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Question 1 of 16
1. Question
A 4-week-old boy is hospitalized with persistent vomiting, fussiness, and feeding intolerance. The emesis was initially clear but became bilious in the last few hours. The infant had been breastfeeding exclusively. His temperature is 37.2 C (99.0 F). Blood pressure and pulse are normal. Physical examination shows a normal abdomen with no rebound or guarding. An upper gastrointestinal series is obtained urgently to evaluate for malrotation and volvulus and shows normal rotation but constriction of the duodenum. An abdominal CT scan reveals pancreatic tissue encircling the duodenum. Which of the following is the most likely cause of this patient’s condition?
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Question 2 of 16
2. Question
A 1-day-old girl is evaluated in the nursery due to persistent vomiting and refusal to feed since early in the morning. The vomitus appears green-yellow. It does not contain blood. The infant appears dehydrated. Examination shows a distended abdomen. The remainder of the physical examination is unremarkable. After initial evaluation, the infant undergoes laparotomy. The full length of the duodenum is present. The proximal jejunum ends in a blind pouch. The distal jejunum and proximal ileum are absent. The distal ileum is present and winds around a thin vascular stalk. Which of the following embryologic processes is most likely responsible for this patient’s condition?
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Question 3 of 16
3. Question
A 3-year-old boy is brought to the emergency department by his parents after he develops acute abdominal pain and vomiting. Examination shows diffuse tenderness to palpation, and abdominal imaging reveals a foreign body lodged within the intestine, causing a small bowel obstruction. Laparotomy is performed to remove the foreign body; during the procedure, an incidental cyst is discovered. The cyst is connected by a fibrous band to the ileum and the umbilicus. The embryologic defect underlying the formation of this patient’s cyst is also associated with which of the following?
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Question 4 of 16
4. Question
A 4-year-old girl is brought to the office after her parents noticed dark red blood on her toilet tissue after a bowel movement. She has had no abdominal pain, dysuria, or discomfort with defecation. The girl has no known medical conditions and takes no medications. Temperature is 36.7 C (98.1 F), blood pressure is 100/40 mm Hg, and pulse is 112/min. Examination shows a soft and nontender abdomen, and bowel sounds are present. Hemoglobin is 8 g/dL, and platelet count is 215,000/mm3. Coagulation studies are normal. Sequential imaging using 99mTc-pertechnetate scintigraphy demonstrates focal radiotracer accumulation in the right lower quadrant. Which of the following embryologic processes most likely resulted in this patient’s condition?
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Question 5 of 16
5. Question
A 30-year-old man comes to the emergency department due to severe abdominal pain. The patient first developed the pain yesterday, and it has become increasingly worse. Over the last few hours, he has also developed bilious emesis. The patient has had no previous surgeries. Temperature is 37.8 C (100 F) and pulse is 110/min. Physical examination shows diffuse abdominal tenderness with guarding during palpation. Abdominal imaging reveals bowel wall thickening within a blind pouch connected to the ileum. A laparotomy is performed. During the procedure, a fibrous band is seen attaching the end of the pouch to the umbilicus. The walls of this pouch are most likely composed of which of the following?
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Question 6 of 16
6. Question
A 6-hour-old boy is in the newborn nursery with feeding difficulties. The patient was born at 39 weeks gestation to a 33-year-old primigravida via cesarean delivery due to failure to progress and late decelerations seen on fetal heart tracing. Apgar scores were 8 and 9, but examination shows an infant with excessive drooling and coughing. Cardiac, respiratory, and abdominal examinations are otherwise normal at rest. When the infant attempts to breastfeed, however, several bouts of coughing and perioral cyanosis develop with oxygen saturation of 85% on room air. Which of the following is the most likely cause of this patient’s condition?
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Question 7 of 16
7. Question
A newborn boy is examined in the nursery shortly after birth. He was born at term by vaginal delivery to a 40-year-old woman who did not receive prenatal care. Temperature is 36.7 C (98 F), pulse is 132/min, and respirations are 38/min. Examination shows slanted palpebral fissures, epicanthal folds, thick nuchal folds, and a single palmar crease. The patient has a large, reducible midline abdominal protrusion covered by skin that is more pronounced when he cries. The umbilical stump is at the center of the protrusion. Which of the following is the most likely cause of this patient’s abdominal finding?
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Question 8 of 16
8. Question
A 3-day-old boy is brought to the emergency department due to poor feeding, emesis, and lethargy over the past 24 hours. He was born via uncomplicated spontaneous vaginal delivery to a 30-year-old woman who had a normal pregnancy. The boy was discharged from the newborn nursery yesterday and was breastfeeding exclusively until the onset of symptoms. Stool and urine output were normal while he was in the hospital. The patient is afebrile and normotensive but tachycardic and tachypneic. He appears dehydrated, and the abdomen is distended. The patient vomits during the examination; the vomitus is shown in the exhibit. On laparotomy, fibrous bands are seen extending from the cecum and right colon to the retroperitoneum, causing extrinsic compression of the duodenum. Which of the following embryologic processes most likely failed in this patient?
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Question 9 of 16
9. Question
Researchers studying neural crest cell migration in a human fetus observe normal activity beginning at the 8th week of embryogenesis with interruption during the 12th week, when migration is typically completed. Which of the following structures is most likely to lack innervation as a result of this disruption?
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Question 10 of 16
10. Question
A 5-month-old boy is brought to the office for right-sided scrotal enlargement. The enlargement has been present since birth and increases when he cries or strains to pass a bowel movement. There is no history of trauma or infection. The boy’s parents do not believe he is in pain and have not noted discoloration of the area. On ultrasonography, the enlargement is found to be a fluid collection around the right testis. The specific embryologic defect giving rise to this patient’s condition can also lead directly to which of the following?
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Question 11 of 16
11. Question
An 8-month-old boy is brought to clinic due to abdominal distension. The patient has had excessive straining and irritability with bowel movements since birth. He had been exclusively breastfed, and his symptoms worsened after transitioning to pureed foods. Vital signs are normal. Abdominal examination shows distension with mild tenderness to palpation. Bowel sounds are present, and there is no hepatosplenomegaly. Barium enema shows a relatively narrow rectum and rectosigmoid area. The rest of the colon proximal to this segment is significantly dilated. Colorectal biopsy of which of the following areas is most likely to reveal the underlying cause of this patient’s condition?
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Question 12 of 16
12. Question
Researchers studying embryologic development observe a disruption in the differentiation of the endoderm within the gastrointestinal system of a developing fetus. Which of the following processes is most likely to be affected?
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Question 13 of 16
13. Question
A newborn boy is being evaluated in the nursery. The patient was born at term via spontaneous vaginal delivery. A cystic lesion is noted overlying the lumbosacral spine region. The remainder of the physical examination is unremarkable. Ultrasound imaging confirms a neural tube defect. The mother had no prenatal care, and further discussion reveals that she took a medication known to be teratogenic during pregnancy. Exposure to the medication most likely occurred during which of the following weeks of embryonic development?
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Question 14 of 16
14. Question
A 21-year-old woman at 18 weeks gestation comes to the office for a routine prenatal visit. A quadruple screen reveals an elevated maternal serum alpha-fetoprotein. Sonographic imaging of the fetus shows an anterior abdominal wall defect with herniation of bowel contents adjacent to the umbilicus. No covering membrane is identified. Color Doppler ultrasound imaging shows a normal 3-vessel cord inserting medial to this defect. The remainder of the anatomical survey is unremarkable. Which of the following is the most likely cause of these fetal findings?
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Question 15 of 16
15. Question
A 2-day-old boy is evaluated in the newborn nursery due to vomiting. He was born at term to a 30-year-old primigravida via spontaneous vaginal delivery. The patient initially tolerated formula after birth. However, the past 2 feeding attempts resulted in bilious emesis. Cardiopulmonary examination is unremarkable. Abdominal examination shows distension with active bowel sounds. There is no hepatosplenomegaly. Digital rectal examination results in a forceful expulsion of gas. Which of the following processes was most likely impaired during embryologic development of this patient’s gastrointestinal system?
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Question 16 of 16
16. Question
An 8-month-old girl is brought to the emergency department due to fussiness. Symptoms began about 4 hours ago, and the patient has vomited several times. The parents state that the vomitus is dark green but nonbloody. The patient was born at term via spontaneous vaginal delivery after an uncomplicated pregnancy. She has no known medical conditions and normally consumes breast milk and pureed foods. Examination demonstrates abdominal distension. Abdominal imaging is shown in the exhibit. Surgical intervention is needed in this patient to prevent ischemia to structures supplied by which of the following?
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