TRANSPORTE POR CARRETERA

Questions

491. A neonate is examined in the nursery and found to have no anal orifice; only a small perineal fistulous opening is visualized. A complete workup is negative for any cardiac, esophageal, genitourinary, or musculoskeletal anomalies. Which of the following is the best next step in the management of this patient?

a. Diverting colostomy only

b. Posterior sagittal anorectoplasty only

c. Posterior sagittal anorectoplasty with diverting colostomy d. Perineal operation only

e. Perineal operation with diverting colostomy

492. A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?

a. Absence of ganglion cells on full-thickness rectal biopsy 2 cm above the dentate line b. Absence of ganglion cells on full-thickness rectal biopsy 1 cm above the dentate line c. Absence of ganglion cells on suction rectal biopsy 1 cm above the dentate line

d. Identification of a transition zone between the sigmoid colon and the distal rectum on barium enema e. Inhibition of the resting anal inhibitory reflex on anorectal manometry

493. A newborn has a midline defect in the anterior abdominal wall. The parents ask what, if anything, should be done. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?

a. Umbilical hernia b. Patent urachus

c. Patent omphalomesenteric duct d. Omphalocele

e. Gastroschisis

494. A neonate is found to have an imperforate anus. As the pediatric surgeon you recommend studies to search for other anomalies. Which of the following is an associated abnormality?

a. Congenital pulmonary airway malformation b. Hydrocephalus

c. Duodenal atresia d. Congenital heart disease e. Corneal opacities

495. A 36-hour-old infant presents with bilious vomiting and an increasingly distended abdomen. At exploration, the segment pictured here is found as the point of obstruction. What is the best next step in management?

a. Gentle, persistent traction on the specimen b. Enteroenterostomy

c. Small bowel resection with exteriorization of the ends d. Small bowel resection with anastomosis

e. Lysis of Ladd band

496. A 1-year-old child has repeated episodes of vomiting and abdominal distention. An x-ray shows obstruction at the second portion of the duodenum. Laparotomy is performed and an annular pancreas is discovered. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice?

a. A Whipple procedure b. Gastrojejunostomy

c. Vagotomy and gastrojejunostomy d. Partial resection of the annular pancreas e. Duodenoduodenostomy

497. Approximately 2 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. No peritoneal signs are present. Intussusception is suspected. Which of the following is the most appropriate next step?

a. Diagnostic air enema with subsequent observation and serial abdominal examinations b. Hydrostatic reduction with air enema

c. Diagnostic laparoscopy with laparoscopic reduction d. Exploratory laparotomy with bowel resection

e. Decompressive colonoscopy with placement of a rectal tube

498. An 18-year-old woman presents with abdominal pain, fever, and leukocytosis. With the presumptive diagnosis of appendicitis, a right lower quadrant (M cBurney) incision is made and a lesion 60 cm proximal to the ileocecal valve is identified (see photo). Which of the following is the most likely diagnosis?

a. Intestinal duplication b. M esenteric cyst c. M eckel diverticulum d. Ileoileal intussusception

e. “Christmas tree” type of ileal atresia

499. A newborn infant born from a mother with polyhydramnios presents with excessive salivation along with coughing and choking with the first oral feeding. An x- ray of the abdomen shows gas in stomach and a nasogastric tube coiled in the esophagus. Which of the following is the most likely diagnosis?

a. Esophageal atresia b. Tracheoesophageal fistula

c. Esophageal atresia and tracheoesophageal fistula (TEF) d. Omphalocele

e. Gastroschisis

500. An infant is born with a defect in the anterior abdominal cavity. Upon examination there are abdominal contents (small bowel and liver) protruding directly through the umbilical ring. Which of the following should be considered in the management of this condition?

a. No further workup is indicated prior to closure of the abdominal wall defect.

b. A Silastic silo should be placed with immediate reduction of the viscera into the abdominal cavity. c. Broad-spectrum intravenous antibiotics should be administered prophylactically.

d. Topical antimicrobial solutions should be administered prophylactically.

e. Enteral feeds for nutritional support should be initiated early prior to operative management.

501. A 2-week-old infant presents with sudden onset of bilious emesis. Plain films of the abdomen show evidence of an intestinal obstruction. An upper gastrointestinal (UGI) contrast series reveals a midgut volvulus with the site of obstruction at the third portion of the duodenum. Which of the following is the most likely diagnosis?

a. Necrotizing enterocolitis (NEC) b. Intussusception

c. Hirschsprung disease

d. Anomalies of intestinal rotation and fixation e. Hypertrophic pyloric stenosis

502. A 29-week-old previously healthy male infant presents with fevers, abdominal distention, feeding intolerance, and bloody stools at 3 weeks of age. The patient undergoes x-ray and ultrasound examination for possible necrotizing enterocolitis. Which of the following findings on imaging is an indication for surgical management? a. Pneumoperitoneum

b. Ascites

c. Portal venous gas d. Ileus

e. Pneumatosis intestinalis

503. A newborn presents with signs and symptoms of distal intestinal obstruction. Abdominal x-rays reveal dilated loops of small bowel, absence of air-fluid levels, and a mass of meconium within the right side of the abdomen mixed with gas to give a ground-glass appearance. Which of the following should be performed as the initial management of the patient?

a. Administration of oral polyethylene glycol

b. Bowel rest with nasogastric tube decompression and broad-spectrum intravenous antibiotics c. Contrast enema

d. Surgical evacuation of the luminal meconium e. Resection of the dilated terminal ileum

504. A 4-week-old male infant presents with projectile, nonbilious emesis. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Which of the following is the best initial management of this patient?

a. Urgent pyloromyotomy b. Urgent pyloroplasty c. Urgent gastroduodenostomy

d. Fluid hydration and correction of electrolyte abnormalities prior to operative management e. Administration of sodium bicarbonate to correct aciduria prior to operative management

505. A 1-month-old female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and an ultrasound of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial management of this patient?

a. NPO and total parenteral nutrition b. Oral choleretic bile salts

c. M ethylprednisolone d. IV antibiotics

e. Exploratory laparotomy

506. A full-term male newborn experiences respiratory distress immediately after birth. A prenatal sonogram was read as normal. An emergency radiograph is shown here. The patient is intubated and placed on 100% O₂. Arterial blood gases reveal pH 7.24, PO₂ 60 kPa, and PCO₂ 52 kPa. The baby has sternal retractions and a scaphoid abdomen. Which of the following should be performed in the management of this patient?

a. Administration of intravenous steroids b. Placement of bilateral tube thoracostomies c. Immediate thoracotomy with lung resection d. Immediate laparotomy with repair of the diaphragm

e. M echanical ventilation with low tidal volumes

507. A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child’s disorder?

a. Administration of indomethacin if there is a patent ductus arteriosus b. Ligation of a patent ductus arteriosus

c. Echocardiography

d. Aortogram with bilateral lower extremity runoffs e. Cardiac catheterization

508. A 35-week-term infant presents with cyanosis shortly after birth. His arterial oxygen saturation is only 30%. Which of the following is the most likely diagnosis?

a. Patent ductus arteriosus b. Coarctation of the aorta c. Atrial septal defect d. Ventricular septal defect e. Transposition of the great vessels