50 Best Choice Questions (BCQs) for Pediatric Surgery Postgraduate Trainees
Based on the American Academy of Pediatrics guidelines, I will provide 50 high-quality BCQs with clinical scenarios in pediatric surgery covering various topics for postgraduate trainees, complete with five homogeneous options and answer keys with references. 1, 2
Neonatal Surgery
BCQ 1
A 1-day-old term neonate presents with bilious vomiting, abdominal distension, and failure to pass meconium. Abdominal X-ray shows dilated bowel loops and absence of distal gas. The most likely diagnosis is: A) Duodenal atresia B) Malrotation with volvulus C) Hirschsprung's disease D) Meconium ileus E) Jejunal atresia Answer: C 1
BCQ 2
A 2-day-old neonate presents with inability to pass a nasogastric tube, excessive salivation, and respiratory distress. Chest X-ray shows a gasless abdomen with a coiled NG tube in the upper esophagus. The most appropriate next step is: A) Immediate thoracotomy B) Contrast esophagogram C) Rigid bronchoscopy D) Echocardiography E) Esophageal dilatation Answer: B 1
BCQ 3
A preterm infant (32 weeks) presents with abdominal distension, bilious vomiting, and pneumatosis intestinalis on abdominal X-ray. The most appropriate initial management is: A) Immediate laparotomy B) Peritoneal drainage C) Bowel rest, nasogastric decompression, and antibiotics D) Contrast enema E) Rectal biopsy Answer: C 1
BCQ 4
A newborn with prenatal diagnosis of congenital diaphragmatic hernia presents with respiratory distress at birth. The most critical initial management step is: A) Immediate surgical repair B) Chest tube placement C) Endotracheal intubation and gentle ventilation D) ECMO initiation E) Nitric oxide therapy Answer: C 2
BCQ 5
A 3-day-old term infant presents with jaundice, acholic stools, and dark urine. Ultrasound shows a triangular cord sign at the porta hepatis. The most likely diagnosis is: A) Choledochal cyst B) Biliary atresia C) Neonatal hepatitis D) Alpha-1 antitrypsin deficiency E) Spontaneous bile duct perforation Answer: B 1
Pediatric Trauma
BCQ 6
A 7-year-old boy presents after falling from a tree with right upper quadrant pain and tachycardia. FAST scan is positive for free fluid. The most appropriate next step is: A) Immediate laparotomy B) CT scan with IV contrast C) Diagnostic peritoneal lavage D) Observation with serial examinations E) Angioembolization Answer: B 1
BCQ 7
A 4-year-old girl presents after a motor vehicle accident with decreased breath sounds on the left side, tracheal deviation to the right, and hypotension. The most urgent intervention is: A) Chest tube placement B) Needle thoracentesis C) Intubation and mechanical ventilation D) FAST scan E) CT chest Answer: B 1
BCQ 8
A 10-year-old boy presents with gross hematuria after falling from his bicycle and striking his abdomen on the handlebar. Vital signs are stable. CT scan shows a grade III renal laceration without vascular injury. The most appropriate management is: A) Immediate surgical exploration B) Angioembolization C) Nephrectomy D) Non-operative management with bed rest E) Ureteral stent placement Answer: D 1
BCQ 9
A 6-year-old child presents with persistent vomiting and abdominal pain 2 days after a fall from a swing. CT scan shows a duodenal hematoma with partial obstruction. The most appropriate management is: A) Immediate laparotomy B) Nasogastric decompression and parenteral nutrition C) Endoscopic decompression D) Duodenal stenting E) Gastrojejunostomy Answer: B 1
BCQ 10
A 12-year-old boy presents with a penetrating injury to the right chest from a metal rod. He is hypotensive with distended neck veins and muffled heart sounds. The most likely diagnosis is: A) Tension pneumothorax B) Cardiac tamponade C) Massive hemothorax D) Traumatic aortic rupture E) Tracheobronchial injury Answer: B 2
Pediatric Oncology
BCQ 11
A 3-year-old presents with a palpable right flank mass, hypertension, and microscopic hematuria. The most appropriate initial imaging study is: A) Abdominal X-ray B) Ultrasound abdomen C) CT abdomen with contrast D) MRI abdomen E) Nuclear scan Answer: C 3
BCQ 12
A 2-year-old girl presents with a rapidly growing soft tissue mass in the right orbit causing proptosis. The most likely diagnosis is: A) Rhabdomyosarcoma B) Retinoblastoma C) Neuroblastoma D) Langerhans cell histiocytosis E) Optic nerve glioma Answer: A 3
BCQ 13
A 4-year-old boy presents with a large abdominal mass crossing the midline. Urine catecholamines are elevated. The most appropriate surgical approach is: A) Complete resection regardless of adjacent structure involvement B) Biopsy only followed by chemotherapy C) Debulking surgery removing >90% of tumor D) Image-guided percutaneous biopsy E) Resection only after neoadjuvant chemotherapy Answer: B 3
BCQ 14
An 8-month-old infant presents with a sacrococcygeal mass that has both external and intrapelvic components. The most appropriate surgical approach is: A) Complete excision including coccygectomy B) Excision of external component only C) Biopsy followed by chemotherapy D) Radiation therapy followed by excision E) Observation until 1 year of age Answer: A 1
BCQ 15
A 6-year-old presents with a large liver mass. Alpha-fetoprotein is markedly elevated. CT shows a solitary right lobe mass without metastases. The most appropriate management is: A) Right hepatectomy B) Liver transplantation C) Percutaneous biopsy followed by chemotherapy D) Radiofrequency ablation E) Transarterial chemoembolization Answer: A 3
Pediatric Urology
BCQ 16
A 2-day-old male neonate presents with bilateral non-palpable testes and hypospadias. The most appropriate next step is: A) Immediate bilateral orchiopexy B) Karyotype and endocrine evaluation C) Diagnostic laparoscopy D) MRI of pelvis E) Testosterone stimulation test Answer: B 1
BCQ 17
A 3-year-old boy presents with a painless, non-reducible right inguinal mass that has been present for 6 months. The most likely diagnosis is: A) Incarcerated inguinal hernia B) Hydrocele C) Undescended testis D) Testicular torsion E) Inguinal lymphadenopathy Answer: C 1
BCQ 18
A 5-year-old boy presents with sudden onset of severe scrotal pain and vomiting. Physical examination reveals a high-riding, tender right testicle with absent cremasteric reflex. The most appropriate next step is: A) Doppler ultrasound B) Immediate surgical exploration C) Antibiotics for epididymitis D) Manual detorsion attempt E) Urinalysis and urine culture Answer: B 1
BCQ 19
A 2-year-old boy presents with recurrent urinary tract infections. Voiding cystourethrogram shows grade IV vesicoureteral reflux on the left side. The most appropriate management is: A) Immediate ureteral reimplantation B) Endoscopic injection of bulking agent C) Antibiotic prophylaxis with follow-up imaging D) Left nephrectomy E) Ureteroureterostomy Answer: C 1
BCQ 20
A newborn male presents with inability to void and palpable bladder. Antenatal ultrasound was normal. The most likely diagnosis is: A) Posterior urethral valves B) Urethral atresia C) Prune belly syndrome D) Neurogenic bladder E) Ureterocele Answer: A 1
Gastrointestinal Surgery
BCQ 21
A 6-week-old infant presents with non-bilious projectile vomiting after feeds and a palpable olive-shaped mass in the right upper quadrant. The most appropriate diagnostic test is: A) Upper GI contrast study B) Abdominal ultrasound C) Abdominal X-ray D) Serum electrolytes E) pH probe study Answer: B 1
BCQ 22
A 3-year-old presents with intermittent abdominal pain, currant jelly stools, and a palpable sausage-shaped mass in the right abdomen. The most appropriate initial management is: A) Immediate laparotomy B) Hydrostatic or pneumatic reduction C) Contrast enema without reduction attempt D) Broad-spectrum antibiotics only E) Observation with serial examinations Answer: B 1
BCQ 23
A 10-year-old presents with right lower quadrant pain, anorexia, and fever. White blood cell count is 15,000/μL. The most appropriate initial imaging study is: A) Abdominal X-ray B) Ultrasound of abdomen C) CT scan with IV contrast D) MRI abdomen E) Nuclear scan Answer: B 1
BCQ 24
A 2-year-old presents with painless rectal bleeding and an intussusception that recurs after two successful pneumatic reductions. The most likely lead point is: A) Meckel's diverticulum B) Polyp C) Lymphoma D) Duplication cyst E) Henoch-Schönlein purpura Answer: A 1
BCQ 25
A 14-year-old presents with dysphagia, regurgitation of undigested food, and weight loss. Barium swallow shows a dilated esophagus with a bird's beak appearance. The most appropriate management is: A) Proton pump inhibitor therapy B) Pneumatic dilatation C) Heller myotomy with fundoplication D) Botulinum toxin injection E) Esophagectomy Answer: C 1
Thoracic Surgery
BCQ 26
A 2-day-old term neonate presents with respiratory distress, excessive salivation, and inability to pass a nasogastric tube. Chest X-ray with contrast shows a blind-ending esophageal pouch. The most likely associated anomaly is: A) Duodenal atresia B) Imperforate anus C) Cardiac defect D) Renal anomaly E) Vertebral anomaly Answer: C 1
BCQ 27
A 6-month-old infant presents with recurrent pneumonia in the right lower lobe. CT chest shows a cystic lesion with air-fluid level. The most likely diagnosis is: A) Congenital pulmonary airway malformation B) Pulmonary sequestration C) Congenital lobar emphysema D) Bronchogenic cyst E) Diaphragmatic hernia Answer: A 1
BCQ 28
A 2-month-old infant presents with respiratory distress and a mediastinal mass on chest X-ray. CT shows a posterior mediastinal mass extending through the neural foramina. The most appropriate next diagnostic test is: A) MRI spine B) Urine catecholamines C) Percutaneous needle biopsy D) Bone marrow aspiration E) MIBG scan Answer: B 3
BCQ 29
A 15-year-old presents with sudden onset of sharp chest pain and shortness of breath. Chest X-ray shows a right-sided pneumothorax. The patient is tall and thin. The most appropriate management is: A) Observation only B) Needle aspiration C) Chest tube placement D) Video-assisted thoracoscopic surgery with pleurodesis E) Open thoracotomy Answer: C 1
BCQ 30
A 12-year-old presents with chronic cough, recurrent pneumonia, and hemoptysis. CT chest shows bronchiectasis in the right middle lobe. The most appropriate management is: A) Prolonged antibiotics B) Bronchoscopy with bronchoalveolar lavage C) Right middle lobectomy D) Inhaled corticosteroids E) Chest physiotherapy Answer: B 1
Minimally Invasive Surgery
BCQ 31
A 5-year-old presents with right lower quadrant pain, fever, and leukocytosis. Ultrasound confirms appendicitis without perforation. The most appropriate surgical approach is: A) Open appendectomy through McBurney's incision B) Laparoscopic appendectomy C) Single-incision laparoscopic appendectomy D) Interval appendectomy after antibiotics E) Percutaneous drainage Answer: B 1
BCQ 32
A 10-year-old presents with symptomatic cholelithiasis confirmed by ultrasound. The most appropriate surgical approach is: A) Open cholecystectomy B) Laparoscopic cholecystectomy C) ERCP with sphincterotomy D) Percutaneous cholecystostomy E) Medical dissolution therapy Answer: B 1
BCQ 33
A 2-year-old presents with a 2 cm umbilical hernia that has not resolved. The parents are concerned about the cosmetic appearance. The most appropriate management is: A) Immediate surgical repair B) Reassurance and observation until age 4-5 C) Compression bandage D) Laparoscopic repair E) Injection sclerotherapy Answer: B 1
BCQ 34
A 6-month-old presents with a right inguinal hernia. The most appropriate management is: A) Observation until 1 year of age B) Elective open herniotomy C) Laparoscopic hernia repair D) Compression garment E) Contralateral exploration in all cases Answer: B 1
BCQ 35
A 12-year-old presents with chronic right upper quadrant pain, nausea with fatty foods, and a positive HIDA scan showing a gallbladder ejection fraction of 20%. The most appropriate management is: A) Observation and diet modification B) Laparoscopic cholecystectomy C) ERCP with sphincterotomy D) Ursodeoxycholic acid therapy E) Open cholecystectomy Answer: B 1
Pediatric Surgical Oncology
BCQ 36
A 4-year-old presents with an asymptomatic abdominal mass. CT shows a 10 cm heterogeneous mass arising from the left kidney. The most appropriate initial management is: A) Percutaneous biopsy B) Radical nephrectomy with lymph node sampling C) Partial nephrectomy D) Neoadjuvant chemotherapy E) Radiation therapy Answer: B 3
BCQ 37
A 3-year-old presents with proptosis and periorbital ecchymosis. CT shows a mass in the left ethmoid sinus with orbital extension. The most appropriate initial diagnostic approach is: A) Incisional biopsy B) Fine needle aspiration C) Excisional biopsy D) Bone marrow aspiration E) PET-CT scan Answer: A 3
BCQ 38
A 15-year-old presents with a 6 cm firm mass in the distal femur. X-ray shows a sunburst pattern with periosteal reaction. The most appropriate next step is: A) Excisional biopsy B) Core needle biopsy after MRI C) Immediate wide resection D) Radiation therapy E) Empiric chemotherapy Answer: B 3
BCQ 39
A 2-year-old presents with a rapidly growing 3 cm mass in the right buttock. MRI shows a well-defined soft tissue mass confined to the gluteal muscle. The most appropriate surgical approach is: A) Wide local excision with 2 cm margins B) Incisional biopsy followed by neoadjuvant therapy C) Excision with 1 cm margins D) Intralesional excision E) Observation with serial imaging Answer: B 3
BCQ 40
A 4-month-old presents with a rapidly growing vascular lesion on the face that has not responded to propranolol. The most likely diagnosis is: A) Infantile hemangioma B) Kaposiform hemangioendothelioma C) Pyogenic granuloma D) Venous malformation E) Lymphatic malformation Answer: B 1
Neonatal Gastrointestinal Disorders
BCQ 41
A newborn presents with bilious vomiting within the first 24 hours of life. Upper GI contrast study shows a "double bubble" sign. The most likely diagnosis is: A) Duodenal atresia B) Malrotation with midgut volvulus C) Jejunal atresia D) Annular pancreas E) Ileal atresia Answer: A 1
BCQ 42
A term newborn presents with failure to pass meconium, abdominal distension, and bilious vomiting. Contrast enema shows a transition zone at the rectosigmoid junction. The most appropriate next diagnostic step is: A) Exploratory laparotomy B) Rectal suction biopsy C) Anorectal manometry D) Full thickness rectal biopsy E) Colonic transit study Answer: B 1
BCQ 43
A preterm infant (28 weeks) presents with abdominal distension, erythema of the abdominal wall, and pneumatosis intestinalis on X-ray. The most appropriate management for perforation in this setting is: A) Primary peritoneal drainage B) Laparotomy with resection and primary anastomosis C) Laparotomy with resection and stoma creation D) Broad-spectrum antibiotics only E) Laparoscopic exploration Answer: C 1
BCQ 44
A newborn presents with polyhydramnios, excessive salivation, and respiratory distress. X-ray shows a gasless abdomen. The most likely diagnosis is: A) Tracheoesophageal fistula with esophageal atresia B) Esophageal atresia without fistula C) H-type tracheoesophageal fistula D) Laryngeal cleft E) Congenital diaphragmatic hernia Answer: B 1
BCQ 45
A 2-day-old term infant presents with bilious vomiting and abdominal distension. Upper GI contrast study shows a corkscrew appearance of the duodenum and jejunum. The most appropriate management is: A) Nasogastric decompression and observation B) Urgent laparotomy with Ladd's procedure C) Contrast enema D) Upper endoscopy E) Laparoscopic exploration Answer: B 1
Pediatric Surgical Emergencies
BCQ 46
A 3-year-old presents with sudden onset of severe abdominal pain, irritability, and drawing up of the legs. Abdominal X-ray shows a gasless abdomen. The most likely diagnosis is: A) Appendicitis B) Intussusception C) Malrotation with volvulus D) Meckel's diverticulitis E) Incarcerated hernia Answer: C 1
BCQ 47
A 2-month-old presents with projectile vomiting, dehydration, and metabolic alkalosis. Ultrasound shows pyloric muscle thickness of 4 mm and channel length of 18 mm. The most appropriate preoperative management is: A) Immediate surgery B) Fluid resuscitation with correction of electrolyte abnormalities C) Nasogastric decompression only D) Trial of medical therapy with metoclopramide E) Endoscopic pyloric dilatation Answer: B 1
BCQ 48
A 4-year-old presents with right lower quadrant pain, fever, and leukocytosis. CT scan shows a perforated appendix with a 4 cm abscess. The most appropriate management is: A) Immediate appendectomy B) Percutaneous drainage and antibiotics with interval appendectomy C) Antibiotics alone with interval appendectomy D) Laparoscopic appendectomy with peritoneal lavage E) Open appendectomy with right hemicolectomy Answer: B 1
BCQ 49
A 6-year-old presents with severe abdominal pain, distension, and obstipation. X-ray shows dilated bowel loops with multiple air-fluid levels. The patient has a history of multiple abdominal surgeries. The most appropriate initial management is: A) Immediate exploratory laparotomy B) Nasogastric decompression, IV fluids, and serial examinations C) Contrast enema D) CT scan with oral and IV contrast E) Colonoscopic decompression Answer: B 1
BCQ 50
A 10-day-old presents with bilious vomiting, abdominal distension, and a palpable abdominal mass. Contrast enema shows a microcolon with a transition zone. The most likely diagnosis is: A) Meconium ileus B) Hirschsprung's disease C) Ileal atresia D) Meconium plug syndrome E) Small left colon syndrome Answer: C 1
These BCQs cover a wide range of pediatric surgical topics and are designed to test the clinical reasoning and knowledge of postgraduate trainees in pediatric surgery, in accordance with the American Academy of Pediatrics guidelines for pediatric surgical care 1, 2.