What are the recommended Best Choice Questions (BCQs) with clinical scenarios for postgraduate trainees in pediatric surgery?

Best Choice Questions (BCQs) for Pediatric Surgery Postgraduate Trainees

The American Academy of Pediatrics recommends creating high-quality BCQs with clinical scenarios that assess diagnostic approaches, therapeutic interventions, and preoperative evaluation in pediatric surgical conditions to effectively evaluate postgraduate trainees' knowledge and clinical reasoning skills. 1

Guidelines for Creating Effective BCQs

• Each BCQ should include a clear clinical scenario with relevant patient information
• Provide five homogeneous options (similar in length and structure)
• Focus on common pediatric surgical conditions requiring specialist management
• Include key references for each question
• Ensure questions assess different cognitive levels, particularly clinical reasoning

25 Best Choice Questions for Pediatric Surgery

Neonatal Surgical Conditions

BCQ 1: Bilious Vomiting in a Newborn

A 2-day-old term neonate presents with bilious vomiting, abdominal distension, and failure to pass meconium. Abdominal X-ray shows dilated bowel loops. Contrast enema demonstrates a transition zone at the rectosigmoid junction.

Which of the following is the most appropriate next step in management?

1. Rectal suction biopsy
2. Exploratory laparotomy
3. Colostomy formation
4. Serial abdominal X-rays
5. Glycerin suppository

Key: 1 1

BCQ 2: Excessive Salivation in a Neonate

A term neonate presents with excessive salivation and respiratory distress. Attempts to pass a nasogastric tube are unsuccessful. Chest X-ray with contrast shows a blind-ending esophageal pouch.

Which of the following associated anomalies is most commonly found in this patient?

1. Cardiac defect
2. Renal anomaly
3. Skeletal anomaly
4. Neurological defect
5. Gastrointestinal anomaly

Key: 1 1

BCQ 3: Abdominal Wall Defect

A newborn presents with an abdominal wall defect to the right of the umbilical cord with exposed intestines covered by a transparent sac.

What is the most likely diagnosis?

1. Gastroschisis
2. Omphalocele
3. Umbilical hernia
4. Bladder exstrophy
5. Cloacal exstrophy

Key: 2 1

BCQ 4: Preterm Infant with Abdominal Distension

A 28-week preterm infant develops sudden abdominal distension, erythema of the abdominal wall, and pneumatosis intestinalis on X-ray.

Which of the following is the most appropriate management if intestinal perforation is confirmed?

1. Laparotomy with resection and stoma creation
2. Primary anastomosis without stoma
3. Peritoneal drainage only
4. Broad-spectrum antibiotics only
5. Observation and serial abdominal X-rays

Key: 1 1

BCQ 5: Jaundiced Infant

A 6-week-old infant presents with jaundice, acholic stools, and dark urine. Ultrasound shows a triangular cord sign at the porta hepatis.

What is the most appropriate initial surgical management?

1. Kasai portoenterostomy
2. Liver transplantation
3. Choledochal cyst excision
4. Cholecystectomy
5. Choledochojejunostomy

Key: 1 1

Gastrointestinal Conditions

BCQ 6: Intermittent Abdominal Pain in a Child

A 9-month-old infant presents with intermittent abdominal pain, currant jelly stools, and a palpable sausage-shaped mass in the right abdomen.

Which of the following is the most appropriate initial management?

1. Hydrostatic or pneumatic reduction
2. Immediate surgical exploration
3. Observation and pain management
4. Contrast enema without reduction
5. Broad-spectrum antibiotics

Key: 1 1

BCQ 7: Right Lower Quadrant Pain

A 10-year-old child presents with right lower quadrant pain, anorexia, and fever. White blood cell count is elevated, and ultrasound shows a non-compressible appendix with surrounding fluid.

What is the most appropriate management?

1. Laparoscopic appendectomy
2. Open appendectomy
3. Intravenous antibiotics only
4. Observation for 24 hours
5. CT scan for further evaluation

Key: 1 1

BCQ 8: Recurrent Abdominal Pain

A 6-year-old child presents with recurrent abdominal pain, vomiting, and growth failure. Upper GI series shows a "string sign" in the terminal ileum.

What is the most likely diagnosis?

1. Crohn's disease
2. Ulcerative colitis
3. Meckel's diverticulum
4. Intestinal tuberculosis
5. Celiac disease

Key: 1 1

BCQ 9: Painless Rectal Bleeding

A 2-year-old child presents with painless rectal bleeding. Colonoscopy reveals a 2 cm polyp in the rectosigmoid region.

Which of the following is the most likely diagnosis?

1. Juvenile polyp
2. Familial adenomatous polyposis
3. Peutz-Jeghers syndrome
4. Inflammatory bowel disease
5. Meckel's diverticulum

Key: 1 1

BCQ 10: Persistent Vomiting in an Infant

A 4-week-old male infant presents with non-bilious projectile vomiting after feeds and visible peristalsis. Ultrasound shows pyloric muscle thickness of 5 mm.

What is the most appropriate management?

1. Pyloromyotomy
2. Pyloroplasty
3. Medical management with metoclopramide
4. Endoscopic pyloric balloon dilatation
5. Nasogastric decompression and observation

Key: 1 1

Thoracic Conditions

BCQ 11: Recurrent Pneumonia

An infant presents with recurrent pneumonia in the right lower lobe. CT chest shows a cystic lesion with air-fluid level.

What is the most likely diagnosis?

1. Congenital pulmonary airway malformation
2. Pulmonary sequestration
3. Bronchogenic cyst
4. Congenital lobar emphysema
5. Diaphragmatic hernia

Key: 1 1

BCQ 12: Respiratory Distress in a Newborn

A term newborn presents with respiratory distress and scaphoid abdomen. Chest X-ray shows bowel loops in the left hemithorax.

What is the most appropriate timing for surgical repair?

1. Immediate repair after stabilization
2. Elective repair at 3-6 months of age
3. Repair at 1 year of age
4. Conservative management without surgery
5. Repair only if symptoms persist beyond 1 week

Key: 1 1

BCQ 13: Chest Wall Deformity

A 14-year-old presents with a depressed anterior chest wall and decreased exercise tolerance. CT scan shows a pectus severity index of 4.2.

Which of the following is the most appropriate management?

1. Minimally invasive repair (Nuss procedure)
2. Open repair (Ravitch procedure)
3. Vacuum bell therapy
4. Observation only
5. Chest physiotherapy

Key: 1 1

BCQ 14: Neck Mass

A 4-year-old child presents with a midline neck mass that moves with swallowing and tongue protrusion. Ultrasound shows a cystic lesion at the base of the tongue.

What is the most likely diagnosis?

1. Thyroglossal duct cyst
2. Branchial cleft cyst
3. Cystic hygroma
4. Dermoid cyst
5. Thyroid nodule

Key: 1 1

BCQ 15: Stridor in an Infant

A 6-month-old infant presents with biphasic stridor and feeding difficulties. Flexible laryngoscopy shows omega-shaped epiglottis and arytenoid prolapse.

What is the most likely diagnosis?

1. Laryngomalacia
2. Subglottic stenosis
3. Vocal cord paralysis
4. Laryngeal web
5. Laryngeal papillomatosis

Key: 1 1

Genitourinary Conditions

BCQ 16: Scrotal Swelling

A 2-month-old male presents with acute scrotal swelling, erythema, and tenderness. Doppler ultrasound shows decreased blood flow to the testis.

What is the most appropriate management?

1. Immediate surgical exploration
2. Intravenous antibiotics only
3. Observation for 24 hours
4. Manual detorsion followed by elective orchiopexy
5. Scrotal support and analgesics

Key: 1 1

BCQ 17: Antenatal Hydronephrosis

A newborn with antenatal diagnosis of bilateral hydronephrosis has postnatal ultrasound showing Society for Fetal Urology grade 4 hydronephrosis. Voiding cystourethrogram is normal.

What is the most appropriate management?

1. Pyeloplasty after confirmation with MAG-3 scan
2. Immediate vesicostomy
3. Prophylactic antibiotics and observation
4. Percutaneous nephrostomy
5. Nephrectomy of the most affected kidney

Key: 1 1

BCQ 18: Ambiguous Genitalia

A newborn presents with ambiguous genitalia, palpable gonads in the labioscrotal folds, and urethral opening at the base of the phallus. Karyotype is 46,XY.

What is the most likely diagnosis?

1. Partial androgen insensitivity syndrome
2. Congenital adrenal hyperplasia
3. 5-alpha reductase deficiency
4. Mixed gonadal dysgenesis
5. True hermaphroditism

Key: 1 1

BCQ 19: Urinary Tract Infection

A 2-year-old female presents with recurrent urinary tract infections. Voiding cystourethrogram shows grade IV vesicoureteral reflux on the left side.

What is the most appropriate management?

1. Ureteral reimplantation
2. Endoscopic injection of bulking agent
3. Prophylactic antibiotics only
4. Observation without antibiotics
5. Nephrectomy

Key: 1 1

BCQ 20: Inguinal Swelling

A 3-year-old male presents with right inguinal swelling that increases with crying and disappears when lying down. Physical examination reveals a palpable thickened cord.

What is the most appropriate management?

1. Elective inguinal hernia repair
2. Emergency hernia repair
3. Observation until puberty
4. Truss application
5. Laparoscopic evaluation only

Key: 1 1

Oncology and Miscellaneous Conditions

BCQ 21: Abdominal Mass

A 3-year-old child presents with an abdominal mass, hypertension, and hematuria. CT scan shows a large heterogeneous renal mass with areas of hemorrhage and necrosis.

What is the most appropriate initial management?

1. Neoadjuvant chemotherapy followed by nephrectomy
2. Primary radical nephrectomy
3. Renal biopsy followed by targeted therapy
4. Partial nephrectomy
5. Radiation therapy followed by surgery

Key: 1 1

BCQ 22: Neck Swelling

A 5-year-old child presents with a firm, non-tender neck swelling that has been slowly enlarging over 3 months. Fine needle aspiration cytology suggests papillary thyroid carcinoma.

What is the most appropriate surgical management?

1. Total thyroidectomy with central lymph node dissection
2. Lobectomy only
3. Total thyroidectomy without lymph node dissection
4. Isthmusectomy
5. Observation and repeat FNAC in 6 months

Key: 1 1

BCQ 23: Preoperative Evaluation

A 2-year-old child with congenital heart disease is scheduled for inguinal hernia repair. The child has a history of tetralogy of Fallot repair at 6 months of age.

Which of the following is most important in the preoperative evaluation?

1. Cardiology consultation and recent echocardiogram
2. Complete blood count and coagulation profile
3. Chest X-ray
4. Electrocardiogram
5. Pulmonary function tests

Key: 1 1

BCQ 24: Trauma Management

A 7-year-old child presents after a fall from height with abdominal pain and gross hematuria. CT scan shows a grade IV splenic laceration and a grade III left renal injury.

What is the most appropriate management?

1. Non-operative management with close monitoring
2. Exploratory laparotomy with splenectomy
3. Angioembolization of splenic artery
4. Partial nephrectomy
5. Exploratory laparotomy with splenorrhaphy

Key: 1 1

BCQ 25: Burn Management

A 4-year-old child presents with a scald burn covering 15% of total body surface area, including the anterior chest and right arm. The burn appears deep partial thickness.

What is the most appropriate initial management?

1. Fluid resuscitation and wound care with consideration for early excision and grafting
2. Immediate escharotomy
3. Conservative management with silver sulfadiazine only
4. Immediate skin grafting
5. Hyperbaric oxygen therapy

Key: 1 1

Best Practices for BCQ Development

• Ensure questions assess different cognitive levels, particularly clinical reasoning and application of knowledge 2, 3
• Create homogeneous options that are similar in length and structure 2
• Avoid item writing flaws such as using "except" or "not" in the lead-in, tricky stems, or opportunities for students to use convergence strategies 3
• Include clinical scenarios that reflect common pediatric surgical conditions requiring specialist management 1
• Focus on conditions where pediatric surgeons have specialized training and expertise 1

Common Pitfalls to Avoid

• Avoid questions that are too easy (difficulty index >70%) 3
• Ensure distractors are functional and plausible 2, 3
• Avoid focusing only on information recall; include questions requiring higher levels of thinking and data interpretation 3
• Ensure questions align with learning outcomes and enhance the ability to measure student competency 3