon sheath infection
E. *a closed space infection
177. The most frequent hospital-acquired infections that develop or are acquired within a hospital involve the
A. lower gastrointestinal tract
B. lower respiratory tract
C. nasopharynx
D. urinary tract
E. *surgical wound
178. Which of the following antibiotics is most appropriate for an otherwise healthy young woman who has swelling and erythema of the dorsum of her right hand together with lymphadenitis and lymphangitis of her right arm?
A. Intravenous clindamycin
B. Intravenous cephalothin
C. Intravenous tetracycline
D. Oral cephalexin
E. *Intravenous penicillin G
179. Severe cases of hidradenitis suppurativa in the groin area are best managed by excision of the involved area and
A. delayed primary closure
B. primary closure
C. split thickness skin grafting
D. transfer of a rectus abdominus muscle flap
E. *closure by secondary intention
180. All of the following statements about hidradenitis suppurativa are true EXCEPT
A. Lesions are found in the axilla, the groin and the perianal area
B. Plugged apocrine glands with secondary infection cause the problem
C. Use of grease deodorants is a frequent causative factor
D. When chronic hydradenitis is present, wide surgical excision is the preferredtreatment
E. *When surgical procedures are done, the wound should be left open to granulate in by secondary intention
181. Which of the following is not a predisposing factor for perirectal abscess?
A. AIDS
B. Crohn Disease
C. Diabetes mellitus
D. Cancer chemotherapy
E. *Hemorrhoidal varicosities
182. Which of the following is false regarding post operative wound infections?
A. S. aureus is the most common cause
B. usually present with fever post of day 3-4
C. increased likelihood in diabetics
D. risk increases with length of surgery
E. *mainly treated with antibiotics
183. Which of the following is the most common cause of pneumonia outside of the neonatal period?
A. S. pneumoniae
B. Mycoplasma
C. Chlamydia
D. Clostridia
E. *Viruses
184. Which factor does not appear to affect the etiology of pneumonia?
A. Age
B. Vaccination status
C. Current antibiotic use
D. weight
E. *Birth rank
185. The most common cause of bronchiolitis is:
A. Human Metapneumovirus
B. Parainfluenza
C. Adenovirus
D. Chlamydia
E. *Respiratory syncytial virus
186. You are investigating a case of cellulitis secondary to a bite wound. The study shows seven different bacterial species isolates. The bite was most likely from:
A. a cat
B. a dog
C. rat
D. a pig
E. *a human
187. Which antibiotic class is NOT considered appropriate for outpatient treatment against cellulitis?
A. Clindamycin
B. Penicillin
C. Cephalosporin
D. Ryphampycin
E. *Aminoglycoside
188. Which one of the following is not a parameter in the definition of SIRS?
A. Tachycardia
B. Tachypnea
C. Leukocytosis
D. Hypothermia
E. *Hypotension
189. Which is an early finding in septic shock?
A. Decreased urine output
B. Decreased blood pressure
C. Diffuse lung infiltrates
D. Decreased cardiac output
E. *Increased cardiac output
190. Which microorganism is a common etiology in endotoxic shock?
A. Staphylococcus aureus
B. Streptococcus pyogenes
C. Streptococcus pneumoniae
D. Pasteurella multocida
E. *Escherichia coli
191. Which of the following skin examination findings is generally not associated with sepsis?
A. Ecthyma gangrenosum
B. Purpura fulminans
C. Petechiae
D. C&D
E. *Pyogenic granuloma
192. Which of the following is true regarding anorectal abscess and fistula?
A. The most common cause is a subepithelial extension of a genital infection.
B. Conservative management should always be considered for fistula-in-ano as many heal spontaneously.
C. Most acute anorectal abscesses require a course of antibiotics.
D. The treatment protocol is not altered for patients with valvular heart disease.
E. *Anal fistula is classified as intersphincteric, transsphincteric, suprasphincteric,or extrasphincteric.
193. Which cell type is essential for wound healing?
A. neutrophil
B. fibroblast
C. lymphocyte
D. endothelial
E. *macrophage
194. The main complication of topical silver nitrate is:
A. metabolic acidosis
B. metabolic alkalosis
C. hyperkalemia
D. hypocalcemia
E. *hyponatremia
195. The adverse effects of steroids on wound healing can be reversed with:
A. vitamin C
B. copper
C. vitamin D
D. vitamin E
E. *vitamin A
196. Infection caused by dog and cat bites is due to:
A. Mycobacterium
B. Staphylococcus aureus
C. Actinomyces
D. Candida
E. *Pasteurella species
197. Which statement(s) is/are true about hidradenitis suppurativa?
A. It is a disease of the apocrine sweat glands.
B. It causes multiple perianal and perineal sinuses that drain watery pus.
C. The sinuses do not communicate with the dentate line.
D. The treatment is surgical.
E. *All of the above.
198. The best cosmetic results for large capillary (port wine) hemangiomas are achieved by
A. excision and split-thickness graft
B. excision and pedicle grafts
C. tattooing
D. cryosurgery
E. *laser destruction
199. Which of the following is the most common presentation for Wilms tumor?
A. Abdominal pain
B. Urinary tract infection
C. Hematuria
D. Varicocele
E. *Abdominal mass
200. Which of the following is the most common site of recurrence after treatment for Wilms tumor?
A. Liver
B. Tumor bed
C. Brain
D. Bone
E. *Lungs
201. Each of the following are risk factors for colon cancer EXCEPT:
A. low fibre diet
B. familial adenomatous polyposis
C. ulcerative colitis
D. high fat diet
E. *severe diverticular disease
202. A one year-old female presents with vaginal bleeding. Vaginal inspection reveals the presence of a multicystic grape-like lesion. The most likely diagnosis is?
A. sexual abuse
B. DES syndrome
C. clear cell Adenocarcinoma
D. exposure to exogenous estrogen
E. *sarcoma botyroides
203. Which of the following is the most common primary lung tumor in infants and children?
A. Pulmonary blastoma
B. Squamous cell carcinoma
C. Leiomyoma
D. Metastatic osteogenic sarcoma
E. *Endobronchial carcinoid
204. An infant is noted to have a left flank mass shortly after birth and an ultrasound examination demonstrates left hydronephrosis. The most common cause of this finding is which of the following?
A. Neonatal Wilm’s tumor
B. Multicystic dysplastic kidney
C. Vesicoureteral reflux
D. None of the above
E. *Congenital ureteropelvic junction obstruction
205. Which of the following statements regarding neuroblastoma are true?
A. Neuroblastoma is the most common abdominal malignancy of childhood
B. Approximately 80% of neuroblastoma patients are diagnosed prior to age 4 years
C. Trk proto-oncogene expression ieuroblastoma tissue is inversely related to survival probability
D. All of the above
E. *A&B
206. Which of the following are considered low risk features for neuroblastoma patients?
A. Age less than one year
B. Stage 2A and 2B disease (International Staging Criteria)
C. Stage 4S disease (International Staging Criteria)
D. Neuron specific enolase plasma level less than 100 ng/ml
E. *All of the above
207. A one month old female infant is brought to you for evaluation of afriable polypoid mass prolapsing through the vaginal introitus. Your presumptive diagnosis is which of the following?
A. Ectopic ureterocele
B. Rectal prolapsed
C. Congenital adrenal hyperplasia with ambiguous genitalia
D. Intussuseption
E. *Embryonal rhabdomyosarcoma
208. Which of the following approaches is considered standard care for most Wilms’ tumor patients in the United States today?
A. Adriamycin and vincristine therapy followed by surgical resection
B. Needle biopsy followed by either chemotherapy or resection depending upon the histology
C. Radiation therapy if judged unresectable on CT or MRI imaging
D. Surgical resection only
E. *Primary surgical resection followed by chemotherapy
209. Which of the following statements regarding rhabdomyosarcoma are true?
A. Surgical resection of the primary tumor results in cure of approximately 80 to 90% of all patients
B. Alveolar histology is a favorable prognostic finding
C. Overall survival of all patients is now approximately 80%
D. None of the above
E. *Currently recommended therapy includes complete resection of primary tumors prior to chemotherapy for small noninvasive lesions, or after documented response with more formidable primary tumors
210. Patients with Wilms’ tumors most frequently present with which of the following?
A. Bilateral metachronous lesions
B. Bilateral synchronous lesions
C. An extrarenal primary
D. A multicentric primary lesion
E. *A unifocal, unilateral lesion
211. Hepatoblastomas are childhood liver tumors characterized by which of the following features?
A. Multicentricity
B. Cirrhosis in the uninvolved liver
C. Jaundice
D. Bleeding
E. *Unresectable tumors subjected to cytoreductive chemotherapy may be resected with long-term survival
212. Common sites of neuroblastoma metastasis are which of the following?
A. Regional lymph nodes
B. Bone marrow
C. Cortical bone
D. None of the above
E. *All of the above
213. Which of the following statements regarding renal tumors of childhood and adolescence are true?
A. Clear cell sarcoma of the kidney has a high rate of metastasis to bone
B. Rhabdoid tumors may arise in the kidney, mediastinum or brain
C. Childhood rhabdoid tumors of the kidney carry an poor prognosis
D. None of the above
E. *All of the above
214. Which of the following syndromes are associated with the development of Wilms’ tumor?
A. Beckwith-Wiedemann Syndrome (hemi-hypertrophy, macroglossia, aniridia)
B. Neurofibromatosis
C. Denys-Drash syndrome (pseudohermaphroditism, glomerulopathy)
D. Gonadal dysgenesis
E. *All of the above
215. Which of the following is NOT a kind of lymphangioma?
A. lymphangioma simplex or circumscriptum
B. capillary lymphangioma
C. cavernous lymphangioma
D. cystic hygroma
E. *subdural hygroma
216. In the U.S., primary treatment of lymphatic malformations can include all of the following EXCEPT:
A. surgical excision
B. no treatment if benign
C. pharmacological sclerotherapy
D. steroidotherapy
E. *radiation therapy
217. Complications of cystic hygromas in the head and neck include all of the following EXCEPT:
A. airway obstruction
B. esophageal obstruction
C. infection
D. hemorrhage
E. *no exceptions (all above are correct)
218. A 2 year old boy presents with a large right flank mass, fever, weight loss, proptosis of the right eye, and ecchymosis around the right eye. The most likely diagnosis is:
A. Wilms’ tumor
B. Neuroblastoma
C. Hydronephrosis
D. lymphangioma
E. *Metastatic neuroblastoma
219. What is the most common secondary tumor that develops after survival of retinoblastoma?
A. Neuroblastoma
B. Soft tissue sarcoma
C. Acute lymphocytic leukemia
D. Wilms’ tumor
E. *Osteosarcoma
220. If a teenager comes in complaining of night pain in his knee, which disorder should be at the top of your differential? Which would be the most likely, and which would be the most serious likely consideration?
A. Juvenile Rheumatoid Arthritis
B. Osteosarcoma
C. Paget’s Disease
D. Stress fracture
E. *Growing pains
221. Which of the following is the most common site for a gastrinoma?
A. gastric antrum
B. duodenum
C. spleen
D. gallbladder
E. *pancreas
222. Which anatomic location is the most common site of extra-adrenal pheochromocytomas?
A. duodenum
B. inferior pole of the kidney
C. parasplenic area
D. peripancreatic area
E. *paraaortic area
223. Characteristically, Wilms tumors are histologically recognizable for which of the following?
A. epithelial elements alone
B. blastemic elements
C. focal keratinization
D. glandular formation
E. *classic triphasic combination of blastema, stromal, and epithelial cells
224. What is the survival rate of Wilms? tumor with chemotherapy, radiation therapy, and surgery?
A. 10%
B. 30%
C. 60%
D. no long-term survival can be achieved with this tumor
E. *90%
225. You are assisting in the nursery and are the first to examine a newborn. On your examination you find a palpable abdominal mass. Which of the following is the most likely diagnosis?
A. neuroblastoma
B. Wilms tumor
C. hepatoma
D. diaphragmatic hernia
E. *hydronephrosis
226. You are called to the newborursery to see a baby with a birthmark on his face. You note a port-wine stain on the right forehead and cheek. The portwine stain is only on the right side. What is the most likely condition?
A. neurofibromatosis, type 1 (von Recklinghausen’s disease)
B. tuberous sclerosis
C. CHARGE Association
D. Beckwith-Wiedemann syndrome
E. *Sturge-Weber syndrome
227. Which of the following is NOT a kind of lymphangioma?
A. lymphangioma simplex or circumscriptum
B. capillary lymphangioma
C. cavernous lymphangioma
D. cystic hygroma
E. *subdural hygroma
228. Complications of cystic hygromas in the head and neck include all of the following EXCEPT:
A. airway obstruction
B. esophageal obstruction
C. infection
D. hemorrhage
E. *no exceptions (all above are correct)
229. Amother brings in her 3-year-old girl because she felt a smooth mass on the left side of her belly when she was giving her a bath. Which of the following is the most likely diagnosis?
A. neuroblastoma
B. acute lymphoblastic leukemia
C. Hodgkin’s disease
D. hepatoblastoma
E. *Wilms tumor
230. A 5-year-old febrile child presents with swelling of the right eyelid. Proptosis and limitation of ocular movements is noted. Which of the following is the most likely diagnosis?
A. retinoblastoma
B. periorbital cellulitis
C. neuroblastoma
D. hyphema
E. *orbital cellulitis
231. Which of the following is the most appropriate next step in management melanoma?
A. wide excision with
B. wide excision with
C. shave biopsy
D. Mohs’ surgical excision
E. *excisional biopsy with 1–2 mm margins
232. The most common site of gastrointestinal lymphoma is:
A. small intestine
B. colon
C. duodenum
D. appendix
E. *stomach
233. Malignant small bowel neoplasms most commonly present with:
A. abdominal pain
B. gastrointestinal bleeding
C. jaundice
D. intestinal perforation
E. *weight loss
234. Sacrococcygeal teratoma:
A. is usually malignant
B. is more common in males
C. diagnosis is ruled out if calcification is absent on Radiography
D. is present with gastrointestinal bleeding
E. *requires complete excision of the coccyx
235. The most common presentation of gastric lymphoma is:
A. weight loss
B. upper gastrointestinal bleeding
C. gastric perforation
D. nausea and vomiting
E. *abdominal pain
236. The treatment for osteosarcoma of the distal femur is:
A. above-knee amputation
B. chemotherapy followed by above-knee amputation
C. chemoradiation
D. chemotherapy alone
E. *chemotherapy and limb-sparing surgery
237. The most important prognostic variable for melanoma is:
A. gender
B. age
C. Clark’s level
D. complexion
E. *Breslow’s thickness
238. The most common intra-abdominal solid tumor in children is:
A. nephroblastoma
B. rhabdomyosarcoma
C. fibrosarcoma
D. teratoma
E. *neuroblastoma
239. The risk of regional node metastases in 0.70mm thick melanoma is:
A. 10%
B. 20%
C. 30%
D. 50%
E. *5%
240. The most common anterior mediastinal tumor is:
A. retrosternal goiter
B. lymphoma
C. teratoma
D. neuroblastoma
E. *thymoma
241. Which of the following variables best predicts prognosis for patients with a recent diagnosis of cutaneous melanoma and no clinical evidence of metastatic disease?
A. Clark’s level.
B. Ulceration.
C. Gender.
D. Celtic complexion.
E. *Breslow thickness.
242. Which of the following statements describes an ideal tumor marker?
A. The ideal tumor marker should be tumor specific; that is, in the normal population or patients with benign diseases, false-positive test results are rare.
B. The ideal marker must have a low false-negative rate; that means that all patients with a particular type of cancer should test positive.
C. The circulating level of an ideal tumor marker should correlate directly with the amount of viable tumor and be a measure of the response to therapy.
D. The ideal tumor marker should act as a prognostic indicator.
E. *All of the above.
243. A marker for the diagnosis of pancreatic cancer is:
A. CA 15-3.
B. Alphafetoprotein (AFP).
C. Carcinoembryonic antigen (CEA).
D. CYFRA 21-1.
E. *CA 19-9.
244. Which of the following tumors may cause elevated CEA levels?
A. Breast cancer.
B. Colorectal cancer.
C. Gastric cancer.
D. Lung cancer.
E. *All of the above.
245. The most useful circulating marker for patients with hepatocellular carcinoma is:
A. CA 50.
B. Levels of vitamin B 12.
C. CEA.
D. hCG.
E. *AFP.
246. Which serum markers are useful in the management of patients with testicular cancer?
A. hCG.
B. AFP.
C. CA 15-3.
D. None of the above.
E. *Two of the above.
247. Patients that have acquired immunodeficiency syndrome are at increased risk for which of the following neoplasms?
A. Colorectal cancer
B. Meningioma
C. Hepatocellular carcinoma
D. Esophageal carcinoma
E. *Kaposi’s sarcoma
248. Which of the following statements about neuroblastoma is truel
A. Neuroblastoma is a benign tumor of the neural crest cells that form the adrenal cortex and the paraspinal parasympathetic ganglion.
B. The majority of neuroblastoma tumors occur in the thoracic cavity.
C. In neuroblastoma of the abdomen, displacement of the kidney and distortion of the calyceal system often occur.
D. Most patients are treated with surgery alone, since distant metastases are rare.
E. *Neuroblastoma is the most common malignant tumor in infancy.
249. Which of the following malignant neoplastic processes has the highest rate of spontaneous regression?
A. Ewing’s sarcoma
B. Wilms’ tumor
C. acute myelogenous leukemia
D. Hodgkin’s disease
E. *neuroblastoma
250. Clark’s classification of melanoma is based on the
A. depth of tissue invasion
B. width of the lesion
C. presence or absence of nodal metastasis
D. none of the above
E. *level of tissue invasion
251. All the following statements concerning sacrococcygeal teratoma are true except that
A. it may present as a postsacral mass
B. it may present as a retrorectal mass
C. it is prone to malignant degeneration
D. it should be excised promptly
E. *it is more common in males
252. The treatment of choice of strawberry hemangioma is
A. surgery
B. radiation therapy
C. argon laser therapy
D. topical corticosteroids
E. *observation
253. Response to treatment of strawberry hemangioma is best described by which of the following statements?
A. recovery will be poor, with probable malignant transformation
B. recovery will be poor, with metastasis to regional lymph nodes
C. recovery will be favorable, but other lesions of the same type are likely to develop
D. there is not enough information to predict outcome
E. *recovery will be total, with no evidence of scar
254. The hepatic caudate lobe:
A. represents segment IV
B. is supplied by the left portal vein only
C. is supplied by the right portal vein only
D. lies to the right of the inferior vena cava
E. *drains directly into the inferior vena cava
255. Which of the following statements regarding neuroblastoma are true?
A. Neuroblastoma is the most common abdominal malignancy of childhood
B. Approximately 80% of neuroblastoma patients are diagnosed prior to age 4 years
C. Trk proto-oncogene expression ieuroblastoma tissue is inversely related to survival probability
D. All of the above
E. *Neuroblastoma is the most common abdominal malignancy of childhood & Approximately 80% of neuroblastoma patients are diagnosed prior to age 4 years
256. Which serum markers are useful in the management of patients with testicular cancer?
A. hCG.
B. AFP.
C. CA 15-3.
D. None of the above.
E. *hCG and AFP.
257. Inflammation of the bone is characterized by:
A. vascular engorgement, edema, & leukocyte activity.
B. abscess formation.
C. edema, bleeding, & leukocyte activity.
D. abscess formation & edema, bleeding, & leukocyte activity.
E. *vascular engorgement, edema, & leukocyte activity & abscess formation
258. In order to emergently decompress a tension pneumothorax, one should insert a large bore needle between:
A. the second and third interspace in the midaxillary line
B. the fourth and fifth interspace in the midclavicular line
C. the sixth and seventh interspace in the midclavicular line
D. either the second and third interspace in the midaxillary line or the fourth and fifth interspace in the midclavicular line
E. *neither the second and third interspace in the midaxillary line or the fourth and fifth interspace in the midclavicular line
259. Which of the following skin examination findings is generally not associated with sepsis?
A. Ecthyma gangrenosum
B. Purpura fulminans
C. Petechiae
D. Purpura fulminans & Petechiae
E. *Pyogenic granuloma
260. ?A mother brings her 2-month-old son to see you because she noticed he had a swollen left scrotum. She reports that he seems fine without any symptoms and his birth history was normal. He was full-term with a birth weight of
A. prepare him for immediate surgery
B. refer him for elective surgery in the next several weeks
C. refer him for genetic consultation
D. send him for a testicular scan
E. *observe
261. A 18-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Which of the following would help confirm the diagnosis?
A. transscrotal needle biopsy
B. transscrotal aspiration of the hydrocele for cytology
C. transscrotal exploration and orchiectomy
D. laparotomy with pelvic and retroperitoneal node dissection
E. *radical orchiectomy through an inguinal Incision
262. A 18-year-old man with a past history of bilateral orchiopexy for cryptorchidism presents with a painless, unilateral right scrotal enlargement. On examination, there is a palpable right testicular mass and enlarged inguinal nodes. Scrotal ultrasonography demonstrates heterogeneity of the testis, with an associated hydrocele. A CT scan of the abdomen and pelvis demonstrated right-sided retroperitoneal adenopathy. CT scan of the chest is normal. Staging workup and surgery reveal a seminoma of the testicle, with positive inguinal and retroperitoneal nodes. Therapeutic management for this patient is which of the following?
A. external beam radiotherapy
B. multidrug combination chemotherapy
C. clinical surveillance
D. laparotomy with pelvic and retroperitoneal node dissection
E. *combination radiotherapy and multidrug chemotherapy
263. The cremaster muscle is derived from:
A. the external oblique muscle
B. the transversus abdominis muscle
C. the transversalis fascia
D. skin
E. *the internal oblique muscle
264. A 18-year-old school basketball player comes to the physician because of a left-sided scrotal mass; he first noticed the mass 2 weeks ago after he was hit with the ball in the left groin during a game. Abdominal examination shows no abnormalities. A 3-cm nontender mass is palpated near the superior pole of the left testis; the mass is nontender and does not transilluminat. Which of the following is the most likely diagnosis?
A. Epididymitis
B. Hematoma
C. Hernia
D. Hydrocele
E. *Tumor
265. Which of the following statements is false?
A. A hydrocele can result from incomplete fusion of the processus vaginalis.
B. A scrotal hydrocele, or simple hydrocele, is a type of non-communicating hydrocele.
C. A communicating hydrocele can develop into an inguinal-scrotal hernia. Some use the terms interchangeably.
D. A hernia sac can contain intestine, omentum, testis/ovary or fallopian tube.
E. *Each testis descends through the inguinal canal into the scrotum within the processus vaginalis.
266. A 2 V2 year old boy presents with a lax left sided scrotal swelling which can be transilluminated. The clinical findings are those of a hydrocele. Which of the following statements best describes the clinical features and management in this patient?
A. The hydrocele is most likely to be of the non-communicating variety
B. There is a 90% probability of spontaneous resolution in the next 12 months
C. The hydrocele should be aspirated and re-assessed after 6 months
D. A Jaboulay operation would be the most appropriate operative procedure
E. *Inguinal ligation of the processus vaginalis would be the most appropriate operative procedure
267. A 17-year-old boy comes to the emergency department because of the acute onset of right-sided scrotal pain. He wants your immediate diagnosis and help. He currently has a girlfriend, but claims he always uses a condom and has not had any sexually transmitted diseases, although he has never been tested. He does not have dysuria or penile discharge. He plays as point guard on the school basketball team. He recalls colliding with another player in a game 2 days ago, but does not remember significantly injuring himself. On examination his right scrotal area is enlarged, erythematous, and tender to palpation. As you carefully elevate the scrotum he states that there is no decrease in the pain. The cremasteric reflex is absent The most appropriate next step in management is to
A. obtain a complete blood count and erythrocyte sedimentation rate
B. obtain a CT scan
C. prescribe oral antibiotics
D. recommend warm soaks and bedrest
E. *obtain an immediate surgical consult
268. A previously healthy 13-year-old boy is brought to the emergency department by his mother because of a 5-hour history of acute right testicular pain. The patient denies a history of trauma and he has never experienced this type of dull, achy visceral pain before. He has tried some nonsteroidal anti-inflammatory drugs that his mother gave him with marginal relief. A urinalysis is negative. His temperature is
A. admit him overnight for pain control and intravenous antibiotics
B. get an immediate ultrasound of the testicles
C. order an immediate nuclear testicular scan to assess for vascular compromise
D. send the patient home with scheduled ibuprofen, with orders to elevate the scrotum and followup in the clinic in 3 days
E. *prepare the patient for immediate surgery for exploration
269. A 14-year-old boy presents with sudden onset of pain and swelling of his right testicle. There was no history of trauma, he is not sexually active, and denies any history of penile discharge. On examination, the scrotum is swollen and tender. The cremasteric reflex is absent. A testicular flow scan shows a “cold spot” or absent flow to the affected side. Which of the following is the most likely cause?
A. inguinal hernia
B. hydrocele
C. epididymitis
D. torsion of the appendix testis
E. *testicular torsion
270. A13-year-old boy is brought to the emergency department at midnight with a 4-hour history of right scrotal pain that was sudden in onset and associated with nausea and one episode of vomiting. On examination, he is in obvious distress. He has mild right lower abdominal tenderness, and high-riding, tender right testes. CBC and urinalysis are normal. Which of the following is the most appropriate next step in management?
A. admit the patient to the hospital and place him on bed rest
B. analgesics and a scrotal support
C. antibiotic therapy
D. schedule a testicular isotope scan
E. *urgent surgical exploration
271. The initial step in management of a 15-year boy with a painless scrotal mass is:
A. fine-needle aspiration and cytology
B. abdominal computed tomography scan
C. observation and repeat examination in 2 weeks
D. orchiectomy
E. *scrotal ultrasound
272. A 15-year-old boy presents with testicular tenderness that started approximately 2 hours ago. Physical exam reveals a swollen, diffusely tender testis with ipsilateral scrotal edema and absent cremasteric reflex. You diagnose testicular torsion. What is the most appropriate next step?
A. scrotal MRI to confirm testicular torsion
B. oral erythromycin and intramuscular ceftriaxone for presumptive treatment of infection by Chlamydia trachomatis and Neisseria gonorrhoeae
C. admission for observation and analgesia until the pain resolves
D. orchiopexy to prevent infertility
E. *surgical detorsion and fixation of the testis to the posterior scrotal envelope
273. A 14-year-old boy is brought to the Emergency Department with lower abdominal pain, nausea, and vomiting that occurred shortly after gym class. Physical examination reveals normal vital signs and a nontender abdomen with normal bowel sounds. Which of the following findings on physical examination would suggest torsion of the spermatic cord?
A. relief of pain on elevation of the scrotum
B. painless, unilateral scrotal swelling
C. a visible “blue dot” on the upper pole of the testis
D. penile discharge
E. *absent cremasteric reflex
274. A 14-year-old boy is brought to the Emergency Department with lower abdominal pain, nausea, and vomiting that occurred shortly after gym class. Physical examination reveals normal vital signs and a nontender abdomen with normal bowel sounds. Once the diagnosis of testicular torsion is suspected, the most appropriate next step is to obtain
A. radionuclide testicular scan
B. urine for urinalysis
C. Doppler ultrasound
D. CT scan
E. *emergent urologic consultation
275. A 14-year-old boy is brought to the Emergency Department with lower abdominal pain, nausea, and vomiting that occurred shortly after gym class. Physical examination reveals normal vital signs and a nontender abdomen with normal bowel sounds. The most appropriate next step in management is
A. administer intravenous diazepam and place patient in Trendelenburg
B. discharge the patient with scrotal support and urologic follow up
C. Foley catheterization
D. scrotal elevation and observation in the Emergency Department
E. *attempt manual detorsion in the Emergency Department
276. A previously healthy 16-year-old boy is brought to the emergency department 1 hour after the sudden onset of abdominal and scrotal pain. There is severe tenderness in the region of the inguinal canal on the right; the right side of the scrotum is empty. Urinalysis shows normal findings. Which of the following is the most effective initial management?
A. Administration of analgesics and observation
B. Administration of gonadotropic hormones
C. Insertion of a nasogastric tube
D. Cystoscopy
E. *Immediate operation
277. A 17-year-old boy comes to the physician because of right groin pain for 2 hours; elevation of the scrotum does not relieve the pain. There is no history of trauma. He is sexually active and has had multiple sexual partners over the past 3 years. He does not use condoms regularly. He had chlamydial urethritis 1 year ago treated with doxycyclin. Examination shows an enlarged, swollen, erythematous, and acutely tender right scrotum. The left testis is found in a horizontal position; the cremasteric reflex is absent on the right. Which of the following is the most likely diagnosis?
A. Epididymitis
B. Hemorrhagic tumor
C. Incarcerated hernia
D. Torsion of the testicular appendix
E. *Torsion of the testicle
278. With respect to painful scrotal swelling, all of the following are true EXCEPT:
A. torsion of testicular appendages will usually subside without surgical intervention
B. ultrasound is helpful in determining the cause of hematocele
C. torsion most commonly occurs in young males
D. orchitis may result in testicular atrophy
E. *nausea/vomiting is very common in epididymitis
279. Which is not a surgical emergency?
A. Testicular torsion
B. Paraphimosis
C. Torsion of testicular appendages
D. Testicular trauma
E. *Phimosis
280. Neonatal testicular torsion is:
A. intra-vaginal
B. complete
C. incomplete
D. Necrotic
E. *extra-vaginal
281. Which of the following is not part of the differential diagnosis of an inguinal-scrotal swelling in children?
A. Varicocele
B. Undescended or retracted testis
C. Testicular torsion
D. Testicular cancer
E. *Volvulus
282. Scrotal exploration is being performed in a 14 year old boy for a presumed diagnosis of right testicular torsion. He has a 10 hour history of symptoms. The diagnosis is confirmed but despite detorsion, the testis remains dark blue in colour with no evidence of perfusion. What action should the surgeon take?
A. Right orchidectomy. Defer fixation of the left testis until a second operation in view of the risk of infection
B. Leave the right testis in situ (in the hope it may contribute to endocrine function).
C. Simultaneous suture fixation of the left testis
D. Right orchidectomy and implantation of silicone gel prosthesis, simultaneous suture fixation of the left testis
E. *Right orchidectomy combined with simultaneous fixation of the left testis with prolene sutures
283. A 5 year old boy presents with diffuse swelling involving both sides of the scrotum He is afebrile and has only minimal discomfort. What action should be takeext?
A. Urgent surgical exploration to exclude an atypical presentation of bilateral synchronous testicular torsion
B. Commence intravenous antibiotics
C. Full blood count, platelet count and plasma viscosity
D. Oral Prednisilone
E. *No specific treatment
284. A 13 year old boy presents with severe right iliac fossa pain of sudden onset. No abnormality if detected on abdominal palpation. His right testis is moderately tender but there is no erythema of the overlying scrotal skin. How should he be investigated and managed?
A. Scrotal ultrasound
B. Admit for observation, re-assess clinical findings after 4 hours
C. Doppler ultrasound
D. Radionuclide scan
E. *No investigation, proceed directly to surgical exploration
285. If torsion of the testicle is suspected, surgical exploration:
A. Can be delayed 24 hours and limited to the affected side.
B. Can be delayed but should include the asymptomatic side.
C. Should be immediate and limited to the affected side.
D. Can be delayed 12 hours and limited to the affected side
E. *Should be immediate and include the asymptomatic side.
286. A 18-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most likely diagnosis?
A. torsion of the right testicle
B. pyelonephritis
C. appendicitis
D. acute urinary retention
E. *right ureteral calculus
287. A 18-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most appropriate next step in management?
A. insertion of a urethral catheter
B. IV fluid hydration, IV analgesics, and arrangements for lithotripsy
C. cystoscopy and retrograde pyelogram
D. urine culture, followed by initiation of antibiotic therapy
E. *IV fluid hydration, IV analgesics, and nonenhanced computed tomography (CT) scan
288. Which of the following statements best describes the use of ultrasonography in the evaluation of the urinary tract in children?
A. The bladder should be empty to facilitate visualisation of ureteroceles
B. Ultrasound is a sensitive modality for detecting minor renal scarring in infants
C. Ultrasound is a sensitive modality for visualizing non-dilated ureters in children
D. Ultrasound is a sensitive modality for detecting grades I to III VUR in children
E. *Ultrasound is a sensitive modality for visualizing calculi in children
289. A 6 year old girl is referred following an episode of left abdominal/loin pain which has now resolved. Ultrasound demonstrates moderate dilatation of the pelvis (AP Diameter 30mm) and calyces. Which of the following would be the most appropriate next investigation?
A. Intravenous urogram
B. Micturating cystourethrogram
C. CT scan
D. Antegrade pyelogram
E. *99mTc MAG3 isotope renogram
290. Which of the following statements best describes the use of MAG3 (Mercaptoacetyltriglycine) for the investigation of upper tract obstruction?
A. Imaging is commenced approximately 3 hours after injection
B. The radio pharmaceutical agent is 1131 MAG3
C. Obstruction can be reliably diagnosed from drainage curve data in the first month of life
D. Measurement of Glomerular Filtration rate can be combined with imaging
E. *MAG3 is more sensitive than MR urography for quantifying differential renal function
291. A 9 year old boy presents with a 1.1cm stone in the distal left ureter. There is moderate dilatation of the ureter and collecting systems on ultrasound. He is pain free but the appearances on further imaging after two weeks are unchanged. Which of the following is now the optimal management of this young patient?
A. External Shockwave lithotripsy (ESWL)
B. Conservative — re-assess with further imaging after two months
C. Open ureterolithotomy
D. Basket extraction
E. *Ureteroscopy and laser lithotripsy
292. Which of the following statements best describes the role of percutaneous nephro lithotomy (PCNL) in children?
A. PCNL can be employed safely and effectively in all age groups of children
B. PCNL can be performed without anaesthesia in older children
C. Stones are most commonly extracted intact from the kidney using a modified stone basket
D. Renal cooling is undertaken to minimise the risk of parenchymal damage
E. *Stones are most commonly disintegrated with an ultrasound probe
293. A 10 year old girl is referred with a provisional diagnosis of xanlhopyelonephritis? Which of the following features of her presentation and investigation is not consistent with this diagnosis?
A. Elevated ESR
B. Weight loss
C. Haemoglobin 8.5g/dl
D. Palpable mass
E. *Differential function 28% on DMSA scan
294. Which of the following is the most common cause of metabolic stones in children?
A. Hyperoxaluria
B. Cystinosis
C. Uric acidaemia
D. Xanthine oxidase deficiency
E. *Hypercalcuria
295. A 2 year old boy presents with haematuria. An ultrasound scan on admission demonstrates a ‘staghorn’ calculus in the left kidney. Urine culture is positive. What is the most likely infecting organism in this case?
A. E.Coli
B. Strep faecalis
C. Enterococcus
D. Staph aureus
E. *Proteus
296. Ureteral obstruction:
A. Is associated with hematuria.
B. Is associated with deterioration of renal function and rising blood urea nitrogen (BUN) and creatinine values.
C. Usually requires open surgical relief of the obstruction.
D. Is usually associated with infection behind the obstruction.
E. *Is commonly caused by a urinary tract calculus.
297. Extracorporeal shock wave lithotripsy (ESWL) has had a dramatic effect on the management of urinary stones. Which of the following statement(s) are true concerning shock wave lithotripsy of urinary stones?
A. The basic principle of lithotripsy involves the generation of shock waves which are focused fluoroscopically on the calculus and are delivered to the patient who is submersed in a water bath
B. The most common complication after lithotripsy is ureteral obstruction secondary to stone fragments
C. ESWL can be associated with stone-free rates ranging between 60%-95% at six months for renal and proximal ureteral stones
D. The combination of ESWL with percutaneous nephrolithotripsy improves the results for stone clearance in patients with large or branched stones such as staghorn calculi
E. *all of the above.
Situation tasks
1. A 17-year-old woman is admitted to the hospital for evaluation of nausea, vomiting, crampy abdominal pain and abdominal distention. Her medical history includes appendectomy 5 years ago. Which of the following is the most likely cause of her symptoms?
A. Femoral hernia
B. Gallstone ileus
C. Perforated diverticulum
D. Sigmoid colon carcinoma
E. *Adhesive band
2. A 16-year-old man comes to the hospital. For the past 5 days he has had colicky abdominal pain, vomiting, abdominal distention, and constipation. The most appropriate measure, after IV hydration and nasogastric decompression, in the initial management of this patient is which of the following?
A. upper GI endoscopy
B. abdominal sonography
C. antiemetic agents
D. promotility drugs
E. *supine and erect x-rays of the abdomen
3. A spry octogenarian who has never before been hospitalized is admitted with signs and symptoms typical of a small bowel obstruction. Which of the following clinical findings would give the most help in ascertaining the diagnosis?
A. Coffee-grounds aspirate from the stomach
B. A leukocyte count of 40,000/?L
C. A pH of 7.5, PCO2 of 50 kPa, and paradoxically acid urine
D. A palpable mass in the pelvis
E. *Aerobilia
4. Marked abdominal distention was noticed in the fifth day of life of a neonate female with intestinal loops visible on the anterior abdominal wall. Meconium was discharged after an enema. On a plain abdominal radiograph, the large intestine was found to be distended. What is the most probable diagnosis?
A. Ladd’s syndrome
B. Ileal stenosis
C. Portal hypertension
D. Intususception
E. *Hirschsprung’s disease
5. A 10-month-old male presents with a 12-hour history of episodes of crying, holding his stomach, and bending over in pain. The parents report one “reddish” stool. He has no past medical history or episodes of similar events. He did have 24 hours of viral symptoms, which resolved a few days ago. Which of the following statements is true?
A. The initial treatment for this child involves emergent laparotomy.
B. Colonic mass is the usual source of this problem in a child.
C. “Dance’s sign” is the appearance on xray of “telescoped” intestine.
D. Recurrence is likely after treatment.
E. *Air contrast enema can be diagnostic AND therapeutic.
6. Approximately two weeks after a viral respiratory illness, an 18-month-old child complains of abdominal pain and passes some bloody mucus per rectum, A long, thin mass is palpable in the right upper quadrant of the abdomen. Intussusception is suspected. Correct statements concerning intussusception in infants include which of the following?
A. Recurrence rates following treatment are high
B. A one- to two-week period of parenteral alimentation should precede surgical reduction when surgery is required
C. Hydrostatic reduction without surgery rarely provides successful treatment
D. The most common type occurs at the junction of the descending colon and the sigmoid colon
E. *It is frequently preceded by a gastrointestinal viral illness
7. A 3-month-old infant male has been crying for 12 hours nonstop and his first-time mother instinctively “knows” this is not colic. He has been eating well and his last bottle was 3 hours ago. He drank it furiously but then forcefully vomited a lot of his formula. Now he will not settle down with anything to drink. You determine that the baby is mildly dehydrated. He has a dry diaper and he is mottled but crying with some tears. You check and discover that the ears, nose, and throat are normal. However, as you pull back his diaper you note a large, firm, tender inguinal mass. The most appropriate management at this time is to
A. order a stat CBC, BUN, and electrolytes
B. order a stat CBC and type and cross blood for imminent surgery
C. order a technetium scan
D. transilluminate the testes
E. *obtain an immediate surgery consult
8. A4-month-old child presents with a 2-day history of vomiting and intermittent irritability. On examination, “currant jelly” stool is noted in the diaper, and a sausage-shaped mass is palpated in the right upper quadrant of the abdomen. Which of the following conditions is most likely to cause this?
A. appendicitis
B. diaphragmatic hernia
C. giardiasis
D. rotavirus gastroenteritis
E. *intussusception
9. A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. Which of the following is the most likely diagnosis?
A. gastroenteritis
B. midgut volvulus
C. Meckel’s diverticulum
D. juvenile rectal polyp
E. *intussusception
10. A 10-month-old infant presents to the emergency department with a 24-hour history of low-grade fever and anorexia. The parents report several episodes in which the child has been suddenly inconsolable and crying, followed by periods of lethargy. He has had nonbilious vomiting and several loose stools. On examination, the infant is pale and mildly dehydrated. His abdomen is soft and nondistended, with fullness to palpation in the right upper quadrant. Which of the following is the most appropriate next step in the diagnostic evaluation and management of this patient?
A. proctoscopy
B. oral rehydration and stool cultures
C. technetium scan
D. IV fluid rehydration, NG decompression, and a UGI contrast study
E. *IV fluid rehydration and a hydrostatic barium enema
11. A 6-week-old breast-fed infant presents to your office one morning appearing quite well. The mother states that for the last week, the infant has had numerous periods of inconsolable crying lasting several hours each. Nothing seems to help. You find that most of the spells occur in the late afternoon and evening; between the episodes, the baby looks and feeds quite well. What is the most likely diagnosis?
A. otitis media
B. intussusception
C. c milk protein intolerance
D. malabsorption
E. *colic
12. A 3-year-old boy presents with violent episodes of intermittent colicky pain, emesis, and blood per rectum. A tubular mass is palpated in the right lower quadrant.The abdominal radiograph reveals a dearth of air in the right lower quadrant and air-fluid levels consistent with ileus. Which of the following procedures will best assist in diagnosis and treatment?
A. esophagogastroduodenoscopy
B. rectal biopsy
C. stool culture
D. colonoscopy
E. * air contrast or barium enema
13. A 2-year-old boy developed emesis and intermittent abdominal pain yesterday, with several small partially formed stools. His parents were not overly concerned because he seemed fine between the pain episodes. Today, however, he has persistent bilious emesis and has had several bloody stools. Examination reveals a lethargic child in mild distress; he is tachycardic and febrile. He has a diffusely tender abdomen with a vague tubular mass in the right upper quadrant. Which of the following is the most appropriate next step in managing this condition?
A. Computerized tomography of the abdomen
B. Intravenous antibiotics for Shigella
C. Parental reassurance
D. Stool cultures
E. *Contrast enema
14. A previously healthy 18-month-old child has vomiting and severe, paroxysmal, writhing abdominal pain (he prefers to have his knees flexed to the chest) alternating with periods of relative comfort with a soft, only mildly tender abdomen. On abdominal examination you find a sausagelike mass. He has not stooled, but you find blood upon digital rectal examination. Which of the following is the best next step in management?
A. Administer morphine for pain control.
B. Order a computerized tomography of the abdomen.
C. Obtain serum acetaminophen levels.
D. Begin antibiotics for Escherichia coli 0157:H7.
E. *Obtain an air contrast enema.
15. A 10-month-old baby is brought to the emergency room with 6-hour history of bilious vomiting, passage of pink jellylike material from the rectum, and intermittent episodes of severe crying. On physical examination a sausage-shaped mass is felt on the right side of the abdomen. The most likely diagnosis is
A. congenital hypertrophic pyloric stenosis
B. intestinal volvulus
C. necrotizing enterocolitis
D. acute pyelonephritis
E. *intussusception
16. A 10-month-old baby is brought to the emergency room with 6-hour history of bilious vomiting, passage of pink jellylike material from the rectum, and intermittent episodes of severe crying. On physical examination a sausage-shaped mass is felt on the right side of the abdomen. The next step in the management of the patient is
A. administration of atropine
B. exploratory laparotomy
C. administration of antibiotics
D. intravenous pyelography
E. *barium enema
17. A 18-year-old male presents complaining of a 1-month history of progressive dysphagia. He reports occasional regurgitation of undigested food at night. His past medical history is noncontributory. The condition has worsened to the point that he is on a liquid diet. What is the best treatment for this patient?
A. proton pump inhibitors
B. referral to a surgeon for a Nissen fundoplication
C. calcium channel blockers
D. serial esophageal sphincter dilations
E. *referral to a surgeon for esophagomyotomy
18. A 18-year-old male presents with difficulty swallowing. Esophageal manometry demonstrates absence of peristaltic waves and a nonrelaxing lower esophageal sphincter (LES). Which of the following is the most likely diagnosis?
A. Barrett’s esophagus
B. diffuse esophageal spasm
C. Plummer-Vinson syndrome
D. esophageal cancer
E. *achalasia
19. A 12-year-old boy presents with a 3-week history of abdominal cramping, diarrhea, and hematochezia. Stool culture results are negative. Fecal testing is negative for Clostridium difficile toxins A and B. Findings on upper GI series with small bowel follow-through are normal. Colonoscopy reveals a confluent colitis beginning in the rectum and extending proximally to the splenic flexure. Biopsies reveal diffuse cryptitis. What is the most likely diagnosis?
A. Crohn disease (CD)
B. Hemolytic-uremic syndrome
C. Meckel diverticulum
D. Appendicitis
E. *Ulcerative colitis (UC)
20. A 3-day-old infant is seen for his hospital discharge examination. He is the 3650-gram, Coombs negative infant of a 20-year-old primigravida mother with an uncomplicated pregnancy, labor, and delivery. He is breastfeeding fairly well, but the mother’s breast milk is only beginning to increase today. His circumcision has some oozing, and his heel is still bleeding from blood sampling an hour ago. He is mildly jaundiced, but the physical examination is otherwise unremarkable. What should the initial workup include?
A. Vitamin K level
B. Cranial ultrasound or CT scan
C. All of the above
D. Only A and C
E. *Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, CBC, and platelet count
21. A 3-day-old infant who weighs
A. Send out protein induced by vitamin K antagonism (PIVKA)-II and vitamin K levels.
B. Administer 1 mg vitamin K IM.
C. Discharge with follow-up in 2 days.
D. Discontinue breast-feeding and begin infant formula.
E. *Administer 1 mg vitamin K IV.
22. A 6-month-old boy bruises easily and has bleeding gums on several occasions for 2 months. A maternal uncle has a bleeding disorder. Examination shows several small bruises on the legs. Partial thromboplastin time is prolonged, and prothrombin time is normal. Which of the following is the most likely coagulation factor deficiency?
A. Factor III
B. Factor VII
C. Factor X
D. Factor XIII
E. *Factor VIII
23. A1-month-old female presents after an episode of bilious emesis. She became irritable 12 hours ago, began vomiting 6 hours ago, and is now lethargic. She had one small stool that was somewhat bloody 2 hours ago. Which of the following statements is true?
A. The most likely explanation is pyloric stenosis.
B. The patient should be admitted for IV fluid resuscitation and observation. If she does not improve over the next 24 hours, a surgical consultation should be obtained.
C. An air contrast enema is the most appropriate next step.
D. A nasogastric tube should be inserted and IV antibiotics started to treat probable necrotizing enterocolitis.
E. *An upper GI contrast study should be obtained immediately.
24. You see a 3-week-old infant in your office for an acute visit. She was born via spontaneous vaginal delivery following a term, uncomplicated prenatal course. The parents are concerned because they have seen some streaks of blood in her diaper over the past few days. The infant’s stools have been soft and not difficult to pass. The parents relate that she is eating
A. Meckel diverticulum
B. group B streptococcal colitis
C. pseudomembranous colitis
D. lactose intolerance
E. *cow’s milk protein intolerance
25. A mother calls the answering service one night because her 12-month-old is “ill”. She was not feeling well earlier in the day and has become increasingly ill. On and off she will play and eat, but then she has episodes where she stops and cries out in pain. The mother thinks she is experiencing abdominal pains. This morning her daughter had one stool that was softer than usual and then she vomited one or two times. Her last stool was soft with some mucus mixed with blood. The infant still breastfeeds and also eats table foods. It is peak season for rotavirus. An older sibling had diarrhea a few days ago, but so far no one else has been ill with vomiting or diarrhea. At this time the best advice to give this mother is to
A. continue to breast-feed, but give additional clear liquids
B. let the infant eat and drink as she wants but call the office for followup in the morning
C. stop the breast-feeding and only give clear liquids
D. take her daughter’s temperature and give a trial dose of liquid acetaminophen
E. *take her daughter to the emergency department
26. Aweek-old infant presents blood in his stools. He was born at home, with the father assisting in the delivery; no physician or midwife was present. He has been breast-fed and has beeursing well. On examination, you also note some blood in his nose. He is not jaundiced; a rectal examination and guaic test of the stool confirms that blood is present. His examination is otherwise normal. He is oo medications. Which of the following is the most likely diagnosis?
A. child abuse
B. breast milk allergy
C. sepsis
D. liver disease
E. *vitamin K deficiency
27. An 18-month-old girl is brought to the hospital with a history of 6 days of bloody diarrhea. She has been drinking well but has not been wetting her diaper. She has been irritable. On physical examination, she has periorbital edema. She appears pale and is tachycardic. Her CBC shows a hemoglobin of 6 g/dL and a platelet count of 100,000/mm3. Her blood urea nitrogen (BUN) is 50 mg/dL and creatinine is 5.5 mg/dL. Her urinalysis shows gross hematuria. Which of the following is the most likely causative organism for her clinical problem?
A. group A Streptococci
B. group B Streptococci (GBS)
C. S. aureus
D. the cause of this illness is not known
E. *coli 0157:H7
28. A 3-year-old boy presents with an elbow hemarthrosis after falling on his elbow. There is no history of spontaneous bleeding. There is no history of epistaxis, gingival bleeding, or cutaneous bruising. The child’s maternal grandfather had frequent spontaneous bleeding and hemarthroses after trauma on multiple occasions. Laboratory results revealed a prolonged PTT, normal PT, and a platelet count of 150,000. The factor VIII coagulant activity is low and the factor IX level is normal. What is the most likely diagnosis?
A. idiopathic thrombocytopenic purpura
B. von Willebrand’s disease
C. c vitamin K deficiency
D. liver disease
E. *hemophilia A
29. A 9-year-old boy has bright red rectal bleeding off and on for a few months. He has a history of constipation and intermittent encopresis. He denies inappropriate touching in the area. Upon examination, the child’s anus has lost its stellate pattern and its tone. He has three deep fissures in the anus and a scar at 8 o’clock. Which of the following is a likely cause of the boy’s findings?
A. Constipation
B. Eczema
C. Hemorrhoids
D. Hirschsprung disease
E. *Penetrating anal trauma
30. A mother states her 4-year-old son has had 2 days of “buttocks pain.” She reports several blood-streaked stools and frequent scratching of the area. He is afebrile, but his perianal region is bright red with a clearly demarcated erythematous border. The area is diffusely tender, but no nodularity, fluctuance, or trauma is found. Appropriate diagnostic testing and therapy includes which of the following?
A. Stool sample for ova and parasites; treatment with albendazole
B. Cellophane tape test for ova; treatment with albendazole
C. Blood culture; parenteral antibiotics
D. Administration of diaper rash ointment
E. *Rapid streptococcal test of the anal area; oral antibiotics
31. A 6-year-old boy who recently moved from the southeastern United States complains of “something coming out” of his buttocks while straining during defecation; it seems to resolve when he relaxes. He also complains of abdominal pain and bloody stools for the last week. Examination reveals a normal external anus without evidence of trauma. When straining, he produces a pink mucosal mass from his anus; it returns when he relaxes. Initial diagnostic evaluation should include which of the following studies?
A. Cellophane tape test upon morning awakening
B. Rectal culture
C. Abdominal ultrasonography
D. Herpes culture
E. *Stool for ova and parasites
32. A previously healthy 5-year-old girl presents to the ED with her parents with a temperature of
A. Appendicitis
B. Colonic arteriovenous malformation
C. Colonic diverticulitis
D. Gastric stress ulcer
E. *Meckel’s diverticulitis
33. An 18-year-old female presents with abdominal pain, fever, and leukocytosis- With the presumptive diagnosis of appendicitis, a right lower quadrant (McBurney) incision is made and a lesion
A. Can best be diagnosed by preoperative angiogram, which should be done whenever the diagnosis is suspected
B. Should routinely be removed when incidentally discovered during celiotomy
C. Often contains ectopic adrenal tissue
D. Is frequently associated with cutaneous flushing and episodic tachycardia
E. *Is embryologically derived from a persistent vitelline duct (omphalomesenteric duct)
34. An 18-year-old woman presents with abdominal pain, fever, and leukocytosis. With the presumptive diagnosis of appendicitis, a right lower quadrant (McBurney) incision is made and the lesion pictured below is delivered. The process is
A. Can best be diagnosed by preoperative angiogram, which should be done whenever the diagnosis is suspected
B. Should routinely be removed when incidentally discovered during celiotomy
C. Often contains ectopic adrenal tissue
D. Is frequently associated with cutaneous flushing and episodic tachycardia
E. *Is embryologically derived from a persistent vitelline duct (omphalomesenteric duct)
35. A 2-year-old child presents with a 2-day history of painless rectal bleeding. On examination, the child is pale with tachycardia. The abdomen is nondistended and nontender. There is dark blood on rectal examination. Which of the following is the most appropriate management?
A. surgical exploration
B. colonoscopy
C. acid suppression therapy
D. IV steroids
E. *aggressive resuscitation followed by surgical exploration
36. A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Which of the following is the most likely diagnosis?
A. juvenile rectal polyp
B. hemorrhoids
C. an anal fissure
D. intussusception
E. *a bleeding Meckel’s diverticulum
37. A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Which of the following is the most appropriate diagnostic study to order for this patient?
A. colonoscopy
B. barium enema
C. UGI contrast study with small-bowel follow-through
D. laparoscopy
E. *technetium scan
38. A 4-year-old previously healthy girl presents to the emergency department with a 24-hour history of rectal bleeding and dizziness. She has no other gastrointestinal symptoms. On examination, she appears pale. Her heart rate is 140 beats/min, and she has a 20 mmHg postural drop in systolic blood pressure. The child’s abdomen is nondistended and nontender, and fresh blood and clots are in the rectal vault on rectal examination. Definitive management of this child should include which of the following?
A. immediate exploratory laparotomy
B. IV fluid resuscitation, followed by a colonoscopic polypectomy
C. hemorrhoidectomy
D. stool softeners and topical steroids
E. *IV fluid resuscitation, transfusion with blood products as indicated, followed by a laparotomy with Meckel’s diverticulectomy and ileal resection
39. A 16-year-old boy comes to the physician because of intermittent lower abdominal pain over the past 3 months. There is no family history of cancer. Examination shows no other abnormalities. His hematocrit is 38%. Test of the stool for occult blood is positive. Colon contrast studies show a 1.5-cm polyp in the descending colon. An upper gastrointestinal series shows no abnormalities. Which of the following is the most appropriate next step in management?
A. Reexamination in 1 year
B. Repeat test of the stool for occult blood after 3 days on a meat-free diet
C. Measurement of serum carcinoembryonic antigen (CEA) concentration
D. Total colectomy
E. *Colonoscopy with polypectomy
40. A 17-year-old female whose father had a colon resection for adenocarcinoma undergoes her first colonoscopy. Over 100 small polyps are seen distributed mainly in her sigmoid and rectum. Multiple polyps are removed and histologic review reveals tubular adenomas with no evidence of atypia or dysplasia. The most appropriate next step in her management is which of the following?
A. surveillance colonoscopy in 5 years
B. surveillance colonoscopy every 2 years until all polyps are removed
C. flexible sigmoidoscopy with representative biopsy every 6 months for 2 years, then yearly for 3 years, then every 3–5 years
D. abdominal perineal resection with sigmoid resection and end colostomy
E. *total proctocolectomy with ileoanal J pouch reconstruction
41. Biopsy of a 4-cm sessile polyp of the cecum during a routine screening colonoscopy reveals it to be a villous adenoma with atypia. Attempt at piecemeal snare polypectomy through the colonoscope is unsuccessful. Which of the following is the most appropriate management?
A. colonoscopy with electrocoagulation of the tumor
B. colonoscopy with repeat biopsy in 6 months
C. open surgery with colotomy and excision of polyp
D. external beam radiation
E. *right hemicolectomy
42. A 18-year-old previously healthy man comes to the office because of a 2-wcek history of rectal bleeding that he describes as blood mixed with stool. The bleeding has been intermittent and not associated with nausea, vomiting, abdominal pain, or any other symptomatology. He denies any previous history of rectal bleeding, diarrhea, or recent foreign travel On eliciting the family history, he says that he is worried about this rectal bleeding because his father had similar complaints and underwent a total colectomy when he was 47 years old. Family history is also suggestive of breast carcinoma in his mother at the age of 52 years and his mother’s sister at the age of 56 years. His father had prostate carcinoma, for which he underwent resection and received chemotherapy. He also vaguely remembers that there was a history of polyps in the colon in his family members, requiring surgery by the age of 40. Clinical examination is unremarkable and laboratory studies are withiormal limits. Rectal examination does not reveal any mass. A flexible sigmoidoscopy performed in the office reveals numerous polyps that cannot be counted. Most of these polyps are less than
A. A CT scan of the abdomen and pelvis is necessary to rule out any metastases.
B. Genetic testing is unnecessary, as he does not have a genetic disease.
C. He should be rescreened in 1 year.
D. It is necessary to biopsy and remove all the polyps.
E. *He should be referred to a surgeon for a colectomy.
43. A 18-year-old man presents to the physician’s office for his yearly physical examination. He is asymptomatic. Family history is positive for breast cancer in his mother at age 50 and colon cancer in his father at age 45. His examination is unremarkable except for guiac positive stool. Barium enema shows a sigmoid colon polyp. Colonoscopy confirms a 3-cm pedunculated polyp in the sigmoid colon, and snare polypectomy is performed. Pathologic examination reveals an adenomatous polyp with a focus of invasive carcinoma in the head, with a 4-mm resection margin and no tumor noted in the stalk. Which of the following is the most appropriate next step in management?
A. CT scan
B. magnetic resonance imaging (MRI) scan
C. surgical resection of sigmoid
D. regular use of nonsteroidal antiinflammatory drugs (NSAIDs)
E. *observation
44. After complete removal of a sessile polyp of 2.0 –
44.
A. Reexcision of the biopsy site with wider margins
B. Abdominoperineal rectosigmoid resection
C. Anterior resection of the rectum
D. External radiation therapy to the rectum
E. *No further therapy
45. A 17-year-old girl presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Examination is unremarkable except for mild epigastric tenderness to deep palpation. Which of the following is the most appropriate next step in management?
A. H2 blockers with re-evaluation by UGI in 6 months
B. vagotomy and pyloroplasty
C. total gastrectomy
D. CT scan
E. *endoscopy
46. A 18-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of
A. small-bowel obstruction
B. dead bowel
C. perforated colon carcinoma
D. perforated gastric ulcer
E. *perforated duodenal ulcer
47. A 18-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of
A. UGI water-soluble contrast study
B. lower GI water-soluble contrast study
C. abdominal ultrasound
D. none of the above
E. *CT scan
48. A 18-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of
A. immediate laparotomy
B. nonoperative management with NG decompression and antibiotics
C. administration of H2 blockers
D. placement of a central venous line
E. *fluid resuscitation
49. A 18-year-old man with a recently diagnosed duodenal ulcer develops melena and near-syncope. After fluid resuscitation, upper gastrointestinal endoscopy is performed. During the examination, a
A. Angiographic embolization of the gastroduodenal artery
B. Transfusion and intravenous cimetidine
C. Angiographic infusion of vasopressin into the gastroduodenal artery
D. Transfusion and oral omeprazole
E. *Irrigation of the clot followed by endoscopic application of a heat probe
50. A 20-year-old patient has undergone truncal vagotomy and antrectomy with Billroth II reconstruction two years ago. The patient now complains of recurrent postprandial pain, nausea, and vomiting. Endoscopic examination reveals bile in the stomach; endoscopic biopsies demonstrate histologic evidence of moderately severe gastritis. No other endoscopic abnormalities are noted. Appropriate therapy could include:
A. Octreotide administration
B. Total gastrectomy
C. Conversion of Billroth II gastrojejunostomy to Billroth I gastroduodenostomy
D. Roux-en-Y hepaticojejunostomy
E. *Conversion of Billroth II gastrojejunostomy to Roux-en-Y gastrojejunostomy
51. A 20-year-old male with a 2 year history of duodenal ulceration develops sudden, severe epigastric pain 4 hours prior to evaluation. Physical examination reveals T 101° F, pulse 80, BP 125/90, diminished bowel sounds, and abdominal muscular rigidity. An upright chest x-ray reveals pneumoperitoneum. At laparotomy, an anterior perforation in the first portion of the duodenum is observed. Optimal treatment would include:
A. Omental patch of the perforation followed by truncal vagotomy and antrectomy after 8 weeks
B. Omental patch of the perforation followed by truncal vagotomy and pyloroplasty after 8 weeks
C. Omental patch of the perforation followed by chronic cimetidine administration
D. Omental patch of the perforation only
E. *Omental patch of the perforation plus proximal gastric vagotomy
52. A 18-year-old male is evaluated because of symptoms of epigastric pain and anorexia. Physical examination is normal except for guaiac positivity of stool. Upper endoscopic examination reveals a
A. Sucralfate
B. Endoscopic cautery of the ulcer base
C. Endoscopic biopsy of the ulcer base
D. Misoprostol 400 mg b.i.d. for 8 weeks
E. *Endoscopic biopsy of the ulcer rim
53. A 18-year-old man presents with sudden onset of severe epigastric pain 6 hours ago. Examination reveals a low-grade fever, tender abdomen throughout, with rigidity of the abdominal musculature. Abdominal roentgenograms show pneumoperitoneum.
A. acute appendicitis
B. sigmoid diverticulitis
C. acute pancreatitis
D. acute cholecystitis
E. *perforated peptic ulcer
54. A 10-year-old, otherwise healthy woman undergoes an appendectomy with primary closure of the wound for a perforated appendix. No antibiotics are administered. Should this patient develop an intraabdominal abscess, which of the following organisms would most likely be responsible?
A. Escherichia coli
B. Streptococcus faecalis
C. Proteus
D. Serratia marcescens
E. *Bacteroides
55. A sexually active 14-year-old girl is brought to the emergency department because of the acute onset of right lower quadrant abdominal pain and loss of appetite for 18 hours. She has had no nausea or vomiting. Her temperature is 38.9EC (102EF). Bimanual pelvic examination shows cervical exudate and tenderness on cervical motion. There is bilateral lower quadrant tenderness. Her leukocyte count is 21,300/mm3. Her serum ?-hCG concentration is withiormal limits. Which of the following is the most appropriate next step in management?
A. Meckel scan
B. Culdocentesis
C. Dilatation and curettage
D. Immediate appendectomy
E. *Antibiotic therapy
56. An 18-year-old woman comes to the emergency department because of lower abdominal pain for 16 hours. She also reports loss of appetite and mild nausea. She is sexually active and takes an oral contraceptive. Her last menstrual period was 3 weeks ago. Her temperature is 37.9EC (100.2EF). There is guarding and tenderness to palpation of the right lower quadrant of the abdomen; palpation of other areas of the abdomen results in referred pain in the right lower quadrant. Bowel sounds are absent. Pelvic examination shows scant mucous discharge from the cervicalos. Palpation on the right produces pain. There is no cervical motion tenderness, and the adnexa and ovaries appear normal. Which of the following is the most likely diagnosis?
A. Ectopic pregnancy
B. Ovarian cyst
C. Tubo-ovarian abscess
D. Ureteral calculus
E. *Appendicitis
57. A 16-year-old woman comes to the physician because of pain in the left lower quadrant of the abdomen for the past 3 days. She had similar episodes on three previous occasions over the past 6 months. Examination shows abdominal tenderness in the left lower quadrant with rebound tenderness. Her hemoglobin concentration is 13.6 g/dL and leukocyte count is 15,400/mm3 with 82% segmented neutrophils and 18% lymphocytes. Urinalysis shows 5–6 WBC/hpf. Which of the following is the most likely diagnosis?
A. Acute cholecystitis
B. Acute pyelonephritis
C. Appendicitis
D. Spontaneous bacterial peritonitis
E. *Acute diverticulitis
58. A 18-year-old girl comes to the emergency department because of fever and increasingly severe pain in the right upper quadrant of the abdomen for 18 hours. She has had no nausea or vomiting. There is no history of fatty food intolerance or previous symptoms. The patient returned from a trip to Mexico 6 months ago. Her temperature is 38.9EC (102EF), pulse is 110/min, respirations are 18/min, and blood pressure is 130/85 mm Hg. Examination shows decreased breath sounds over the right base. Abdominal examination shows tenderness to percussion over the right upper quadrant and normal bowel sounds; Murphy sign is absent. Leukocyte count is 20,500/mm3 (25% bands, 55% eosinophils, 5% lymphocytes, and 15% monocytes). Which of the following is the most likely diagnosis?
A. Appendicitis
B. Cholecystitis
C. Hepatitis
D. Pyogenic abscess
E. *Amebic abscess
59. A 16-year-old boy was performed an appendectomy. He has been hospitalized for right lower quadrant abdominal pain within 18 hours. The surgical specimen is edematous and erythematous. Infiltration by what of the following cells is the most typical for the process occuring here?
A. Eosinophils
B. Monocytes
C. Basophils
D. Limphocytes
E. *Neutrophils
60. A 10-year-old boy complains of a headache, weakness, fever [temperature- 400N], vomiting. On physical examination: there is an expressed dyspnea, pale skin with a flush on a right cheek, right hemithorax respiratory movement delays, dullness on percussion of the lower lobe of the right lung, weakness of vesicular respiration in this region. The abdomen is painless and soft by palpation. What disease causes these symptoms and signs?
A. Acute cholecystitis
B. Influenza
C. Intestinal infection
D. Acute appendicitis
E. *Pneumonia croupousa
61. A 12-year-old boy presents with a 3-week history of abdominal cramping, diarrhea, and hematochezia. Stool culture results are negative. Fecal testing is negative for Clostridium difficile toxins A and B. Findings on upper GI series with small bowel follow-through are normal. Colonoscopy reveals a confluent colitis beginning in the rectum and extending proximally to the splenic flexure. Biopsies reveal diffuse cryptitis. What is the most likely diagnosis?
A. Crohn disease (CD)
B. Hemolytic-uremic syndrome
C. Meckel diverticulum
D. Appendicitis
E. *Ulcerative colitis (UC)
62. A child of 3 suddenly fell sick 16 hours ago with a sudden rise in temperature to
A. Acute gastritis
B. Acute gastroduodenitis
C. Gastroenteritis
D. Peritonitis
E. *Acute appendicitis
63. A 17-year-old woman comes to the physician because of pain in the left lower quadrant of the abdomen for the past 3 days. She had similar episodes on three previous occasions over the past 6 months. Examination shows abdominal tenderness in the left lower quadrant with rebound tenderness. Her hemoglobin concentration is 13.6 g/dL and leukocyte count is 15,400/mm3 with 82% segmented neutrophils and 18% lymphocytes. Urinalysis shows 5–6 WBC/hpf. Which of the following is the most likely diagnosis?
A. Acute cholecystitis
B. Acute pyelonephritis
C. Appendicitis
D. Spontaneous bacterial peritonitis
E. *Acute diverticulitis
64. A child of 3 was taken ill 2 hrs ago with right iliac fossa and suprapubic abdominal pains, a body temperature of 38.2C, recurrent emesis and diarrhea. On examination, the abdomen was found to be tense around the umbilicus and in the lower regions. Signs of peritoneal irritation were positive with a muco-purulent vaginal discharge. Your diagnosis:
A. Acute appendicitis
B. Acute intestinal obstruction
C. Acute non-specific mesenteric adenitis
D. Pelvic inflammatory disease
E. *Primary peritonitis
65. During an operation for presumed appendicitis, the appendix is found to be normal; however, the terminal ileum is markedly thickened and feels rubbery to firm, its serosa is covered with a gray-white exudate, and several loops of apparently normal small intestine are adherent to it. The most likely diagnosis is:
A. Perforated Meckel’s diverticulum
B. Ulcerative colitis
C. Ileocecal tuberculosis
D. Acute ileitis
E. *Crohn’s disease of the terminal ileum
66. A 17-year-old woman is admitted to the emergency department with evidence of spreading peritonitis. Her temperature is
A. administration of broad-spectrum antibiotics intravenously
B. correction of hyperglycemia
C. immediate diagnostic celiotomy
D. laparoscopic evaluation to establish a diagnosis
E. *correction of ketoacidosis
67. During the past week a one month old infant was reported to have been having projectile vomiting. The child was in a severe state, adynamic with 2nd degree hypotrophy. On palpation, the abdomen was found to be soft, intestinal peristalsis of the “sand-clock” was evident. Which investigation would prove most appropriate at arriving at a diagnosis?
A. Gastro-duodenoscopy
B. Plain radiography
C. Thermography
D. CT scan
E. *Ultrasonography
68. A 18 y.o. patient suddenly fell ill 12 hours ago. There was pain in epigastric area, nausea, sporadic vomiting. In few hours the pain localized in the right iliac area. On examination: positive rebound tenderness symptom. WBC 12.2*109/L. What is the most probable diagnosis?
A. Perforated ulcer
B. Acute pancreatitis
C. Acute cholecystitis
D. Rightside kidney colic
E. *Acute appendicitis
69. An 18-year-old woman comes to the emergency department because of lower abdominal pain for 16 hours. She also reports loss of appetite and mild nausea. She is sexually active and takes an oral contraceptive. Her last menstrual period was 3 weeks ago. Her temperature is 37.9EC (100.2EF). There is guarding and tenderness to palpation of the right lower quadrant of the abdomen; palpation of other areas of the abdomen results in referred pain in the right lower quadrant. Bowel sounds are absent. Pelvic examination shows scant mucous discharge from the cervicalos. Palpation on the right produces pain. There is no cervical motion tenderness, and the adnexa and ovaries appear normal. Which of the following is the most likely diagnosis?
A. Ectopic pregnancy
B. Ovarian cyst
C. Tubo-ovarian abscess
D. Ureteral calculus
E. *Appendicitis
70. A sexually active 14-year-old girl is brought to the emergency department because of the acute onset of right lower quadrant abdominal pain and loss of appetite for 18 hours. She has had no nausea or vomiting. Her temperature is 38.9EC (102EF). Bimanual pelvic examination shows cervical exudate and tenderness on cervical motion. There is bilateral lower quadrant tenderness. Her leukocyte count is 21,300/mm3. Her serum ?-hCG concentration is withiormal limits. Which of the following is the most appropriate next step in management?
A. Meckel scan
B. Culdocentesis
C. Dilatation and curettage
D. Immediate appendectomy
E. *Antibiotic therapy
71. A child of 3 was taken ill 2 hrs ago with right iliac fossa and suprapubic abdominal pains, a body temperature of 38.2C, recurrent emesis and diarrhea. On examination, the abdomen was found to be tense around the umbilicus and in the lower regions. Signs of peritoneal irritation were positive with a muco-purulent vaginal discharge. Your diagnosis:
A. Acute appendicitis
B. Acute intestinal obstruction
C. Acute non-specific mesenteric adenitis
D. Pelvic inflammatory disease
E. *Primary peritonitis
72. A 10-year-old, otherwise healthy woman undergoes an appendectomy with primary closure of the wound for a perforated appendix. No antibiotics are administered. Should this patient develop an intraabdominal abscess, which of the following organisms would most likely be responsible?
A. Escherichia coli
B. Streptococcus faecalis
C. Proteus
D. Serratia marcescens
E. *Bacteroides
73. During laparoscopic abdominal procedures, the abdominal cavity is usually insufflated with carbon dioxide to a pressure of 15 mmHg. Increasing the intra-abdominal pressure to these levels produces which of the following physiologic responses?
A. decreased afterload
B. depressed cardiac output
C. depressed diaphragm
D. alkalosis
E. *hypercarbia
74. A 18-year-old man, previously in good health, suddenly develops severe abdominal pain radiating from the left loin to the groin and associated with nausea, perspiration, and frequent urination. He is restless, tossing in bed, but has no abnormal findings. The most likely diagnosis is which of the following?
A. herpes zoster
B. sigmoid diverticulitis
C. torsion of the left testicle
D. retroperitoneal hemorrhage
E. *left ureteral calculus
75. Apatient is operated on with the presumptive diagnosis of acute appendicitis. However, at operation, the appendix and cecum are found to be normal. The terminal ileum though is red, edematous, and thickened with creeping of the mesenteric fat onto the ileum for a distance of approximately
A. closure of the abdomen
B. ileostomy proximal to the area of involvement
C. side-to-side ileotransverse colostomy
D. right hemicolectomy
E. *appendectomy
76. Following an uneventful appendectomy for acute appendicitis, the pathology report reveals the presence of a
A. formal right hemicolectomy
B. partial cecectomy—excision of the base of the cecum at the appendectomy site
C. total abdominal colectomy with ileorectal anastomosis
D. partial small bowel resection
E. *no further operative intervention required
77. Tuboovarian abscess is one of the complications of acute pelvic inflammatory disease (PID), and occurs in up to 15–30% of women hospitalized with PID. The most cost-effective antibiotic regimen for treating inpatient women with tuboovarian abscess is which of the following?
A. cefotetan IV plus oral doxycycline
B. gentamycin IV
C. penicillin IM
D. ancef IV
E. *ampicillin IV plus gentamycin IV plus clindamycin IV
78. A 5-ycar-old boy has had increasing abdominal pain over the past 24 hours. He has no vomiting, diarrhea, or other symptoms of illness except for mild decrease in appetite. On physical examination he appears ill and is in mild distress. Temperature is
A. an abdominal ultrasound
B. a CBC and blood culture
C. serum amylase and lipase
D. a urine culture
E. *a chest x-ray
79. A previously healthy 12-year-old boy is brought to the emergency department because of abdominal pain that began earlier that same day. He did not eat any breakfast or lunch and when he developed a fever this afternoon, the parents became worried. The boy tells you that his pain was initially around his belly button but now it hurts more on the right side. He prefers to lie still since any movement makes the pain worse. He is not hungry and vomited one time in the car. His temperature is
A. admit the patient for hydration and antibiotics
B. admit the patient for serial abdominal examinations
C. order a CT scan
D. prepare the patient for emergent exploratory laparotomy
E. *prepare the patient for emergent appendectomy
80. A 19-year-old man comes to the emergency department complaining of severe abdominal pain. He tells you that he has had intermittent epigastric pain for several months, but today the pain suddenly worsened. He has been taking an increased amount of ibuprofen over the last 6 months to help control the pain from a knee injury he suffered during a company softball game. He denies any other medical or surgical history. He takes no other medications. He does drink on a social basis. His temperature is
A. begin a morphine drip and admit for observation
B. order a CT scan of the abdomen and pelvis
C. perform colonoscopy
D. schedule a barium enema
E. *prepare him for emergent exploratory laparotomy
81. A 19-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most likely diagnosis?
A. torsion of the right testicle
B. pyelonephritis
C. appendicitis
D. acute urinary retention
E. *right ureteral calculus
82. A 19-year-old previously healthy man presents with sudden onset of severe abdominal pain that radiates from the right loin (flank) to groin. This pain is associated with nausea, sweating, and urinary urgency. He is distressed and restless, but an abdominal examination is normal. Which of the following is the most appropriate next step in management?
A. insertion of a urethral catheter
B. IV fluid hydration, IV analgesics, and arrangements for lithotripsy
C. cystoscopy and retrograde pyelogram
D. urine culture, followed by initiation of antibiotic therapy
E. *IV fluid hydration, IV analgesics, and nonenhanced computed tomography (CT) scan
83. A 18-year-old previously healthy woman presents with abdominal pain of 48-hour duration. The pain was initially periumbilical and on progression became localized in the right lower quadrant. The woman had nausea and a decreased appetite. She denied dysuria. Her last menstrual period was 2 weeks earlier. On examination, she was febrile (temperature
A. gastroenteritis
B. perforated peptic ulcer
C. acute cholecystitis
D. ruptured ovarian cyst
E. *acute appendicitis
84. A 18-year-old man with a history of alcohol abuse presents after an episode of binge drinking. He is complaining of epigastric pain, radiating to the back, associated with nausea and vomiting. On examination, he has marked tenderness in the epigastrium, with guarding, decreased bowel sounds, and moderate abdominal distention. Laboratory findings include leukocytosis and increased serum amylase and lipase. Abdominal roentgenograms demonstrate several dilated bowel loops in the upper abdomen. Select the most likely diagnosis.
A. gastroenteritis
B. acute appendicitis
C. perforated peptic ulcer
D. acute cholecystitis
E. *acute pancreatitis
85. A 18-year-old man presents with a 4-day history of worsening lower abdominal pain and constipation. On examination, he is febrile (
A. acute appendicitis
B. perforated peptic ulcer
C. acute pancreatitis
D. cecal volvulus
E. *sigmoid diverticulitis
86. A 18-year-old man presents with sudden onset of severe epigastric pain 6 hours ago. Examination reveals a low-grade fever, tender abdomen throughout, with rigidity of the abdominal musculature. Abdominal roentgenograms show pneumoperitoneum. Select the most likely diagnosis.
A. acute appendicitis
B. sigmoid diverticulitis
C. acute pancreatitis
D. acute cholecystitis
E. *perforated peptic ulcer
87. A 20-year-old woman presents to the emergency room with a 3-day history of worsening abdominal pain, with nausea and vomiting. Examination reveals a low-grade fever and abdominal tenderness in the right upper quadrant with guarding, especially during inspiration. Laboratory findings include a mild leukocytosis and a slightly elevated bilirubin. Select the most likely diagnosis.
A. acute appendicitis
B. perforated peptic ulcer
C. sigmoid diverticulitis
D. acute pancreatitis
E. *acute cholecystitis
88. An 8-year-old boy presents with a 1 -day h istory of emesis and periumbilical pain that has moved to the right lower quadrant. There is no history of diarrhea. Abdominal examination reveals guarding and rebound tenderness. The white blood cell count is elevated, at 20.000, with a left shift. Which of the following is the most likely diagnosis?
A. pancreatitis
B. c viral gastroenteritis
C. urinary tract infection
D. diabetes mellitus
E. *appendicitis
89. A 15-year-old adolescent female has experienced abdominal pain, vomiting, and lethargy for 3 days. Her chest and throat examinations are clear, but her abdominal examination is significant for right lower quadrant pain. Rectal examination is equivocal for pain, and her pelvic examination is remarkable for pain upon movement of her cervix. Laboratory data include a white blood cell count of 18,000/mm3, serum glucose level of 145 mg/dL, and serum bicarbonate level of 21 mEq/dL. Her urinalysis is remarkable for 1+ white blood cells, 1+ glucose, and 1+ ketones. Which of the following is the most likely diagnosis?
A. Appendicitis
B. Diabetic ketoacidosis (DKA)
C. Gastroenteritis
D. Right lower lobe pneumonia
E. *Pelvic inflammatory disease (PID)
90. A 16-year-old adolescent female presents with a 1-day history of stabbing left groin pain, and white vaginal discharge and mild dysuria for the past week. There has beeo abnormal vaginal bleeding, with her last menses approximately 3 weeks ago. She reports one UTI since menarche, but no STDs. She has been sexually active for the past year and takes an oral contraceptive. Her partners irregularly use condoms. She is afebrile, but has left lower quadrant and suprapubic abdominal pain on deep palpation and minimal guarding. Which of the following is the most appropriate next step?
A. Request emergent surgery consultation.
B. Order pelvic ultrasonography.
C. Perform pelvic examination and Pap smear.
D. Order follicle-stimulating hormone and luteinizing hormone.
E. *Perform urinalysis and urine pregnancy testing.
91. A 7-year-old has right-sided abdominal pain and fever to
A. Abdominal computerized tomography
B. Liver function tests
C. Stool leukocytes
D. Stool for culture, ova, and parasites
E. *Chest radiograph
92. A 14-year-old adolescent female with a 3-day history of abdominal pain, anorexia, and vomiting and a 1-day history of fever underwent laparoscopic surgery for suspected appendicitis, which was perforated at the time of surgery. Intravenous ampicillin, gentamicin, and clindamycin were initiated prior to surgery and continued postoperatively. On the seventh postoperative day, she continues to have fevers to
A. Add metronidazole to the antibiotic regimen.
B. Change the antibiotics to amikacin and a cephalosporin.
C. Send a urinalysis and urine culture.
D. Perform a pelvic examination.
E. *Order a computerized tomography scan stat.
93. A previously healthy 8-year-old boy presents to your office with abdominal pain, anorexia, and vomiting that have worsened over the previous 24 hours. The pain is located in the umbilical region. Despite the emesis, he appears well hydrated. A CBC reveals a white blood count of 17,000 cells/mm3 with 50% polymorphonuclear cells. A urine dipstick on a clean-catch specimen shows 2+ leukocytes and 1+ protein but no nitrites. Which of the following is the most appropriate management at this point?
A. Obtain a complete chemistry panel and continue to observe him in the office.
B. Give him a prescription for trimethoprim-sulfamethoxazole; schedule a follow-up visit in 2 days to reevaluate the urine.
C. Admit him to the hospital for intravenous antibiotics to treat presumed pyelonephritis.
D. Schedule a computerized tomography scan of the abdomen for the next morning.
E. *Send the patient immediately to the hospital for an abdominal ultrasound.
94. A 17-year-old adolescent male has left shoulder and left upper quadrant abdominal tenderness and vomiting. He reports having “mono” last month but says he is completely recovered. He was playing flag football with friends when the pain started an hour ago. On examination, his heart rate is 150 bpm and his blood pressure is 80/50 mm Hg. He is pale, weak, and seems disoriented. He has diffuse rebound abdominal tenderness. Emergent management includes which of the following?
A. Laparoscopic appendectomy
B. Intravenous antibiotics
C. Hospital admission for observation
D. Synchronized cardioversion for supraventricular tachycardia
E. *Fluid resuscitation and blood transfusion
95. A 15-year-old adolescent female presents to the local hospital emergency center complaining of several days of left sided abdominal pain, mild vaginal bleeding, and dizziness. Upon further questioning you learn that she has had near-syncopal episodes the last few times she has tried to stand up. She denies fever, sexual activity, previous episodes of mid-cycle vaginal bleeding, and abdominal or genitourinary trauma. On examination, she is pale and tachycardic. She has abdominal pain with rebound and guarding in the upper and lower left quadrants that radiates to the back. Her hemoglobin is 5 g/dL, her white count is 12,000/mm3, and her platelet count is 210,000/mm3. Her serum s-HCG is 1800 IU/mL. Which of the following is the most likely diagnosis?
A. Metrorrhagia with subsequent anemia
B. Pelvic inflammatory disease
C. Salicylate overdose
D. Uterine malignancy
E. *Ruptured ectopic pregnancy
96. A 19-year-old adolescent female presents with a temperature of
A. Levofloxacin, 500 mg orally once a day for 14 days as monotherapy
B. Ofloxacin, 400 mg orally twice a day for 14 days as monotherapy
C. Ceftriaxone, 250 mg IM in a single dose as monotherapy
D. Levofloxacin, 500 mg orally once a day, and doxycycline, 100 mg orally twice a day, both for 14 days
E. *Ceftriaxone, 250 mg IM as a single dose and doxycycline, 100 mg orally twice a day for 14 days
97. A previously healthy 15-yearold boy is brought to the emergency room with complaints of about 12 h of progressive anorexia, nausea, and pain of the right lower quadrant. On physical examination, he is found to have a rectal temperature of
A. Close the abdomen after culturing the exudate
B. Resect the involved terminal ileum
C. Perform the ileocolic resection
D. Perform an ileocolostomy to bypass the involved terminal ileum
E. *Perform a standard appendectomy
98. A 32-year-old woman presents to the hospital with a 24-h history of abdominal pain of the right lower quadrant. She undergoes an uncomplicated appendectomy for acute appendicitis and is discharged home on the fourth postoperative day. The pathologist notes the presence of a carcinoid tumor (
A. The patient should be advised to undergo ileocolectomy
B. The most common location of carcinoids is in the appendix
C. The carcinoid syndrome occurs in more than half the patients with carcinoid tumors
D. Carcinoid syndrome is seen only when the tumor is drained by the portal venous system
E. *The tumor is an apudoma
99. A 28-year-old previously healthy woman arrives in the emergency room complaining of 24 h of anorexia and nausea and lower abdominal pain that is more intense in the right lower quadrant than elsewhere. On examination she has peritoneal signs of the right lower quadrant and a rectal temperature of
A. Cecal diverticula are acquired disorders
B. Cecal diverticula are usually multiple
C. Cecal diverticula are mucosal herniations through the muscularis propria
D. An ileocolectomy is indicated even with well-localized inflammation
E. *Diverticulectomy, closure of the cecal defect, and appendectomy may be indicated
100. A patient is operated on with the presumptive diagnosis of acute appendicitis. However, at operation, the appendix and cecum are found to be normal. Terminal ileum for a distance of approximately
A. closure of the abdomen
B. ileostomy proximal to the area of involvement
C. side-to-side ileo-transverse colostomy
D. right hemicolectomy
E. *appendectomy
101. A 18-year-old woman comes to the ER complaining of the sudden onset of epigastric and right upper quadrant pain, radiating to the back, associated with vomiting. On examination, tenderness is elicited in the right upper quadrant, bowel sounds are decreased, and laboratory data show leukocytosis as well as normal serum levels of amylase, lipase, and bilirubin. What is the most likely diagnosis?
A. perforated peptic ulcer disease
B. myocardial infarction
C. acute pancreatitis
D. sigmoid diverticulitis
E. *acute cholecystitis
102. A 18-year-old woman comes to the ER complaining of the sudden onset of epigastric and right upper quadrant pain, radiating to the back, associated with vomiting. On examination, tenderness is elicited in the right upper quadrant, bowel sounds are decreased, and laboratory data show leukocytosis as well as normal serum levels of amylase, lipase, and bilirubin. Which of the following is the most useful diagnostic test to confirm the diagnosis?
A. two-way roentgenogram of the abdomen
B. CT scan of the abdomen and pelvis with oral contrast
C. HIDA (hydroxy iminodiacetic acid) scan
D. magnetic resonance cholangiopancreatography (MRCP)
E. *ultrasonography of the upper abdomen
103. A 18-year-old slightly obese woman comes to the office complaining of right-sided crampy abdominal pain. The pain became severe after she ate lunch and radiates to the area underneath the right shoulder blade. She has suffered from many similar episodes in the past 6 months and the pain typically lasts for several hours and then slowly dissipates. She denies any vomiting, dysuria, hematuria, fevers, chills, or change in bowel habits. On physical examination in your office, she is comfortable and afebrile with normal vital signs. She has hypoactive bowel sounds without abdominal distention. There is mild tenderness in the right upper quadrant without rebound or guarding. There is no costovertebral angle tenderness. Pelvic and rectal examinations are normal. Urine dipstick in the office is negative for blood, white cells, or bilirubin. At this time, the most appropriate imaging study to confirm this patient’s diagnosis is
A. aHIDAscan
B. an MRI of the abdomen
C. a plain film abdominal x-ray
D. a renal/bladder ultrasound
E. *an abdominal ultrasound
104. A 18-year-old woman develops pain of the right lower quadrant while playing tennis. The pain progresses and the patient presents to the emergency room later that day with a low-grade fever, a white blood count of 13,000, and complaints of anorexia and nausea as well as persistent, sharp pain of the right lower quadrant. On examination she is tender in the right lower quadrant with muscular spasm and there is a suggestion of a mass effect. An ultrasound is ordered and shows an apparent mass in the abdominal wall. Which of the following is the most likely diagnosis?
A. Acute appendicitis
B. Cecal carcinoma
C. Torsion of an ovarian cyst
D. Cholecystitis
E. *Hematoma of the rectus sheath
105. A 20-year-old man undergoes a colonoscopy for abdominal pain, weight loss, and diarrhea. Pathologic evaluation reveals transmural chronic inflammation with ofteoncaseating granulomas. What is the most likely diagnosis?
A. ulcerative colitis
B. ischemic colitis
C. pseudomembranous colitis
D. celiac sprue
E. *Crohn’s disease
106. A 18-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Which of the following is the most likely diagnosis?
A. ulcerative colitis
B. appendicitis
C. irritable bowel syndrome
D. lactose intolerance
E. *Crohn’s disease
107. A 18-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Which of the following is the best diagnostic test to confirm the diagnosis?
A. repeat CT scan with delayed imaging
B. ultrasonography
C. sigmoidoscopy
D. colonoscopy
E. *small-bowel radiography
108. A 18-year-old woman presents with a 6-month history of weight loss, abdominal cramps, and intermittent nonbloody diarrhea. On examination, her abdomen is mildly distended and there is a palpable mass in the right lower quadrant. Stool cultures yield normal fecal flora. CT scan with oral contrast demonstrates an inflammatory mass in the right lower quadrant, with thickening of the terminal ileum and ileocecal valve. Initial management should include which ofthe following?
A. antibiotics and IV fluids
B. lactose-free diet
C. antispasmodics
D. laparotomy
E. *nutritional supplementation and systemic steroids
109. A 16-year-old male adolescent with ulcerative colitis develops abdominal pain, abdominal distention, high fever, and toxic appearance. Abdominal radiography shows dilated loops of colon with multiple air/fluid levels. What is the next most appropriate step in the treatment of this patient?
A. Barium enema
B. Colonoscopy
C. Intravenous steroids
D. Intravenous cyclosporin
E. *Surgical consultation
110. A 1500-gram, 30-week gestatioeonate is fed at 2 weeks of age. He develops abdominal distention, bilious vomiting and guaiac-positive stool. A plain film of the abdomen demonstrates pneumotosis intestinalis. Which of the following related statements are true?
A. An emergency barium upper GI series should be done to rule out malrotation
B. The likelihood of intestinal perforation is in excess of 50%
C. The expected mortality rate is in the range of 70%
D. An emergency USD should be done to rule out malrotation
E. *The child should have a nasogastric tube placed, broad spectrum intravenous antibiotics begun, and sequential abdominal films obtained.
111. A 19-year-old male presents with abdominal pain and bloody diarrhea. On examination, he has a low-grade fever and mildly tender abdomen. Lower endoscopy is performed which reveals edematous mucosa with contiguousinvolvement from the rectum to the left colon. Random biopsies are performed which reveals acute and chronic inflammation of the mucosa and submucosa with multiple crypt abscesses. There are no granulomas seen. What can you tell this patient about his condition?
A. He will likely require an operation.
B. There is no known cure.
C. The use of intravenous corticosteroids is contraindicated.
D. Perianal fistulas are characteristic.
E. *There is a substantially increased longterm risk of developing colon cancer.
112. A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. Acomplete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. Further therapeutic interventions should include which one of the following?
A. 6-mercaptopurine
B. azathioprine
C. opioid antidiarrheals
D. colonoscopic decompression
E. *high-dose IV steroids and broad-spectrum Antibiotics
113. A 16-year-old girl with a history of ulcerative colitis managed with steroid therapy presents to the emergency department with a 36-hour history of nausea, crampy abdominal pain, and severe bloody diarrhea. On examination, the patient is febrile and pale, with a blood pressure of 90/60 mmHg and heart rate of 130 beats/min. Her abdomen is distended and diffusely tender. Acomplete blood count (CBC) demonstrates a leukocytosis with a left shift. The patient receives IV fluid resuscitation and nasogastric (NG) tube decompression. After 48 hours, there is no clinical improvement. Which of the following is the most appropriate next step in management?
A. colonoscopic decompression
B. cyclosporine
C. proctocolectomy with ileal pouch-anal anastomosis
D. abdominal colectomy with ileorectal Anastomosis
E. *abdominal colectomy and ileostomy and Hartmann’s procedure
114. A neonate born at 28 weeks’ gestation is now 2 weeks of age. Nasogastric feeds are started Forty-eight hours after starting feeds, the neonate develops a distended abdomen, bloody stool, pneumatosis intestinalis, and free air on abdominal radiograph. Laboratory studies reveal thrombocytopenia.The child becomes persistently hypotensive despite maximal medical therapy. The most likely diagnosis is:
A. sepsis
B. aspiration pneumonia
C. c malrotation
D. jejunal atresia
E. *necrotizing enterocolitis
115. A 6-year-old girl is brought to the office with a large, swollen, and tender right axillary node. History reveals that a week or two ago she received multiple scratches from her playful kitten. She says, “my armpit really hurts, especially when I’m bored or trying to go to sleep at night.” There is no drainage, but slight erythema, some induration, and definite tenderness in the right axillary region. The most appropriate next step in management is to
A. aspirate the node for Gram stain and culture
B. biopsy the node and send for pathology assessment
C. obtain a chest x-ray
D. placea PPD
E. *treat with trimemoprim-sulfamethoxazole
116. A 3-year-old boy presents to the physician’s office with an asymptomatic neck mass located in the midline, just below the level of the thyroid cartilage. The mass moves with deglutition and on protrusion of the tongue. Select the most likely diagnosis.
A. cystic hygroma
B. acute suppurative lymphadenitis
C. lipoma
D. branchial cleft cyst
E. *thyroglossal duct cyst
117. A 19-year-old man presents to the physician’s office for evaluation of a posterior neck mass. The mass has been present for years, but has slowly enlarged over the last 2 years. Examination reveals a subcutaneous mass that is soft, nontender, and movable. Select the most likely diagnosis.
A. cystic hygroma
B. acute suppurative lymphadenitis
C. thyroglossal duct cyst
D. branchial cleft cyst
E. *lipoma
118. A 6-year-old boy presents to the emergency department with a cough, sore throat, and malaise of 4 days’ duration. Examination reveals a temperature of 101.5°F, erythematous pharynx, and a tender right neck mass with overlying erythema. Select the most likely diagnosis.
A. cystic hygroma
B. thyroglossal duct cyst
C. lipoma
D. branchial cleft
E. *acute suppurative lymphadenitis
119. An 18-month-old girl is brought to the physician’s office for evaluation of left neck mass. Examination reveals a 2-cm soft, nontender, fluctuant mass in the left lateral neck. This is located at the anterior border of the sternomastoid, midway between the mastoid and clavicle. Select the most likely diagnosis.
A. cystic hygroma
B. acute suppurative lymphadenitis
C. thyroglossal duct cyst
D. lipoma
E. *branchial cleft cyst
120. A 20-year-old woman presents to the physician’s office for evaluation of a right neck mass. The mass has been present for 3 years and is painless. On examination, a nontender, firm, 2.5-cm mass is noted slightly below and posterior to the angle of the mandible on the right. Select the most likely diagnosis.
A. branchial cleft cyst
B. cystic hygroma
C. acute suppurative lymphadenitis
D. lipoma
E. *mixed parotid tumor (pleomorphicad enoma)
121. A 62-day-old female infant presents with a 4-week history of periumbilical erythema unresponsive to topical antibiotics. The umbilical cord did not separate until day 48. Records reveal that a previous sibling died in infancy. Which of the following diagnoses is most likely?
A. Bruton agammaglobulinemia
B. Congenital HIV infection
C. Adenosine deaminase deficiency
D. Selective immunoglobulin A deficiency
E. *Leukocyte adhesion deficiency
122. A 28-day-old infant presents with a 3-day history of increasing periumbilical erythema. On examination, the diaper is removed and a distinct greenish brown staining is discovered that overlies the umbilical region at the top of the diaper. The mother comments that this is a common finding. Which of the following diagnoses is most likely?
A. Patent urachus
B. Neonatal alloimmune neutropenia
C. Maple syrup urine disease
D. Homocystinuria
E. *Patent omphalomesenteric duct
123. A 4-week-old newborn girl of an uncomplicated delivery was seen 2 days ago when her grandmother brought in the baby and stated, “She is not moving her left leg.” The child was afebrile and feeding well. Physical examination findings were normal. The patient was sent home to be observed. Two days later, the patient returns with an abscesslike area over her left leg. After obtaining radiographs and appropriate blood cultures and assessing the patient, which of the following should be prescribed?
A. Nafcillin 150-200 mg/kg/d
B. Cefotaxime 150-200 mg/kg/d
C. Ampicillin 200-300 mg/kg/d and gentamicin 7.5 mg/kg/d
D. Penicillin 250,000 units/kg/d
E. *Nafcillin 150-200 mg/kg/d and gentamicin 7.5 mg/kg/d
124. A 15-month-old child recently adopted from China is brought in with septic arthritis of the knee. After blood and aspirate cultures are obtained, the patient is started on cefazolin 100 mg/kg/d. Next-day laboratory results report gram-negative pleomorphic rods in the blood culture. Which of the following is not appropriate management?
A. Perform a careful physical examination. If no new findings are present, switch to cefuroxime 200 mg/kg/d.
B. Patient and other siblings need chemoprophylaxis for Haemophilus influenzae type b (Hib).
C. Report the case to the health department.
D. Immunize the patient with Hib vaccine after recovery.
E. *Perform a careful physical examination. If no new findings are present, continue cefazolin.
125. A 1,5 y.o. child fell ill acutely with high temperature
A. Hip joint arthritis
B. Polyartropathy
C. Osteomyelitis
D. Viral encephalitis
E. *Polyomyelitis
126. A14-year-old male is evaluated for thigh pain. He has no history of injury. An x-ray of the leg shows a mass in the distal femur that extends into the soft tissue. Abiopsy is performed and cytogenetic studies show translocation of chromosomes 11 and 22. What is this patient’s diagnosis?
A. osteosarcoma
B. osteoblastoma
C. metastatic carcinoma
D. multiple myeloma
E. *Ewing sarcoma
127. You see a 6-year-old girl in your office for leg aches. The mother relates that she has been complaining that her knees and ankles have been bothering her for the past 3 months. The pain is worse in the morning. She has not noticed any swelling, redness, or warmth in her joints. The mother says that she seems to have a fever once a day. She has never taken her temperature, but she seems flushed and has a lacy rash in the evening. She has not lost any weight. Her examination is essentially normal, with the exception of mild fluid notable in both of her knees. The knees have full range of motion and do not seem to bother her when you move them. You perform some blood tests which reveal the following: white blood cell (WBC) 28,000 (polymorphonuclear [PMN] 88%, lymph 10%, and no blasts on the smear), hematocrit 10.2 mg/dL, platelets 765,000, and erythrocyte sedimentation rate (ESR) 112. What is the most likely diagnosis?
A. growing pains
B. osteogenic sarcoma
C. infectious arthritis
D. acute toxic synovitis (ATS)
E. *juvenile rheumatoid arthritis (JRA) (Still’s disease)
128. You see a 6-year-old girl in your office for leg aches. The mother relates that she has been complaining that her knees and ankles have been bothering her for the past 3 months. The pain is worse in the morning. She has not noticed any swelling, redness, or warmth in her joints. The mother says that she seems to have a fever once a day. She has never taken her temperature, but she seems flushed and has a lacy rash in the evening. She has not lost any weight. Her examination is essentially normal, with the exception of mild fluid notable in both of her knees. The knees have full range of motion and do not seem to bother her when you move them. You perform some blood tests which reveal the following: white blood cell (WBC) 28,000 (polymorphonuclear [PMN] 88%, lymph 10%, and no blasts on the smear), hematocrit 10.2 mg/dL, platelets 765,000, and erythrocyte sedimentation rate (ESR) 112. What is the most appropriate next step?
A. diagnostic arthrocentesis
B. bilateral hip, knee, and ankle x-rays
C. a trial of oral corticosteroids
D. MRI of both knees
E. *a trial of nonsteroidal anti-inflammatory medication (NSAID)
129. A 15-year-old African American boy with sickle cell disease is admitted to the hospital with fever, chills, and mild leg pain. He developed pain in the middle third of his right anterior thigh 14 days following a bacterial gastroenteritis from which he is recovering. He denies trauma to the area despite the fact that his right thigh is swollen and tender. His temperature is
A. despite the ultrasound examination, begin a heparin drip until an MR1 can be obtained
B. ibuprofen and discharge
C. meperidine and promethazine for his acute sickle cell pain crisis
D. a radionuclide bone scan
E. *blood cultures and a needle biopsy of the bone, followed by 4 to 6 weeks of organism-specific intravenous antibiotics
130. A 2-year-old girl comes to the office with limping and difficulty walking for 1 day. She complains of pain in her right leg. On examination, she is afebrile and has no point tenderness or swelling in her lower extremities. There is full range of motion in all joints except pain with abduction of her right hip. Which of the following is the most likely diagnosis?
A. slipped capital femoral epiphysis
B. aseptic necrosis of the femoral head
C. septic arthritis of the hip
D. osteomyelitis
E. *toxic synovitis
131. A 6-year-old boy has a purpuric and petechial rash over the buttocks and lower extremities. He appears to be well and is afebrile, but has swelling of the right knee. His CBC is normal. Which of the following is the most likely diagnosis?
A. idiopathic thrombocytopenic purpura (ITP)
B. systemic lupus erythematosus (SLE)
C. meningococcemia
D. juvenile rheumatoid arthritis
E. *Henoch-Schonlein (anaphylactoid) purpura (HSP)
132. An obese adolescent male presents to your urgent care facility with a chief complaint of intermittent knee pain for 2 weeks. He has no known history of trauma but does play soccer twice a week. He has had no fever or upper respiratory symptoms. The knee exam is normal; however, the hip exam demonstrates limited internal rotation and mild tenderness. Which of the following is the most likely cause of this patients limp based on the history and exam?
A. Legg-Calve-Perthes disease
B. osteomyelitis
C. septic arthritis
D. Osgood-Schlatter disease
E. *slipped capital femoral epiphysis
133. A 3-year-old boy is brought to the physician because of fever, cough, and difficulty breathing for 2 weeks. An x-ray of the chest shows a right middle-lobe infiltrate and a large pleural effusion. Thoracentesis shows purulent fluid; culture of the fluid grows Bacteroides melaninogenicus. The infection is most likely a complication of which of the following?
A. Cystic fibrosis
B. Immunologic defect
C. Inhalation of a toxic hydrocarbon
D. Subacute appendicitis
E. *Foreign body aspiration
134. A 18-year-old male presents to the emergency department (ED) with complaints of right-sided chest pain and dyspnea. He has no other significant medical history. There is no history of trauma. On examination, he has a pulse of 95, BP of 110/70, and SpO2 of 95% on
A. Since the patient is hemodynamically stable, he can be observed with oxygen supplementation, pain control, and serial chest x-rays.
B. This condition is probably due to small lacerations in the apex of the right lung.
C. His risk of recurrence is 10%.
D. Recurrences are usually on the contralateral side since adhesions prevent recurrence on the ipsilateral side.
E. *The patient is likely to have a tall, thin habitus.
135. A 6-year-old girl is brought to you for evaluation of respiratory distress and right upper quadrant abdominal pain. You note the presence of fever, cough, and tachypnea. On lung exam, she has right lower lobe crackles and egophony.Chest radiograph reveals right lower lobecon-solidation with a small pleural effusion. You make a diagnosis of bacterial pneumonia and attribute the abdominal pain to pleuritic pain secondary to the pneumonia with effusion. What is the most likely bacterial cause of this child’s’pneumonia?
A. Haemophilus influenzae type b
B. nontypeable Haemophilus influenzae
C. Staphylococcus aureus
D. group B streptococci
E. *Streptococcus pneumonia
136. A term infant is born vaginally after an uncomplicated pregnancy. She appears normal but has respiratory distress when she stops crying. When crying she is pink; wheot she makes vigorous respiratory efforts but becomes dusky. Which of the following is the likely explanation for her symptoms?
A. Diaphragmatic hernia
B. Meconium aspiration
C. Neonatal narcosis
D. Pneumothorax
E. *Choanal atresia
137. A number of different principles apply to the immediate management of a child in septic shock. In general, management should be prioritized in order of urgency. Which of the following is not an immediate priority in the resuscitation phase of a child in septic shock (2)?
A. Ensure adequate airway support
B. Administer volume resuscitation
C. Cardiovascular support
D. Empiric antibiotic treatment
E. *Correct anemia
138. A 6-year-old boy has a 2-day history of swelling in the right side of the neck and fevers up to 101.5°F. Examination of the right anterior cervical region shows a 4-cm firm tender mass with erythema of the overlying skin. The child has no sick contacts that may explain lymphadenitis. Which of the following initial procedures should be used in this patient?
A. Throat swab for culture of the pharynx
B. Lateral neck x-ray
C. Incision and drainage
D. No action
E. *Empiric antibiotic therapy
139. A 30-year-old man presents to the ED with perirectal pain, fever, and an erythematous tender mass in the perianal area. The mass is located in the deep tissue spaces, and aspiration reveals purulent material. What is the most appropriate treatment?
A. Outpatient referral for follow-up examination in a week
B. Incision and debridement in the ED after local anesthetic infiltration
C. Incision and debridement in the ED with the use of methohexital
D. Oral antibiotics and Sitz baths
E. *Surgical consultation for incision and debridement and possible fistulotomy in the operative suite under general anesthesia
140. A 7-year-old boy is brought to the physician 3 days after sustaining a small laceration of the left eyebrow. His temperature is 38.8EC (101.8EF). Examination shows erythema and edema of the left eyelid and periorbital region with moderate proptosis and decreased ocular movement; eye movement is painful. The disc margins are sharp, and there are no retinal abnormalities. Which of the following is the most likely diagnosis?
A. Cavernous sinus thrombosis
B. Lateral sinus thrombosis
C. Preseptal (periorbital) cellulitis
D. Sagittal sinus thrombosis
E. *Orbital cellulitis
141. A 1-month-old male infant is brought to the office with a 5-day history of nonbilious vomiting. He has been otherwise healthy. Over the last 3 days, his parents have switched formulas twice on the advice that the child has formula intolerance. The child now vomits 5-15 minutes after every feeding, usually forcefully. Skin turgor is decreased and the fontanelle is depressed. What is the most likely diagnosis?
A. Gastroesophageal reflux
B. Lactose intolerance
C. Malrotation and midgut volvulus
D. Sepsis
E. *Infantile hypertrophic pyloric stenosis
142. You are managing a serious pediatric burn victim who has developed cellulitis after repeated procedures for debridement of necrotic tissue. The patient has been on IV antibiotics and urinary catheterization since admission one month ago. Recent labs show hypogammaglobulinemia. The most likely pathogen is
A. Pasteurella multocida
B. E. coli
C. Herpesvirus
D. Cryptosporidium
E. *Pseudomonas aeruginosa
143. You have obtained a CT scan on a toxic-appearing patient, and the radiologist calls you to report a finding of an extensive deep cellulitis. A re-examination of the area shows only slight erythema superficial to the area of extensive deep cellulitis as seen on CT. A CBC of the patient is likely to show:
A. thrombocytopenia
B. absolute lymphocytosis
C. monocytosis
D. increase red cell distribution width
E. *neutropenia
144. A number of different principles apply to the immediate management of a child in septic shock. In general, management should be prioritized in order of urgency. Which of the following is not an immediate priority in the resuscitation phase of a child in septic shock (2)?
A. Ensure adequate airway support
B. Administer volume resuscitation
C. Cardiovascular support
D. Empiric antibiotic treatment
E. *Correct anemia
145. You are working in the emergency department evaluating a 19-year-old woman with complaints of “back paiear her tailbone.” Upon questioning, the patient reports pain on the right side of her “low back” for the past 3 days. She has taken acetaminophen and ibuprofen with only minimal relief of the pain. Today she noticed that there was swelling and she thought that she should come in to be evaluated. She feels otherwise well and denies trauma, fever, or change in her bowel or bladder function. She does report that occasionally she will have painful bowel movements and has had more pain with this illness, but was unsure if they were related. She also says that she thinks that one of her uncle’s had the same problem in the past but is unsure. Her temperature is
A. you suspect that she may have Crohn disease and will need an immediate colonoscopy
B. you suspect that she has Crohn disease and this area is likely rectal cancer that needs to be surgically removed
C. you suspect that she may have Crohn disease and will prescribe steroids to help control the inflammatory response
D. you will prescribe stronger pain medication and eventually this will resolve without further treatment
E. *she will need to have the area drained immediately
146. A 3-year-old boy was bitten while teasing a neighborhood cat. On examination, there are two puncture wounds on the right hand and some superficial scratch marks. There is erythema, warmth, and induration around the puncture sites. Which of the following organisms most likely caused the infection?
A. Bartonella henselae
B. Eikenella corrodens
C. Peptostreptococcus species
D. alpha Streptococci
E. *Pasturella multicoda
147. A 4-year-old child presents with an enlarged submandibular node that is
A. cat-scratch fever
B. acute pyogenic lymphadenitis
C. acute lymphoblastic leukemia
D. tuberculous lymphadenitis
E. *atypical mycobacteria lymphadenitis
148. A 12-year-old girl has had a sore throat over 2 days. She now has a fever of
A. retropharyngeal abscess
B. acute uvulitis
C. acute pharyngitis
D. lateral pharyngeal abscess
E. *peritonsillar abscess
149. A mother notices a lump on her 5-year-old son’s neck. He complains about pain in the region and difficulty swallowing. Appetite and intake are normal. He had a “chest cold” last week that has since resolved. His past medical history is otherwise unremarkable. On examination, he is afebrile with a 3-cm x 3-cm area of mild erythema, fluctuance, and tenderness of the central anterior neck. The mass moves superiorly when he opens his mouth. His oropharynx is clear. Which of the following is the most likely explanation for these findings?
A. Contact dermatitis
B. Lymphadenopathy
C. Salivary gland tumor
D. Streptococcal pharyngitis
E. *Thyroglossal duct cyst
150. A 9-year-old girl complains of sore throat and anterior neck pain of 1-day duration, and nasal congestion and cough over the past 3 days. There has beeo nausea or change in appetite. She describes “lumps growing in her neck” over the past day. Her past medical history is unremarkable. She is afebrile with a clear posterior oropharynx and a supple neck. She has four firm, fixed, and minimally tender submandibular masses without overlying skin changes; the largest mass is
A. Peritonsillar abscess
B. Retropharyngeal abscess
C. Sialadenitis
D. Streptococcal pharyngitis
E. *Lymphadenopathy
151. A father states that his 7-year-old daughter has a 1-week history of mouth and neck pain. She describes pain on chewing and swallowing. Slight swelling around her right, lower jaw was first noted yesterday. She has been afebrile and exhibits no URI symptoms. Her examination reveals a temperature of
A. Admit her immediately to the hospital for intravenous antibiotics.
B. Obtain an immediate surgery consult.
C. Order a cervical CT and obtain ear, nose, and throat (ENT) consultation today.
D. Perform a rapid strep immunoassay in your office.
E. *Commence a broad-spectrum antibiotic and advise her to see a dentist as soon as possible.
152. A previously healthy, 4-year-old boy has been febrile for 1 day. He does not want to drink and vomited this morning. There have beeo URI symptoms nor diarrhea. On examination, he is sleepy, but arousable, and has a temperature of
A. Coxsackie pharyngitis
B. Lymphadenitis
C. Parapharyngeal abscess
D. Retropharyngeal abscess
E. *Streptococcal tonsillitis
153. A 15-year-old adolescent boy has had gradual and persistent lymph node enlargement for the last 5 months. Lymph nodes are firm, nontender, and located in the right cervical area. Accompanying symptoms include weight loss, intermittent fever, and night sweats. Which of the following causes of lymphadenitis is the most likely diagnosis?
A. Tuberculosis
B. Infectious mononucleosis
C. Non-Hodgkin lymphoma
D. Catscratch disease
E. *Hodgkin lymphoma
154. A previously healthy 17-year-old woman comes to the physician 3 months after discovering a mass in the lower outer quadrant of her right breast. Examination shows a 2-cm, oval, firm, smooth, mobile mass. No axillary masses are present. Excisional biopsy is most likely to show which of the following?
A. Fat necrosis
B. Fibrocystic changes of the breast
C. Intraductal carcinoma
D. Intraductal papilloma
E. *Fibroadenoma
155. A 18-year-old school basketball player comes to the physician because of a left-sided scrotal mass; he first noticed the mass 2 weeks ago after he was hit with the ball in the left groin during a game. Abdominal examination shows no abnormalities. A 3-cm nontender mass is palpated near the superior pole of the left testis; the mass is nontender and does not transilluminate. Which of the following is the most likely diagnosis?
A. Epididymitis
B. Hematoma
C. Hernia
D. Hydrocele
E. *Tumor
156. A 19-year-old female presents to your office with rectal bleeding, itching, and irritation. On examination, a 3-cm ulcerating lesion is seen in the anal canal. Biopsy of the lesion reveals squamous cell carcinoma (SCC). Which of the following is the most appropriate treatment?
A. low anterior resection
B. abdominal perineal resection
C. wide local excision of the lesion
D. wide local excision of the lesion and bilateral inguinal lymph node dissection
E. *chemotherapy and pelvic radiation protocol
157. During initial exploration in a patient scheduled to undergo a right hemicolectomy for colon cancer, a deep 4-cm liver mass is seen in the right lobe of the liver. The left lobe appears to be normal. Intraoperative biopsy of the lesion is positive for metastatic colon cancer. The best management of this patient includes which of the following?
A. Immediately close the patient and refer for chemotherapy only.
B. Perform right hemicolectomy and right hepatic lobectomy.
C. Perform right hemicolectomy and wide excision of the liver lesion.
D. Perform liver resection only.
E. *Perform right hemicolectomy only.
158. A mobile mass is found on rectal examination in a 19-year-old male with complaints of blood in his stool. On workup, he is found to have a stage I (Dukes’ A), well-differentiated adenocarcinoma. The most appropriate intervention is which of the following?
158.
A. abdominal perineal resection
B. low anterior resection
C. placement of endorectal wallstent
D. neoadjuvant chemotherapy followed by transanal resection
E. *transanal excision
159. A 18-year-old man comes to the hospital. For the past 5 days he has had colicky abdominal pain, vomiting, abdominal distention, and constipation. The most appropriate measure, after IV hydration and nasogastric decompression, in the initial management of this patient is which of the following?
A. upper GI endoscopy
B. abdominal sonography
C. antiemetic agents
D. promotility drugs
E. *supine and erect x-rays of the abdomen
160. You had previously seen a 18-year-old male in your office for evaluation of a suspicious looking mole. He had undergone a punch biopsy, which demonstrated a melanoma. He has no prior history of skin cancer, no family history of skin cancer, nor any history of blistering sunburns. Which of the following results in the pathology report are most predictive of outcome?
A. size of the melanoma
B. color of the melanoma
C. presence of ulceration
D. site of the melanoma
E. *depth of the melanoma
161. A 5-year-old male is admitted to the hospital following a 3-week history of spiking fevers and fatigue. Your examination reveals pale mucous membranes and skin. You also find splenomegaly. You are concerned about a possible malignancy. What is the most common malignancy of childhood?
A. medulloblastoma
B. Wilms’ tumor
C. neuroblastoma
D. rhabdomyosarcoma
E. *leukemia
162. A 3 1/2-year-old female presented with a left upper quadrant abdominal mass. The child had no previous history of medical illnesses. An ultrasound examination revealed a markedly deformed left kidney with
A. hydronephrotic kidney
B. tuberculosis
C. congenital malformation
D. papillary transitional cell carcinoma of the renal pelvis
E. *Wilms tumor
163. A 14-year-old male is evaluated for thigh pain. He has no history of injury. An x-ray of the leg shows a mass in the distal femur that extends into the soft tissue. Abiopsy is performed and cytogenetic studies show translocation of chromosomes 11 and 22. What is this patient’s diagnosis?
A. osteosarcoma
B. osteoblastoma
C. metastatic carcinoma
D. multiple myeloma
E. *Ewing sarcoma
164. You are called to the newborursery to see a baby with a birthmark on his face. You note a port-wine stain on the right forehead and cheek. The portwine stain is only on the right side. What is the most common complication of this disorder?
A. cardiac abnormalities
B. polycystic kidney disease
C. cystic or fibrous pulmonary changes
D. hypoglycemia
E. *seizures and mental retardation
165. An 18-year-old girl comes to the office for a well checkup before leaving for college. Her past medical history is unremarkable and her immunizations are up-to-date. Her 55-year-old father was diagnosed 6 months ago with early stage melanoma. She is concerned because she has many freckles and “moles”. You review with her what she needs to know about any future changes in her “moles” To educate her about the ABCD or ABCDE signs of melanoma recognition, you tell her that these letters represent
A. asymmetry, bleeding easily, color change or variegation, diameter >
B. asymmetry, border irregular, central telangiectasia, deep and lobular
C. asymmetry, border irregular, color change or variegation, diameter >
D. asymmetry, border irregular, color change or variegation, deep, and exfoliating
E. *asymmetry, border irregular, color change or variegation, diameter >
166. A 20-year-old woman gives birth to a full-term, 19-inch baby boy of
A. differential white count
B. erythrocyte sedimentation rate
C. liver function tests
D. urine analysis
E. *platelet count
167. A 16-year-old man comes to the office complaining of a “new mole” on his right shoulder. He is a pale man with blond hair and he enjoys staying outside in the sun. He vaguely recalls that an uncle “had some cancer removed from his face once.” Physical examination shows a 2-cm, slighdy raised lesion with irregular borders on his shoulder. There are no significantly palpable lymph nodes and no other similar lesions anywhere else on his body. You perform an excisional biopsy of the lesion, which the pathologist informs you is a melanoma. The most correct statement about this condition is:
A. It is the most common form of skin cancer.
B. A negative surgical margin of
C. A shave biopsy would also have been appropriate for diagnosis.
D. The Clark microstaging system will most accurately determine prognosis.
E. *Tumor thickness most accurately determines therapy and prognosis.
168. A 18-year-old healthy man comes to the employee health clinic complaining of a 2-week history of a constant dull, achy feeling in his left testicle. He denies any trauma, dysuria, fevers or chills, unprotected sexual activity, or prior similar episodes. On physical examination you find that the right testicle is normal in location, size, and consistency. The left testicle is enlarged, hard, irregular, and nontender to palpation. There is no trans-illumination of light through this scrotal mass. Serum beta hCG (human chorionic gonadotropin) and AFP (alpha-fetal protein) levels are elevated. At this time the most correct statement about his condition is:
A. Chemotherapy is required before surgery.
B. He should undergo exploration through an incision in the scrotum.
C. His condition has a poor prognosis.
D. Radiation therapy is required before surgery.
E. *Radical orchiectomy is the first line of treatment.
169. A 16-year-old male in good health presents to you for a school physical. His family history reveals that his father died of colon cancer at age 37. Your physical exam reveals a healthy young man with several lipomas on his back and legs and a nodule on his jaw. You should:
A. Suggest colonoscopy at age 32.
B. Suggest colonoscopy now.
C. Suggest flexible sigmoidoscopy and barium enema at age 32.
D. Biopsy his jaw lesion.
E. *Suggest flexible sigmoidoscopy and barium enema now.
170. If a teenager comes in complaining of night pain in his knee, which disorder should be at the top of your differential? Which would be the most likely, and which would be the most serious likely consideration?
A. Juvenile Rheumatoid Arthritis
B. Paget’s Disease
C. Stress fracture
D. Growing pains
E. *Osteosarcoma
171. A 17-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?
A. squamous cell carcinoma
B. basal cell carcinoma
C. Merkel cell carcinoma
D. keratoacanthoma
E. *melanoma
172. A 18-year-old man presents with a melanoma on the skin of the right calf measuring
A. In the absence of systemic disease, the primary melanoma of the right calf should be excised with at least a 2-cm. margin.
B. Complete right inguinal node dissection should be performed if there is no evidence of systemic metastasis.
C. Chemotherapy for melanoma is primarily palliative; so surgical therapy is preferred if there is no evidence of metastatic disease beyond the inguinal region.
D. If the nodes do not contain metastatic disease but are simply reactive, the chance of 5-year survival is 50% or less.
E. *If further work-up reveals multiple lung metastases of melanoma, they should be excised as soon as possible.
173. A mother recently feels a mass in the abdomen of her 4-year-old son during a bath, and brings him to your clinic for evaluation. He has no history of emesis, abnormal stooling, or abdominal pain. Physical examination reveals a resting blood pressure of 130/88 mm Hg, heart rate of 82 beats/minute, pallor, and a firm left-sided abdominal mass that doesn’t cross the midline. Which of the following is the most likely explanation for these findings?
A. Constipation
B. Intussusception
C. Neuroblastoma
D. Volvulus
E. *Wilms tumor
174. A 1-week-old infant presents with a right midquadrant abdominal mass and decreased urinary output. There has beeo temperature lability, irritability, or abnormal stooling or urine appearance. Which of the following is the most likely diagnosis?
A. Intussusception
B. Neuroblastoma
C. Sepsis
D. Wilms tumor
E. *Hydronephrosis
175. A father presents his otherwise healthy 15-month-old daughter to the emergency center with cough, post-tussive emesis, and subjective fever over the past 3 days. He also thinks her abdomen has been hurting her. Diarrhea started yesterday, with “regular” stooling prior to this illness. She has been drinking well and recently had a wet diaper. Physical examination reveals a temperature of
A. Constipation
B. Lymphoma
C. Neuroblastoma
D. Appendicitis
E. *Mesenteric lymphadenitis
176. During a routine preventive health visit for a 3-year-old boy, you incidentally note an irregular abdominal mass involving both lower quadrants. His mother denies having noted this previously and declares her son to be generally healthy. There has beeeither gastrointestinal distress nor apparent abdominal pain. Beyond the abdominal mass and pallorous conjunctivae, his vital signs and physical examination are normal. Which of the following tests would be most helpful in determining the etiology of his abdominal mass?
A. Abdominal radiograph
B. Chest radiograph
C. Complete blood count
D. Urine myoglobin
E. *Urinary catecholamines
177. A 6-month-old infant male presents to your clinic with an abdominal mass, which was discovered by his new foster mother during the child’s bath. On physical examination, you also find macroglossia and right-sided hemihypertrophy. This infant is likely to have which of the following?
A. Down syndrome with duodenal atresia
B. Alagille syndrome and biliary atresia
C. Neurofibromatosis and abdominal neurofibromas
D. Zellweger syndrome and hepatomegaly
E. *Beckwith-Wiedemann syndrome with Wilms tumor
178. A mother notices an abdominal mass in her 3-year-old son while giving him a bath. There is no history of any symptoms, but the boy’s blood pressure is elevated at 105/85 mm Hg. Metastatic workup is negative and the patient is explored. The mass is found within the left kidney. Which of the following statements concerning this disease is correct?
A. The majority of patients present with an asymptomatic abdominal mass and hematuria
B. Treatment with surgical excision, radiation, and chemotherapy results in survival of less than 60% even in histologically low-grade tumors
C. Surgical excision is curative and no further treatment is ordinarily advised
D. This tumor is the most common malignancy in childhood
E. *This tumor is associated with aniridia, hemihypertrophy, and cryptochidism
179. Although wide surgical excision is the traditional treatment for malignant melanoma, narrow excision of thin (less than
A.
B.
C.
D.
E. *1 cm
180. A 2-month-old boy is being evaluated for the growth. At birth his skin was clear, but when he was 1 month old his mother noted a light red growth on his arm. During the last month, it increased in size and turned bright red. The most likely diagnosis of the skin lesion is
A. melanoma
B. osteochondroma
C. nevus flammeus
D. cavernous hemangioma
E. *strawberry hemangioma
181. A 3-day-old infant is seen for his hospital discharge examination. He is the 3650-gram, Coombs negative infant of a 20-year-old primigravida mother with an uncomplicated pregnancy, labor, and delivery. He is breastfeeding fairly well, but the mother’s breast milk is only beginning to increase today. His circumcision has some oozing, and his heel is still bleeding from blood sampling an hour ago. He is mildly jaundiced, but the physical examination is otherwise unremarkable. What should the initial workup include?
A. Vitamin K level
B. Cranial ultrasound or CT scan
C. All of the above
D. Only Vitamin K level and Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, CBC, and platelet count
E. *Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen levels, CBC, and platelet count
Tests to photos
1. An 11-month-old male presents to the emergency department with vomiting. His mother states that he had “stomach flu” 2 weeks ago and hashad five episodes of vomiting since the previous night (without blood or bilious material). He has been crying intermittently, every 10–20 minutes. He has had three loose stools without blood or mucus. On exam he appears nontoxic and his vitals are temperature of
A. Ileus.
B. Bowel obstruction.
C. Appendicitis.
D. Meckel’s diverticulum.
E. *Intussusception.
2. What is present on the X-ray (Fig. 32) that makes intussusception diagnosis more likely?
A. Paucity of bowel gas.
B. Distended loops of small bowel.
C. Air in the rectum.
D. Free air in the abdominal cavity
E. *Absent liver edge.
3. What is the gold standard for diagnosis of intussusception is shown (Fig. 30)?
A. Abdominal plain films.
B. CT scan.
C. Surgical exploration.
D. Ultrasound.
E. *Contrast enema.
4. What is the investigation for diagnosis of intussusception is shown (Fig. 31)?
A. Abdominal plain films.
B. CT scan.
C. MR imagine.
D. Contrast enema.
E. *Ultrasound.
5. A 1-month-old female presents to the emergency department with nonbilious vomiting for the past couple of days. The vital signs are normal and the infant appears well hydrated. You obtain abdominal X-rays (Fig. 39). What is the correct interpretation of this X-ray?
A. Small bowel obstruction.
B. NEC.
C. Normal abdominal X-ray.
D. Volvulus.
E. *Ileus.
6. A 1-month-old female presents to the emergency department with nonbilious vomiting for the past couple of days. The vital signs are normal and the infant appears well hydrated. Condition that shown on the Figure 39 can occur most commonly after:
A. Incarcerated inguinal hernia.
B. Adhesions.
C. Volvulus.
D. Intraluminal mass.
E. *Recent abdominal surgery.
7. A 1-month-old male presents to the emergency department with poor feeding and occasional vomiting. Comparison of his birthweight to his current weight shows poor weight gain. The patient’s vital signs are as follows: temperature of 98.6°F, heart rate 146, respiratory rate 40, blood pressure 96/49. The exam was unremarkable and the patient was admitted for failure to thrive. The vomiting then became bilious and the following abdominal series was obtained (Fig. 40). What is the correct interpretation of these X-rays?
A. Ileus.
B. Normal.
C. Nonspecific bowel gas pattern.
D. Toxic megacolon.
E. *Obstruction.
8. A 3-day-old female is brought in by her parents with vomiting and fussiness. Her vital signs are normal but she does appear to cry more with palpation of the abdomen. There are no abdominal masses and the rest of the physical exam is normal. You obtain the following X-rays (Fig. 39).What is the correct interpretation of this X-ray?
A. Volvulus.
B. Obstruction.
C. Normal bowel gas.
D. Pseudo-obstruction.
E. Ileus.
9. A 9-day-old male is brought into the ED with vomiting. The child appears well-hydrated but is fussy and crying. The vital signs are normal. The physical exam is unremarkable except for the fact that you have a difficult time determining any abdominal tenderness. You obtain the following abdominal X-rays.(Figure 40). What is the correct impression of this X-ray?
A. Ileus.
B. Normal bowel gas pattern.
C. Perforated viscus.
D. Appendicitis.
E. *Bowel obstruction.
10. A 9-day-old male is brought into the ED with vomiting. The child appears well-hydrated but is fussy and crying. The vital signs are normal. The physical exam is unremarkable except for the fact that you have a difficult time determining any abdominal tenderness. You obtain the following abdominal X-rays.(Figure 40). All of the following are potential causes of this, except:
A. Intussusception.
B. Inguinal hernia.
C. Malrotation.
D. Hirschsprung’s disease.
E. *Trauma.
11. A 7-month-old female presents to the emergency department with vomiting. She appears well hydrated and her vital signs are normal. She does seem to cry more when you palpate her abdomen. Here are the abdominal X-rays you get.(Figure 29). What is the correct interpretation of these X-rays?
A. Meckel’s diverticulum.
B. Volvulus.
C. Appendicitis.
D. Normal.
E. *Intussusception.
12. A 7-month-old female presents to the emergency department with vomiting. She appears well hydrated and her vital signs are normal. She does seem to cry more when you palpate her abdomen. Here are the abdominal X-rays you get.(Figure 32) What is the best initial approach to the treatment of this condition?
A. Intravenous antibiotics, serial abdominal exams.
B. Immediate surgical repair.
C. Nothing by mouth, nasogastric tube, intravenous fluids.
D. None of the above.
E. *Air contrast or barium enema.
13. A 17-year-old woman is admitted to the hospital for evaluation of nausea, vomiting, crampy abdominal pain and abdominal distention. Her medical history includes cholecystectomy and appendectomy 5 years ago. CT of the abdomen is shown (Figure 37). Which of the following is the most likely cause of her symptoms?
A. Femoral hernia
B. Gallstone ileus
C. Perforated diverticulum
D. Sigmoid colon carcinoma
E. *Adhesive band
14. Patients with established, complete, simple, distal small bowel obstruction usually have the following findings on plain and upright abdominal radiographs wich shown in Figure 39:
A. Free air
B. Modest amount of gas in the pelvis.
C. Peripheral, rather than central, distribution of gas.
D. Prominent haustral markings.
E. *Multiple air-fluid levels.
15. A 17-year-old woman is admitted to the hospital for evaluation of nausea, vomiting, crampy abdominal pain and abdominal distention. Her medical history includes cholecystectomy and appendectomy 5 years ago. Intraoperative finding is shown (Figure 38). Which of the following is the most likely cause of her symptoms?
A. Femoral hernia
B. Gallstone ileus
C. Perforated diverticulum
D. Sigmoid colon carcinoma
E. *Adhesive band
16. A listless 9-month-old boy presents with acute onset of severe intermittent abdominal pain. Rectal exam is guaiac positive. You can see the intraoperative finding of this pathology on Figure 33. What is it?
A. Meckel’s diverticulum.
B. Acute appendicitis.
C. Intestinal polyp.
D. Gastritis.
E. *Intussusception.
17. Which type of intussusception is shown in Figure 34:
A. ileoileal
B. ileocolic
C. ileo-ileocolic
D. Ileocecal
E. *colocolic
18. Which type of intussusception is shown in Figure 35:
A. colocolic
B. ileocolic
C. ileo-ileocolic
D. Ileocecal
E. *Ileoileal
19. Which type of intussusception is shown in Figure 35:
A. Ileoileal
B. colocolic
C. ileocolic
D. ileo-ileocolic
E. *Ileocecal
20. An 18-year-old female presents with abdominal pain, fever, and leukocytosis- With the presumptive diagnosis of appendicitis, a right lower quadrant (McBurney) incision is made and a lesion
A. Can best be diagnosed by preoperative angiogram, which should be done whenever the diagnosis is suspected
B. Should routinely be removed when incidentally discovered during celiotomy
C. Often contains ectopic adrenal tissue
D. Is frequently associated with cutaneous flushing and episodic tachycardia
E. *Is embryologically derived from a persistent vitelline duct (omphalomesenteric duct)
21. A 17-year-old girl presents to the physician’s office with a 6-month history of epigastric discomfort, poor appetite, and 10-lb weight loss. Examination is unremarkable except for mild epigastric tenderness to deep palpation. An UGI x-ray series is shown in Figure 44. Which of the following is the most likely diagnosis?
A. cholecystoenteric fistula
B. duodenal ulcer
C. gastric diverticulum
D. duodenal diverticulum
E. *gastric ulcer
22. A 18-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of
A. small-bowel obstruction
B. dead bowel
C. perforated colon carcinoma
D. perforated gastric ulcer
E. *perforated duodenal ulcer
23. A 10-month-old baby is brought to the emergency room with 6-hour history of bilious vomiting, passage of pink jellylike material from the rectum, and intermittent episodes of severe crying. On physical examination a sausage-shaped mass is felt on the right side of the abdomen. The next step in the management of the patient is shown in Figure 30. What is it?
A. Abdominal plain films.
B. CT scan.
C. MR imagine.
D. Ultrasound.
E. *Contrast enema.
24. Which is the most common pathological lead point (see Figure 42) found with intussusception?
A. neoplasm
B. appendicitis
C. polyps
D. intestinal duplication
E. *Meckel’s diverticulum
25. A 10-month-old male presents with a 12-hour history of episodes of crying, holding his stomach, and bending over in pain. The parents report one “reddish” stool. He has no past medical history or episodes of similar events. He did have 24 hours of viral symptoms, which resolved a few days ago. The following study was obtained (See Figure 29.). Which of the following statements is true?
A. The initial treatment for this child involves emergent laparotomy.
B. Colonic mass is the usual source of this problem in a child.
C. “Dance’s sign” is the appearance on xray of “telescoped” intestine.
D. Recurrence is likely after treatment.
E. *Air contrast enema can be diagnostic AND therapeutic.
26. What from the stages of acute appendicitis is represented on Figure 1?
A. Early stage
B. Suppurative appendicitis
C. Gangrenous appendicitis
D. Perforated appendicitis
E. *Phlegmonous appendicitis
27. What from the stages of acute appendicitis is represented on Figure 2?
A. Early stage
B. Suppurative appendicitis
C. Perforated appendicitis
D. Phlegmonous appendicitis
E. *Gangrenous appendicitis
28. What from the stages of acute appendicitis is represented on Figure 3?
A. Early stage
B. Suppurative appendicitis
C. Gangrenous appendicitis
D. Phlegmonous appendicitis
E. *Perforated appendicitis
29. What inspection is shown on Figure 4, that helps to put the diagnosis of «pelvic appendicitis»?
A. colonoscopy
B. contrast enema
C. stool examination
D. a review with a rectal mirror
E. *digital rectal examination
30. Wich symptoms of acute appendicitis is represented on Figure 5?
A. Psoas sign;
B. Obturator sign;
C. Dunphy sign;
D. Blumberg sign.
E. *Rovsing sign;
31. In what area of front abdominal wall, that it is represented on Figure 6 the pain mainly appears during palpation in case of acute appendicitis?
A. 1;
B. 2;
C. 4;
D. 5.
E. *3;
32. Which of the following complications of acute appendicitis are shown in the radiograph (Figure 7)?
A. Peritonitis
B. Obstruction
C. Appendicile mass
D. Abscess
E. *Perforation with pneumoperitonium
33. Which of the following complications of acute appendicitis is shown on ultrasound (Figure 8)?
A. Peritonitis
B. Obstruction
C. Appendicile mass
D. Perforation with pneumoperitonium
E. *Abscess
34. Which of the following complications of acute appendicitis is shown on CT (Figure 9)?
A. Peritonitis
B. Obstruction
C. Appendiceal mass
D. Perforation with pneumoperitonium
E. *Abscess
35. Which of the etiological factors shown in Figure 10, which is important in case of acute appendicitis in children?
A. allergy;
B. raw food;
C. injury;
D. worms.
E. *Fecaliths;
36. In Figure 11 – Intraoperative view of appendix. What is the stage of acute appendicitis?
A. Early stage
B. Suppurative appendicitis
C. Gangrenous appendicitis
D. Perforated appendicitis
E. *Phlegmonous appendicitis
37. In Figure 12 – Intraoperative view of appendix. What is the stage of acute appendicitis?
A. Early stage
B. Suppurative appendicitis
C. Perforated appendicitis
D. Phlegmonous appendicitis
E. *Gangrenous appendicitis
38. In Figure 13 – Intraoperative view of appendix. What is the stage of acute appendicitis?
A. Early stage
B. Suppurative appendicitis
C. Gangrenous appendicitis
D. Phlegmonous appendicitis
E. *Perforated appendicitis
39. In what position of appendix research, as displayed in Figure 4 will be the most informative?
A. Retrocecal
B. Subcaecal
C. Postileal
D. Preileal
E. *Pelvic
40. Which of inconstancy of appendix position is shown in Figure 14?
A. Pelvic
B. Subcaecal
C. Postileal
D. Preileal
E. *Retrocecal
41. Wich of inconstancy of appendix position is shown in Figure 15?
A. Retrocecal
B. Pelvic
C. Subcaecal
D. Postileal
E. *Intramural
42. Which stage of the appendectomy is shown in Figure 16?
A. Mobilization of appendiceal base.
B. The mesoappendix is held between clamps, divided, and ligated.
C. Ligation of base. A purse-string suture is laid in the wall of the cecum at the base of the appendix
D. The appendix is divided between the ligature and clamp.
E. *Mobilization of appendiceal tip
43. Which stage of the appendectomy is shown in Figure 17?
A. Mobilization of appendiceal tip
B. The mesoappendix is held between clamps, divided, and ligated.
C. Ligation of base. A purse-string suture is laid in the wall of the cecum at the base of the appendix
D. The appendix is divided between the ligature and clamp.
E. *Mobilization of appendiceal base.
44. Which stage of the appendectomy is shown in Figure 18?
A. Mobilization of appendiceal tip
B. Mobilization of appendiceal base.
C. Ligation of base. A purse-string suture is laid in the wall of the cecum at the base of the appendix
D. The appendix is divided between the ligature and clamp.
E. *The mesoappendix is held between clamps, divided, and ligated.
45. Which stage of the appendectomy is shown in Figure 19?
A. Mobilization of appendiceal tip
B. Mobilization of appendiceal base.
C. The mesoappendix is held between clamps, divided, and ligated.
D. The appendix is divided between the ligature and clamp.
E. *Ligation of base. A purse-string suture is laid in the wall of the cecum at the base of the appendix
46. Which stage of the appendectomy is shown in Figure 20?
A. Mobilization of appendiceal tip
B. Mobilization of appendiceal base.
C. The mesoappendix is held between clamps, divided, and ligated.
D. Ligation of base. A purse-string suture is laid in the wall of the cecum at the base of the appendix
E. *The appendix is divided between the ligature and clamp.
47. What is the best diagnostic test to perform to rule in Meckel’s is shown on Figure 45?
A. Standard X-ray.
B. Barium enema.
C. Upper GI series.
D. Red-cell tagged scan.
E. *Meckel’s scan with radioisotope for gastric mucosa.
48. A 6-year-old male presents to the emergency department with vomiting and abdominal pain. He has diffuse tenderness on examination of the abdomen. Here is the abdominal series that you order.(Figure 7). What is the correct interpretation of this X-ray?
A. Ileus.
B. Obstruction.
C. NEC.
D. Ureteral stone.
E. *Free air.
49. A 3-year-old male is brought into the emergency department following a 5-minute tonicclonic seizure associated with a high temperature. The fever started yesterday and he had a few episodes of vomiting the previous night. Parents report that his appetite is poor and he was complaining of some right-sided abdominal pain. Vital signs are as follows: temperature of 103.6°F, heart rate 152, respiratory rate 23, blood pressure 112/72. Physical exam reveals an uncomfortable child who starts crying when you approach him. He has no signs of menigismus; heart and lung sounds are normal. His abdomen is soft and nondistended, with active bowel sounds. He is difficult to examine but you believe he has some tenderness in the right lower quadrant. His gait is normal. You obtain the following USD (Figure 8). What is the correct interpretation of these USD?
A. Appendiceal mass.
B. Fecalith.
C. Kidney stone.
D. Normal USD.
E. *Abscess.
50. A 3-year-old male is brought into the emergency department following a 5-minute tonicclonic seizure associated with a high temperature. The fever started yesterday and he had a few episodes of vomiting the previous night. Parents report that his appetite is poor and he was complaining of some right-sided abdominal pain. Vital signs are as follows: temperature of 103.6°F, heart rate 152, respiratory rate 23, blood pressure 112/72. Physical exam reveals an uncomfortable child who starts crying when you approach him. He has no signs of menigismus; heart and lung sounds are normal. His abdomen is soft and nondistended, with active bowel sounds. He is difficult to examine but you believe he has some tenderness in the right lower quadrant. His gait is normal. You obtain the following USD (Figure 8). The most likely diagnosis is:
A. Renal colic.
B. Small bowel obstruction.
C. Intussusception.
D. Volvulus.
E. *Appendicitis.
51. A patient presents with a 24-hour history of periumbilical pain, now localized to the right lower quadrant. An abdominal CT scan is obtained in the ER, which is shown in Figure 9. Which of the following is considered a physical sign often associated with this diagnosis?
A. concave and empty right lower quadrant
B. pain on flexion of the right hip
C. flank bruising
D. inspiratory arrest while palpating under the right costal margin
E. *pain in right lower quadrant with palpation in left lower quadrant
52. A 28-day-old infant presents with a 3-day history of increasing periumbilical erythema is shown on the figure 71. Which of the following diagnoses is most likely?
A. Patent urachus
B. Neonatal alloimmune neutropenia
C. Maple syrup urine disease
D. Patent omphalomesenteric duct
E. *Omphalitis
53. Pathology that shown in Figure 55
A. Is an infection of the muscle caused by a fungal infection.
B. Is a joint & muscle infection caused by a virus.
C. Is a form of bone cancer that is predominately found in children.
D. Is a joint infection caused by bacteria.
E. *Is a bone infection usually caused by bacteria.
54. What diagnosis can be set based on figure 53?
A. Phlegmon
B. Boil
C. Abscess
D. Carbuncle
E. *Mastitis
55. What diagnosis can be set based on pictures 54?
A. Hemorrhoids
B. Tumor
C. Hemangioma
D. Lymphadenitis
E. *Perianal abscess
56. What diagnosis can be set based on X-ray that shown in Figure 55?
A. Brodie’s disease
B. Sarcoma Yuinha
C. Osteoyid-osteoma
D. Osteochondroma
E. *Chronic osteomyelitis
57. Put a diagnosis based on X-ray shown in Figure 56?
A. Right sided pneumonia
B. Pneumothorax
C. Lung emphysema
D. Bullous disease
E. *Lung abscess
58. Put a diagnosis based on X-ray that shown in Figure 57?
A. Lung abscess
B. Right sided pneumonia
C. Pneumothorax
D. Bullous disease
E. *Lung emphysema
59. Put a diagnosis on the basis of this X-ray that shown in Figure 58?
A. Lung abscess
B. Right sided pneumonia
C. Lung emphysema
D. Pleural empyema
E. *Spontaneous pneumothorax
60. Put a diagnosis on the basis of this X-ray that shown in Figure 59?
A. Lung abscess
B. Right sided pneumonia
C. Spontaneous pneumothorax
D. Lung emphysema
E. *Pleural empyema
61. Put a diagnosis on the basis of this X-ray that shown in Figure 62?
A. Lung abscess
B. Right sided pneumonia
C. Lung emphysema
D. Pleural empyema
E. *Tension pneumothorax
62. What diagnosis can be put on the basis of Figure 64?
A. Erysipelas
B. Boil
C. Left thigh abscess
D. Burn of the left hip
E. *Necrotising fasciitis with necrosis of the skin
63. What diagnosis can put a picture on the basis of 66?
A. Phlegmon
B. Physiological breast swelling
C. Abscess
D. Infiltration
E. *Mastitis
64. This x-ray picture that shown in Figure 67 is typical for:
A. Right sided pneumonia
B. Tumor of the right lung
C. Right sided pleural empyema
D. Bullous disease
E. *Right sided pneumothorax
65. This x-ray picture that shown in Figure 68 is typical for:
A. Right sided pneumonia
B. Tumor of the right lung
C. Right sided pleural empyema
D. Bullous disease
E. *Right sided tension pneumothorax
66. A 18-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 85. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most likely diagnosis?
A. squamous cell carcinoma
B. basal cell carcinoma
C. Merkel cell carcinoma
D. keratoacanthoma
E. *melanoma
67. A 18-year-old man presents to the physician’s office for evaluation of a skin lesion on his abdomen. He states that the lesion has been present for 1 year, but has recently enlarged over the last 2 months. The mass is nontender, and he is otherwise asymptomatic. Past history is unremarkable. Examination reveals a 3-cm, pigmented, irregular skin lesion located in the left lower quadrant of the abdomen, as shown in Figure 85. Heart, lung, and abdominal examination are normal. There are no palpable cervical, axillary, or inguinal lymph nodes. Chest x-ray and liver function tests are normal. Which of the following is the most appropriate next step in management?
A. wide excision with
B. wide excision with
C. shave biopsy
D. Mohs’ surgical excision
E. *excisional biopsy with 1–2 mm margins
68. A mother notices an abdominal mass in her 3-year-old son while giving him a bath. There is no history of any symptoms, but the boy’s blood pressure is elevated at 105/85 mm Hg. Metastatic workup is negative and the patient is explored. In X-ray revealed the following picture (see Figure 104). Which of the following statements concerning this disease is correct?
A. The majority of patients present with an asymptomatic abdominal mass and hematuria
B. Treatment with surgical excision, radiation, and chemotherapy results in survival of less than 60% even in histologically low-grade tumors
C. Surgical excision is curative and no further treatment is ordinarily advised
D. This tumor is the most common malignancy in childhood
E. *This tumor is associated with aniridia, hemihypertrophy, and cryptochidism
69. A 2-month-old boy is being evaluated for the growth pictured on figure 82. At birth his skin was clear, but when he was 1 month old his mother noted a light red growth on his back. During the last month, it increased in size and turned bright red. The most likely diagnosis of the skin lesion pictured is
A. melanoma
B. osteochondroma
C. nevus flammeus
D. cavernous hemangioma
E. *strawberry hemangioma
70. A 2-month-old boy is being evaluated for the growth pictured on figure 82. At birth his skin was clear, but when he was 1 month old his mother noted a light red growth on his back. During the last month, it increased in size and turned bright red. The treatment of choice of this disorder is
A. surgery
B. radiation therapy
C. argon laser therapy
D. topical corticosteroids
E. *observation
71. A 2-month-old boy is being evaluated for the growth pictured on figure 82. At birth his skin was clear, but when he was 1 month old his mother noted a light red growth on his back. During the last month, it increased in size and turned bright red. Response to treatment is best described by which of the following statements?
A. recovery will be poor, with probable malignant transformation
B. recovery will be poor, with metastasis to regional lymph nodes
C. recovery will be favorable, but other lesions of the same type are likely to develop
D. there is not enough information to predict outcome
E. *recovery will be total, with no evidence of scar
72. What diagnosis can be set based on figure 83?
A. Infiltrate the left shin
B. Angiofibroma
C. Cavernous hemangioma
D. Lymphostasis.
E. *Lymphangioma
73. About the diseases that can say, looking at figure 86?
A. pigmented mole
B. hemangioma
C. papilloma
D. ichthyosis
E. *melanoma
74. What diagnosis can be set based on figure 90?
A. Dermoid cyst
B. Abscess
C. Teratoma
D. Wilm?s tumor
E. *Lymphangioma
75. In the
A. surgical excision
B. no treatment if benign
C. pharmacological sclerotherapy
D. steroidotherapy
E. *radiation therapy
76. A 5 year old boy (see figure 93) presents with a large right flank mass, fever, weight loss, proptosis of the right eye, and ecchymosis around the right eye. The most likely diagnosis is:
A. Wilms’ tumor
B. Neuroblastoma
C. Hydronephrosis
D. lymphangioma
E. *Metastatic neuroblastoma
77. You had previously seen a 18-year-old male in your office for evaluation of a suspicious looking mole (see Figure 85). He had undergone a punch biopsy, which demonstrated a melanoma. He has no prior history of skin cancer, no family history of skin cancer, nor any history of blistering sunburns. Which of the following results in the pathology report are most predictive of outcome?
A. size of the melanoma
B. color of the melanoma
C. presence of ulceration
D. site of the melanoma
E. *depth of the melanoma
78. A 3 1/2-year-old female presented with a left upper quadrant abdominal mass. The child had no previous history of medical illnesses. An CT examination (see figure 105) revealed a markedly deformed left kidney. Medial displacement of the bowel loops was also noted. What would be the most likely diagnosis in this case?
A. hydronephrotic kidney
B. tuberculosis
C. congenital malformation
D. papillary transitional cell carcinoma of the renal pelvis
E. *Wilms tumor
79. A 17-year-old male is evaluated for thigh pain, presents with a fever, weight loss. He has no history of injury (see figure 106). What is this patient’s diagnosis?
A. osteoblastoma
B. metastatic carcinoma
C. multiple myeloma
D. Ewing sarcoma
E. *Osteosarcoma
80. Which of the following is the most appropriate next step in management pathology that shown in figure 85?
A. wide excision with
B. wide excision with
C. shave biopsy
D. Mohs’ surgical excision
E. *excisional biopsy with 1–2 mm margins
81. Pathology that shown in figure 100:
A. is usually malignant
B. is more common in males
C. diagnosis is ruled out if calcification is absent on Radiography
D. is present with gastrointestinal bleeding
E. *requires complete excision of the coccyx
82. The treatment for pathology that shown in the X-ray of the femur (see Figure 106) is:
A. above-knee amputation
B. chemotherapy followed by above-knee amputation
C. chemoradiation
D. chemotherapy alone
E. *chemotherapy and limb-sparing surgery
83. A 6-year-old boy is referred to you with fever, failure to thrive, periorbital ecchymoses (see Figure 93), and a large abdominal mass. What is the most likely diagnosis?
A. Hepatoblastoma
B. Wilms tumor
C. Ovarian teratoma
D. Rhabdomyosarcoma
E. *Neuroblastoma
84. What diagnosis can be put on the basis of Picture53?
A. Phlegmon
B. Furuncle
C. Abscess
D. Carbuncle
E. *Mastitis
85. What diagnosis can be put on the basis of these Pictures 54?
A. Hemorrhoids
B. Tumour
C. Hemangioma
D. Lymphadenitis
E. *Perianal abscess
86. What diagnosis can be put on the basis of radiographs that depicted in Figure 55?
A. Brodie abscess
B. Ewing’s sarcoma
C. Osteoyid-osteoma
D. Osteohondroma
E. *Chronic osteomyelitis
87. Put a diagnosis based on radiographs that depicted in Figure 56?
A. right-sided pneumonia
B. pneumothorax
C. emphysema
D. Bullous Lung Disease
E. *Lung abscess
88. Put a diagnosis based on radiographs that depicted in Figure 57?
A. Lung abscess
B. right-sided pneumonia
C. pneumothorax
D. Bullous Lung Disease
E. *emphysema
89. Put a diagnosis based on radiographs that depicted in Figure 58?
A. Lung abscess
B. right-sided pneumonia
C. emphysema
D. Pyopneumothorax
E. *pneumothorax
90. Put a diagnosis based on radiographs that depicted in Figure 59?
A. Lung abscess
B. right-sided pneumonia
C. pneumothorax
D. emphysema
E. *Pyopneumothorax
91. Put a diagnosis on the basis of radiographs that depicted in Figure 60?
A. Empyema of pleura
B. Spontaneous pneumothorax
C. Emphysema of lungs
D. Pyopneumothorax
E. *Pleurisy
92. Put a diagnosis on the basis of radiographs that depicted in Figure 61?
A. Pleurisy
B. Spontaneous pneumothorax
C. Emphysema of lungs
D. Pyopneumothorax
E. *Empyema of pleura
93. What diagnosis can be set based on this photo 64?
A. Erypsipelas
B. Furunculosis
C. Left thigh abscess
D. Burn of the left thigh
E. *A necrotizing phlegmon with necrosis of skin
94. What diagnosis can be set based on picture 66?
A. Phlegmon
B. Physiological breast engorgement
C. Abscess
D. Infiltration
E. *Mastitis
95. Most characteristic and complete signs of phlegmonous form of omphalitis on Figure 71 ?
A. serous content from wounds navel
B. condition not violations
C. process within the navel
D. infiltration of tissues near the navel
E. *flushing of the skin around the navel and the infiltration of tissues near the navel
96. What is the most likely diagnosis in this infant with this huge mass(Fig. 100)?
A. Hepatoblastoma
B. Wilms tumor
C. Neuroblastoma
D. Rhabdomyosarcoma
E. *Teratoma
97. Figure 78 shows lesion that is found in a child of 1 year old. In the left axillary region, of
A. lipoma
B. pigmented naevus
C. papilloma
D. atheroma
E. *hemangioma
98. Figure 79 shows lesion that is found in a child of 1 year on the back of the neck area. Formation of
A. cryotherapy;
B. sclerotherapy;
C. electrocoagulation;
D. hormone therapy.
E. *Surgical
99. What is the most likely diagnosis in the patient shown below(Fig. 44)?
A. Gastric carcinoma
B. Gastric polyp
C. Gastrinoma
D. Gastric emphysema
E. *Gastric ulcer
100. Look at the following case(Fig.68). Why is this an emergency? The patient has:
A. An acute pneumonia of the right lung.
B. Had a pulmonary embolism
C. A simple pneumothorax.
D. Been shot.
E. *A tension pneumothorax.
101. This patient came in complaining of severe abdominal pain(Fig. 7) . Why is this an emergency? The patient has:
A. A ruptured abdominal aortic aneurysm.
B. Acute appendicitis.
C. Acute renal failure.
D. An abscess in the psoas muscle.
E. *A ruptured gastric ulcer.
102. This patient had acute abdominal pain after a year-long bout of chronic abdominal pain(Fig.7). Why is this an emergency? The patient has:
A. A ruptured abdominal aortic aneurysm
B. An enlarged spleen.
C. A pericardial effusion.
D. Acute appendicitis.
E. *A ruptured gastric ulcer.
103. The patient shown below most likely has(Fig. 57):
A. Atelectasis of the left lung
B. A large left pleural effusion
C. A large right pneumothorax
D. Pneumonia in the left lung
E. *Lung emphysema
104. What is wrong with this patient(Fig. 56)?
A. Atelectasis of the left lung
B. A large right pneumothorax
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Lung abscess
105. The patient shown below most likely has(Fig. 56):
A. Atelectasis of the left lung
B. A large right pneumothorax
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Lung abscess
106. The patient shown below most likely has(Fig. 58):
A. Atelectasis of the left lung
B. A large left pleural effusion
C. Pneumonia in the left lung
D. Lung emphysema
E. *A large right pneumothorax
107. What is wrong with this patient(Fig. 59)?
A. Lung abscess
B. A large right pneumothorax
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Pleural empyema
108. The patient shown below most likely has(Fig. 59):
A. Lung abscess
B. A large right pneumothorax
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Pleural empyema
109. This child suddenly developed respiratory distress and cyanosis (Fig. 68). Diagnosis?
A. pneumoperitoneum
B. bronchopneumonia
C. pulmonary edema
D. Pleural empyema
E. *pneumothorax
110. The patient shown below most likely has(Fig. 62):
A. Pleural empyema
B. Lung abscess
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Tension pneumothorax
111. What is wrong with this patient(Fig. 67)?
A. Pleural empyema
B. Lung abscess
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Right sided pneumothorax
112. The patient shown below most likely has(Fig. 67):
A. Pleural empyema
B. Lung abscess
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Right sided pneumothorax
113. The patient shown below most likely has(Fig. 68):
A. Pleural empyema
B. Lung abscess
C. Pneumonia in the right lung
D. Unilateral pulmonary edema
E. *Right sided tension pneumothorax
114. What is the most likely diagnosis in the patient shown below(Fig. 51)?
A. Colonic volvulus
B. Colonic polyps
C. Ulcerative colitis
D. Colonic carcinoma
E. *Diverticulitis
115. What is the most likely diagnosis in the patient shown below(Fig. 41)?
A. Colonic polyps
B. Ulcerative colitis
C. Diverticulitis
D. Colonic carcinoma
E. *Colonic volvulus
116. The patient shown below most likely has(Fig.22):
A. Large bowel obstruction
B. Small bowel obstruction
C. Generalized ileus
D. Localized ileus
E. *Free intraperitoneal air
117. What is wrong with this patient(Fig. 7)?
A. Large bowel obstruction
B. Small bowel obstruction
C. Generalized ileus
D. Localized ileus
E. *Free intraperitoneal air
118. The patient shown below most likely has(Fig.7):
A. Large bowel obstruction
B. Small bowel obstruction
C. Generalized ileus
D. Localized ileus
E. *Free intraperitoneal air
119. What is wrong with this patient(Fig. 39)?
A. Large bowel obstruction
B. Generalized ileus
C. Localized ileus
D. Free intraperitoneal air
E. *Small bowel obstruction
120. The patient shown below most likely has(Fig.39):
A. Large bowel obstruction
B. Generalized ileus
C. Localized ileus
D. Free intraperitoneal air
E. *Small bowel obstruction
121. What is wrong with this patient(Fig. 40)?
A. Small bowel obstruction
B. Generalized ileus
C. Localized ileus
D. Free intraperitoneal air
E. *Large bowel obstruction
122. The patient shown below most likely has(Fig.40):
A. Small bowel obstruction
B. Generalized ileus
C. Localized ileus
D. Free intraperitoneal air
E. *Large bowel obstruction
123. This tumor in a four year old is likely to be (Fig.107)
A. Neuroblastoma
B. Gravitz tumor
C. Hodgkin’s disease
D. Non-hodgkin’s lymphoma
E. *Wilms’ tumor
124. This girl with hemangioma (Fig. 82) needs
A. Trial of steroids
B. L ocal steroids
C. I njection of boiling water
D. L aser ablation
E. *Surgical excision
125. This boy with hemangioma (Fig. 96) needs
A. Surgical excision
B. L ocal steroids
C. I njection of boiling water
D. L aser ablation
E. *Trial of steroids
126. This girl with hemangioma (Fig. 97) needs
A. Trial of steroids
B. L ocal steroids
C. I njection of boiling water
D. L aser ablation
E. *Surgical excision
127. This large wilms’ tumor has been removed (Fig.105).What additional treatment the patient may require
A. No treatment
B. Kidney transplant
C. Chemotherapy
D. Bone marrow t ansplant
E. *Chemotherapy and radiotherapy
128. This girl with a large wilms’ tumor in left kidney is about to undergo surgery. What is the preferred approach?
A. Lumbotomy
B. Flank incision, extraperitoneal
C. Laparoscopic excision
D. Cystoscopic excision
E. *Transperitoneal
129. This tumor arising from lower pole of kidney has been r emoved (Fig.107). This tumor is named after.
A. Christopher Columbus
B. Galileo Galilee
C. John Hunter
D. Ewing
E. *Wilms
130. Diagnosis(Fig. 71)?
A. Umbilical her nia
B. Appendicitis
C. Umbilical granuloma
D. Ectopia cordis
E. *Omphalitis
131. This pathology (Fig. 42) most commonly presents as:
A. Obstruction.
B. Diverticulitis.
C. Intermittent abdominal pain.
D. Perforation
E. *Gastrointestinal bleeding.
132. All of the following statements about the pathology (Fig. 42) are true except:
A. usually arises from the ileum within
B. results from the failure of the vitelline duct to obliterate.
C. It is a true diverticulum possessing all layers of the intestinal wall.
D. Gastric mucosa is the most common ectopic tissue found within it.
E. *The incidence in the general population is 5%.
133. Patients with established, complete, simple, distal small bowel obstruction usually have the following findings on plain and upright abdominal radiographs(Fig. 39):
A. B. Multiple air-fluid levels.
B. Modest amount of gas in the pelvis.
C. Prominent haustral markings.
D. Free air.
E. *Peripheral, rather than central, distribution of gas.
134. This pathology (Fig. 105) does not complicate pyelonephritis:
A. pyonephrosis
B. papillary necrosis
C. renal stones
D. perinephric abscess
E. *renal cell carcinoma
135. All are true about this condition (Fig. 47) except.
A. Multiple fissures suggest a diagnosis of tuberculosis or Crohn’s Disease
B. 50% of acute fissures heal with the use of a bulking agent
C. Sphincterotomy has a success rate of over 90%
D. Sphincterotomy is associated with minor faecal incontinence in over 15% of patients
E. *10% occur in the posterior midline
136. This condition (Fig. 46) cause bleeding per rectum
A. Anal fistula
B. Meckel’s diverticulum
C. Anal fissure
D. Diverticulitis
E. *Rectal polyp
137. This condition (Fig. 47) cause bleeding per rectum
A. Meckel’s diverticulum
B. Anal fissure
C. Rectal polyp
D. Diverticulitis
E. *Anal fistula
138. This condition (Fig. 42) cause bleeding per rectum
A. Anal fistula
B. Anal fissure
C. Rectal polyp
D. Diverticulitis
E. *Meckel’s diverticulum
139. This condition (Fig. 51) cause bleeding per rectum
A. Anal fistula
B. Meckel’s diverticulum
C. Anal fissure
D. Rectal polyp
E. *Diverticulitis
140. Basedonthis X-rays (Fig. 29), whatisthemostlikelydiagnosis?
A. Ileus.
B. Bowel obstruction.
C. Appendicitis.
D. Meckel’s diverticulum.
E. *Intussusception.
141. Whati s the investigation for diagnosis of intussusception is shown (Fig. 31)?
A. Abdominal plain films.
B. CT scan.
C. MR imagine.
D. Contrast enema.
E. *Ultrasound.
142. What is the investigation for diagnosis of intussusception is shown (Fig. 32)?
A. CT scan.
B. MR imagine.
C. Contrast enema.
D. Ultrasound.
E. *Abdominal plain films.
143. What is the investigation for diagnosis of intussusception is shown (Fig. 29)?
A. Abdominal plain films.
B. CT scan.
C. MR imagine.
D. Ultrasound.
E. *Contrast enema.
144. What is the investigation for diagnosis of intussusception is shown (Fig. 30)?
A. Abdominal plain films.
B. CT scan.
C. MR imagine.
D. Ultrasound.
E. *Contrast enema.
145. What is the correct interpretation of this X-ray(Fig. 7)?
A. small-bowelobstruction
B. deadbowel
C. coloncarcinoma
D. gastriculcer
E. *perforatedduodenalulcer
146. What is the correct interpretation of these X-rays(Fig. 29)?
A. Meckel’s diverticulum.
B. Volvulus.
C. Appendicitis.
D.
E. *Intussusception.
147. What is the correct interpretation of these X-rays(Fig.30)?
A. Meckel’s diverticulum.
B. Volvulus.
C. Appendicitis.
D.
E. *Intussusception.
148. What is the correct interpretation of these X-rays(Fig.39)?
A. Small bowel obstruction.
B. NEC.
C. Normal abdominal X-ray.
D. Volvulus.
E. *Ileus.
149. Which of thefollowingfindingsonplainanduprightabdominalradiographsin patientswithestablished, complete, simple, distalsmallbowelobstructionshown in Figure 39:
A. Free air
B. Modest amount of gas in the pelvis.
C. Peripheral, rather than central, distribution of gas.
D. Prominent haustral markings.
E. *Multiple air-fluid levels.
150. What is the correct in terpretation of these USD(Figure 8)?
A. Appendiceal mass.
B. Fecalith.
C. Kidney stone.
D. Normal USD.
E. *Abscess.
151. What is the correct interpretation of these USD(Figure31)?
A. Ileus.
B. Bowel obstruction.
C. Appendicitis.
D. Meckel’s diverticulum.
E. *Intussusception.
152. What is the correct interpretation of these X-rays(Fig.56)?
A. Rightsidedpneumonia
B. Pneumothorax
C. Lungemphysema
D. Bullous disease
E. *Lungabscess
153. What is the correct interpretation of these X-rays(Fig.57)?
A. Lungabscess
B. Rightsidedpneumonia
C. Pneumothorax
D. Bullous disease
E. *Lungemphysema
154. What is the correct interpretation of these X-rays(Fig.58)?
A. Lungabscess
B. Rightsidedpneumonia
C. Lungemphysema
D. Bullous disease
E. *Spontaneouspneumothorax
155. What is the correct interpretation of these X-rays(Fig.59)?
A. Lungabscess
B. Rightsidedpneumonia
C. Spontaneouspneumothorax
D. Lungemphysema
E. *Pleuralempyema
156. What is the correct interpretation of these X-rays(Fig.62)?
A. Lungabscess
B. Rightsidedpneumonia
C. Lungemphysema
D. Bullous disease
E. *Tensionpneumothorax
157. What is the correct interpretation of these X-rays(Fig.67)?
A. Lungabscess
B. Rightsidedpneumonia
C. Rightsidedpneumothorax
D. Lungemphysema
E. *Pleuralempyema
158. What is the correct interpretation of these X-rays(Fig.68)?
A. Lungabscess
B. Rightsidedpneumonia
C. Lungemphysema
D. Bullous disease
E. *Rightsidedtensionpneumothorax
159. Biopsy of these lesion (Fig. 79) shows stratified squamous epithelium covering loose connective tissue that contains many thin-walled engorged, vascular space. Most likely diagnosis is:
A. papilloma
B. lymphangioma
C. granular cell myoblastoma
D. neurofibromas
E. *hemangioma
160. The most likely diagnosis of the skin lesion pictured is (Fig. 82)
A. melanoma
B. osteochondroma
C. nevusflammeus
D. cavernoushemangioma
E. *strawberryhemangioma
161. The most likely diagnosis of the skin lesion pictured is (Fig. 83)
A. Infiltratetheleftshin
B. Angiofibroma
C. Cavernoushemangioma
D. Lymphostasis.
E. *Lymphangioma
162. The most likely diagnosis of the skin lesion pictured is (Fig. 86)
A. osteochondroma
B. nevusflammeus
C. cavernoushemangioma
D. strawberryhemangioma
E. *melanoma
163. The most likely diagnosis of the skin lesion pictured is (Fig. 78)
A. melanoma
B. osteochondroma
C. nevusflammeus
D. strawberryhemangioma
E. *cavernoushemangioma
164. The most likely diagnosis of the skin lesion pictured is (Fig. 89)
A. melanoma
B. osteochondroma
C. nevusflammeus
D. strawberryhemangioma
E. *cavernoushemangioma
165. The most likely diagnosis of the skin lesion pictured is (Fig. 97)
A. melanoma
B. osteochondroma
C. nevusflammeus
D. strawberryhemangioma
E. *cavernoushemangioma
166. Regarding this condition (Fig. 86). Which of the following statements is true?
A. Some lesions have the clinical features of a melanoma
B. Individuals with this condition have an increased risk of melanoma when compared with the general population
C. Epiluminescent microscopy has not been shown to aid earlier clinical detection of melanoma
D. Regular photography may be of value as melanomas always arise within existing lesions
E. *The risk of melanoma is less in sporadic than familial forms
